Published: 08 March 2018
When people hear about Chronic Kidney Disease (CKD) it’s generally in the context of dialysis or kidney transplantation.
However, a more pressing risk facing people with CKD is that they are at greatly increased likelihood of heart attacks and strokes. The risks of cardiovascular disease in CKD are typically between two to five times higher than the general population and at least as high as they are in people with diabetes*.
It's also not widely recognised how common CKD is. We believe that as many as one in eight adults have kidneys that are not working as well as they should. Most of these people don't have any symptoms and many of them are not even aware they have the condition.
Reducing risk
Some people’s conditions may deteriorate to the point that they require dialysis or a kidney transplant if they suffer complete kidney failure. But kidney failure, although devastating, is actually pretty uncommon. There are over 6 million people in the UK with CKD but only around 50,000 who need kidney dialysis or a transplant. Therefore it is the high risk of heart disease that is what matters to most people with CKD and that is why it is so important that we find new ways to reduce the risk.
Could aspirin be the answer?
One treatment which could help reduce these risks is aspirin – a medication which is most probably sitting in your medicine cupboard at home.
This is the background to a large trial about to get underway which has been funded by NIHR and the British Heart Foundation. Our study, Aspirin To Target Arterial events in Chronic Kidney disease (ATTACK), is going to test the hypothesis that taking a low-dose aspirin tablet once a day reduces the risk of heart attacks and strokes in people with CKD. As aspirin can also increase the chances of bleeding, our research is also designed to find out whether, and by how much, these benefits outweigh the risks.
The humble (and inexpensive) aspirin tablet has been widely studied since it was first developed in 1899. We know that in people who already have cardiovascular disease it is very effective in preventing further heart attacks and strokes. On the other hand in the general population (who are at much lower risk) there is less to gain and so any beneficial effects are largely cancelled out by the risks of bleeding.
So the question is whether aspirin is of overall benefit in people with CKD, a group who are at much higher risk of heart disease than the general population, but may also be more susceptible to bleeding. There is some evidence already that this is the case, but it isn't conclusive.
One dose a day
To answer the question definitely we intend to recruit around 25,000 people with CKD from GP surgeries across the country, making it, to the best of our knowledge, the largest ever trial of its kind in people with CKD.
They will be randomised to receive low-dose (75 mg once daily) aspirin (prescribed by their GP) or no additional treatment and followed up for an average of just under five years.
Simple, yet sophisticated
Whilst the concept of the ATTACK study and the trial intervention are both very simple, our research is supported by sophisticated IT. Our trial management software will automatically identify potential participants and collect our trial outcomes from GP electronic records and hospital (HES) data, so patients in the trial do not have to come back for any special follow-up.
This means that we have been able to design a large-trial without the need for commercial funding. Aspirin is affordable and familiar, and so we hope that our results will be relevant for people with CKD in the NHS and also in other healthcare systems internationally.
These are exciting times for the research team! We are gearing up to start recruitment in September 2018, and would like to hear from you if you are a GP and are interested in your practice taking part or if you would just like to talk to us about the study.
Dr Gallagher’s study was funded by the NIHR’s Health Technology Assessment (HTA) Programme and by the British Heart Foundation. More information on the study is available on the NIHR Journals Library.
Footnote
*In the case of type 1 diabetes, research shows that overall life expectancy is only reduced in people with the condition who also have CKD (Groop at al. Diabetes. 2009 Jul; 58(7): 1651–1658).
The views and opinions expressed in this blog are those of the authors and do not necessarily reflect those of the NIHR, NHS or the Department of Health and Social Care.