ABSTRACT
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 20-70 ml/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 a 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.
Subject(s)
Cardiovascular Agents/therapeutic use , Cardiovascular Diseases/nursing , Cardiovascular Diseases/prevention & control , Nurse Practitioners , Preventive Health Services , Renal Insufficiency, Chronic/nursing , Renal Insufficiency, Chronic/therapy , Risk Reduction Behavior , Aged , Cardiovascular Diseases/blood , Cardiovascular Diseases/mortality , Cardiovascular Diseases/physiopathology , Combined Modality Therapy , Disease Progression , Female , Glomerular Filtration Rate , Guideline Adherence , Humans , Kidney/physiopathology , Kidney Failure, Chronic/mortality , Kidney Failure, Chronic/nursing , Kidney Failure, Chronic/prevention & control , Linear Models , Male , Middle Aged , Motor Activity , Myocardial Infarction/mortality , Myocardial Infarction/nursing , Myocardial Infarction/prevention & control , Netherlands , Practice Guidelines as Topic , Proportional Hazards Models , Renal Insufficiency, Chronic/blood , Renal Insufficiency, Chronic/diagnosis , Renal Insufficiency, Chronic/mortality , Renal Insufficiency, Chronic/physiopathology , Risk Assessment , Risk Factors , Severity of Illness Index , Smoking Cessation , Stroke/mortality , Stroke/nursing , Stroke/prevention & control , Time Factors , Treatment Outcome , Weight LossABSTRACT
Children born very prematurely who show intrauterine growth retardation (IUGR) are suggested to be at risk of developing high blood pressure as adults. Renal function may already be impaired by young adult age. To study whether very preterm birth affects blood pressure in young adults, we measured 24-h ambulatory blood pressure (Spacelabs 90207 device) and renin concentration in 50 very premature individuals (<32 weeks of gestation), either small (SGA) or appropriate (AGA) for gestational age (21 SGA, 29 AGA), and 30 full-term controls who all were aged 20 years at time of measurement. The mean (standard deviation) daytime systolic blood pressure in SGA and AGA prematurely born individuals, respectively, was 122.7 (8.7) and 123.1 (8.5) mmHg. These values were, respectively, 3.6 mmHg [95% confidence interval (CI) -0.9 to 8.0] and 4.2 mmHg (95% CI 0.4-8.0) higher than in controls [119.6 (7.6)]. Daytime diastolic blood pressure and nighttime blood pressure did not differ between groups. We conclude that individuals born very preterm have higher daytime systolic blood pressure and higher risk of hypertension at a young adult age.
