***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: PURPOSE Though case management has been recommended to improve the outcomes of patients with costly or morbid conditions , it has seldom been studied in controlled trials . We performed a r and omized , controlled clinical trial of an intensive , multidisciplinary case management program for patients with chronic renal insufficiency and followed patients for 5 years . PATIENTS AND METHODS We enrolled 437 primary -care patients ( 73 % of those eligible ) with chronic renal insufficiency ( estimated creatinine clearance consistently < 50 mL/min with the last serum creatinine level > 1.4 mg/dL ) who were attending an urban academic general internal medicine practice . The intensive case management , administered during the first 2 years after enrollment , consisted of m and atory repeated consultations in a nephrology case management clinic staffed by two nephrologists , a renal nurse , a renal dietitian , and a social worker . Control patients received usual care . Primary outcome measurements included serum creatinine level , estimated creatinine clearance , health services use , and mortality in the 5 years after enrollment . Secondary measures included use of renal sparing and potentially nephrotoxic drugs . RESULTS There were no differences in renal function , health services use , or mortality in the first , second , or third through fifth years after enrollment . There were significantly more outpatient visits among intervention patients , mainly because of the added visits to the nephrology case management clinic . There were also no significant differences in the use of renal sparing or selected potentially nephrotoxic drugs . The annual direct costs of the intervention were $ 89,355 ( $ 484 per intervention patient ) . CONCLUSION This intensive , multidisciplinary case-management intervention had no effect on the outcomes of care among primary -care patients with established chronic renal insufficiency . Such expensive and intrusive interventions , despite representing state-of-the-art care , should be tested prospect ively before being widely introduced into practice BACKGROUND AND OBJECTIVES It is unclear how to optimally care for chronic kidney disease ( CKD ) . This study compares a new coordinated model to usual care for CKD . DESIGN , SETTING , PARTICIPANTS , & MEASUREMENTS A r and omized trial in nephrology clinics and the community included 474 patients with median estimated GFR ( eGFR ) 42 ml/min per 1.73 m(2 ) identified by laboratory-based case finding compared care coordinated by a general practitioner ( controls ) with care by a nurse-coordinated team including a nephrologist ( intervention ) for a median ( interquartile range [ IQR ] ) of 742 days . 32 % were diabetic , 60 % had cardiovascular disease , and proteinuria was minimal . Guided by protocol s , the intervention team targeted risk factors for adverse kidney and cardiovascular outcomes . Serial eGFR and clinical events were tracked . RESULTS The average decline in eGFR over 20 months was -1.9 ml/min per 1.73 m(2 ) . eGFR declined by ≥4 ml/min per 1.73 m(2 ) within 20 months in 28 ( 17 % ) intervention patients versus 23 ( 13.9 % ) control patients . Control of BP , LDL , and diabetes were comparable across groups . In the intervention group there was a trend to greater use of renin-angiotensin blockers  and more use of statins  in those with initial LDL > 2.5 mmol/L. Treatment was rarely required for anemia , acidosis , or disordered mineral metabolism . Clinical events occurred in 5.2 % per year . CONCLUSIONS Patients with stage 3/4 CKD identified through community laboratories largely had nonprogressive kidney disease but had cardiovascular risk . Over a median of 24 months , the nurse-coordinated team did not affect rate of GFR decline or control of most risk factors compared with usual care BACKGROUND Chronic kidney disease ( CKD ) is associated with an increased risk of incident cardiovascular disease ( CVD ) ; however , the role of statins for the primary prevention of acute cardiovascular events in patients with CKD and the effect of statins on kidney function loss in persons without prevalent CVD have not been studied . STUDY DESIGN Post hoc analysis of the Air Force/Texas Coronary Atherosclerosis Prevention Study . SETTING & PARTICIPANTS Multicenter , r and omized , double-blind , placebo-controlled trial of 5,608 men and 997 women without CVD r and omly assigned to treatment with lovastatin or placebo .  INTERVENTION Placebo or lovastatin , 20 mg/d . OUTCOMES & MEASUREMENTS First major acute cardiovascular event in participants with mild CKD and kidney function loss in persons with or without CKD .  