Reference no: EM132470640
Title: Multifactorial intervention with nurse practitioners does not change cardiovascular outcomes in patients with chronic kidney disease.
Strict implementation of guidelines directed at multiple targets reduces vascular risk in diabetic patients. Whether this also applies to patients with chronic kidney disease (CKD) is uncertain. To evaluate this, the MASTERPLAN Study randomized 788 patients with CKD (estimated GFR 20-70ml/min) to receive additional intensive nurse practitioner support (the intervention group) or nephrologist care (the control group). The primary end point was a composite of myocardial infarction, stroke, or cardiovascular death. During mean follow-up of 4.62 years, modest but significant decreases were found for blood pressure, LDL cholesterol, anemia, proteinuria along with the increased use of active vitamin D or analogs, aspirin and statins in the intervention group compared to the controls. No differences were found in the rate of smoking cessation, weight reduction, sodium excretion, physical activity, or glycemic control. Intensive control did not reduce the rate of the composite end point (21.3/1000 person-years in the intervention group compared to 23.8/1000 person-years in the controls (hazard ratio 0.90)).No differences were found in the secondary outcomes of vascular interventions, all-cause mortality or end-stage renal disease. Thus, the addition of intensive support by nurse practitioner care in patients with CKD improved some risk factor levels, but did not significantly reduce the rate of the primary or secondary end points.
Chronic kidney disease (CKD) is a known risk factor for cardiovascular disease (CVD).This increased CVD risk is attributed to traditional risk factors (e.g., hypertension, dyslipidemia, diabetes, male gender, and smoking) and kidney disease-specific risk factors such as anemia, albumi-nuria, and calcium-phosphate disbalance.
The contribution of one risk factor to CVD risk is small, but a combination results in a very high CVD risk. Despite the existence of guidelines, studies in several high-risk groups demonstrated that goals for treatment are often not met. The same holds for CKD patients. Physicians usually do not have the time to address all relevant issues regarding CVD risk. Nurse practitioners may be of help. The benefits of coaching by nurse practitioners are evident in other high-risk populations. Studies in patients with diabetes mellitus or heartfailure showed that a multifactorial intervention implemented by nurse practitioners significantly improved metabolic control and reduced CVD. Given the high CVD risk and the multitude of modifiable risk factors a multifactorial approach could also be of benefit for patients with CKD. The aim of our study was to assess whether the addition of nurse practitioner care to standard care by a nephrologist in patients with moderate-to-severe CKD, aimed at strict implementation of current guidelines with emphasis on CVD medication and lifestyle changes, improves cardiovascular outcome.
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