Patients undergoing maintenance dialysis for kidney failure face a substantial risk of cardiovascular disease and death, yet relatively few proven preventive therapies currently exist. To address this gap, an international team—including CVC Faculty Member Dr. David Collister—conducted the ACHIEVE trial, a randomized controlled study investigating whether the heart failure medication spironolactone, as compared to placebo, could reduce cardiovascular complications in this high-risk population.
The trial spanned 12 countries and 143 dialysis programs, enrolling adult patients who had been receiving maintenance dialysis for at least three months. Following a preliminary run-in period to ensure medication tolerance and adherence, 2,538 participants were randomly assigned to receive either 25 mg of spironolactone daily or a placebo. To maintain objectivity, the study was double-blinded so neither patients nor their providers knew the treatment assignments. Researchers tracked the time to either cardiovascular death or heart failure hospitalization as the primary composite outcome for all participants. Dr. Collister led event adjudication internationally in the ACHIEVE trial.
Following a planned interim analysis, the trial was terminated early after showing no significant benefit from the treatment. Over a median follow-up of 1.8 years, the primary outcomes occurred at similar rates: 10.46 events per 100 patient-years in the spironolactone group compared to 11.33 in the placebo group. Furthermore, the study found no significant differences in overall death or general hospitalization rates between the two cohorts.
Ultimately, the ACHIEVE trial demonstrated that spironolactone provides no measurable benefit for patients receiving maintenance dialysis. While earlier meta-analyses suggested potential advantages, these robust new data do not support such claims. Consequently, researchers must look beyond traditional steroidal mineralocorticoid receptor antagonists—which may have limiting side effects like high potassium—to identify alternative therapies to improve cardiovascular outcomes for those with kidney failure.
