Question

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.

Questions:

What is the topic and why is important?

What is the current knowledge on the topic, gaps in knowledge?

What is the specific aim of this study?

What are the important strengths and weaknesses of the study?

Answer 1

The topic is about the multifactorial intervention for patient with CKD to reduce the risk of CVD with the nurse practitioner.The topic is important to assess the link between these two diseases when there is implementation of certain intervention to reduce its risk.

The current knowledge on the topic is that the the composite end point was not reduced as a result of intensive control

The aim of the study was to assess whether the addition of nurse practitioner care to standard care with nephrologist iin patient with moderate to severe CKD showed improvement in CVD

The strength are

• Addition of nurse practitioner
• Using guidelines
• It showes a decrease of CVD rate in case of diabetic patients than CKD
• Beneficial to other high risk population

The weakness are

• Lack of time to the physician
• Goals are not met even after intervention