Estimated glomerular filtration rate was calculated using the 4-variable Modification of Diet in Renal Disease Study equation . RESULTS At baseline ,  mean estimated glomerular filtration rate in participants with CKD ( n = 304 ) was 53.0 + /- 6.0 mL/min/1.73 m(2 ) . After an average follow-up of 5.3 + /- 0.8 years , the incidence of a fatal and nonfatal CVD event was lower in participants with CKD receiving lovastatin than in those receiving placebo ( adjusted relative risk [ RR ] , 0.31 ; 95 % CI , 0.13 - 0.72 ; P = 0.01 ) . Tests for interaction suggested that the benefit of lovastatin was independent of the presence of CKD . Lovastatin did not reduce the annualized mean decrease in estimated glomerular filtration rate ( -1.3 + /- 0.07 vs -1.4 + /- 0.07 mL/min/1.73 m(2)/y , respectively ; P = 0.1 ) or the frequency of a > or = 25 % decrease in kidney function ( adjusted RR , 1.10 ; 95 % CI , 0.96 - 1.28 ; P = 0.2 ) or incident CKD ( adjusted RR , 1.04 ; 95 % CI , 0.86 - 1.27 ; P = 0.6 ) . LIMITATIONS Unable to determine the cause and duration of kidney disease , and information regarding proteinuria was not available . CONCLUSIONS Lovastatin is effective for the primary prevention of CVD in patients with CKD , but is not effective in decreasing kidney function loss in persons with no CVD BACKGROUND Few studies have directly compared the renoprotective effects of angiotensin II-receptor blockers and angiotensin-converting-enzyme ( ACE ) inhibitors in persons with type 2 diabetes . METHODS In this prospect i ve , multicenter , double-blind , five-year study , we r and omly assigned 250 subjects with type 2 diabetes and early nephropathy to receive either the angiotensin II-receptor blocker telmisartan ( 80 mg daily , in 120 subjects ) or the ACE inhibitor enalapril ( 20 mg daily , in 130 subjects ) . The primary end point was the change in the glomerular filtration rate ( determined by measuring the plasma clearance of iohexol ) between the baseline value and the last available value during the five-year treatment period . Secondary end points included the annual changes in the glomerular filtration rate , serum creatinine level , urinary albumin excretion , and blood pressure ; the rates of end-stage renal disease and cardiovascular events ; and the rate of death from all causes . RESULTS After five years , the change in the glomerular filtration rate was -17.5 ml per minute per 1.73 m2 ( where the minus sign denotes a decrement ) in the telmisartan-treated subjects , as compared with -15.0 ml per minute per 1.73 m2 in the enalapril-treated subjects ; the treatment difference was thus -2.6 ml per minute per 1.73 m2 ( 95 percent confidence interval , -7.1 to 2.0 ml per minute per 1.73 m2)[corrected ] The lower boundary of the confidence interval , in favor of enalapril , was greater than the predefined margin of -10.0 ml per minute per 1.73 m2 , indicating that telmisartan was not inferior to enalapril . The effects of the two agents on the secondary end points were not significantly different after five years . CONCLUSIONS Telmisartan is not inferior to enalapril in providing long-term renoprotection in persons with type 2 diabetes . These findings do not necessarily apply to persons with more advanced nephropathy , but they support the clinical equivalence of angiotensin II-receptor blockers and ACE inhibitors in persons with conditions that place them at high risk for cardiovascular events Mild renal impairment is an important risk factor for late cardiovascular complications . This sub study of the Lescol Intervention Prevention Study ( LIPS ) assessed the effect of fluvastatin on outcome of patients who had renal dysfunction and those who did not . Complete data for creatinine clearance calculation ( Cockcroft-Gault formula ) were available for 1,558 patients ( 92.9 % of the LIPS population ) . Patients were r and omized to  fluvastatin or placebo after successful completion of a first percutaneous coronary intervention . Follow-up time was 3 to 4 years . The effect of baseline creatinine clearance on coronary atherosclerotic events ( cardiac death , nonfatal myocardial infa rct ion , and coronary re interventions not related to restenosis ) was evaluated . Baseline creatinine clearance ( logarithmic transformation ) was inversely associated with an incidence of adverse events among patients who received placebo ( hazard ratio 0.99 , 95 % confidence interval 0.982 to 0.998 , p = 0.01 ) . However , no association was noted between creatinine clearance and the incidence of adverse events among patients who received fluvastatin ( hazard ratio 1.0 , 95 % confidence interval 0.99 to 1.0 , p = 0.63 ) . No further deterioration in creatinine clearance was observed during follow-up , regardless of baseline renal function or allocated treatment . Occurrence of adverse events was not related to changes in renal function during follow-up . Fluvastatin therapy markedly decreased the risk of coronary atherosclerotic events after percutaneous intervention in patients who had lower values of creatinine clearance at baseline . The benefit of fluvastatin was unrelated to any effect on renal function BACKGROUND The effect of atorvastatin on kidney function was assessed in patients with stages 2 - 4 chronic kidney disease . METHODS We conducted a r and omised , double-blind , placebo-controlled trial in chronic kidney disease clinics in Northern Tasmania and enrolled 132 patients with serum creatinine levels > 120 μmol/l , not taking lipid-lowering therapy and at all levels of proteinuria and serum cholesterol . Patients were r and omly assigned to receive either 10 mg of atorvastatin/day ( 64 ) or placebo ( 68 ) and were followed with trial visits 3-monthly for a mean of 2.5 yrs . The primary outcome was the rate of both MDRD eGFR and Cockcroft-Gault creatinine clearance ( C-G CrCl ) decline . Analysis was based on intention to treat and included all patients that had at least one follow-up visit . RESULTS The rate of MDRD eGFR decline was 29 % lower ; 1.04 ± 3.84 vs. 1.47 ± 3.74 ml/min/1.73 m(2)/yr ( P=0.53 ) , and the C-G CrCl was 20 % lower ; 1.88 ± 5.07 vs. 2.36 ± 4.61 ml/min/1.73 m(2)/yr ( P=0.58 ) in atorvastatin-treated , compared with placebo-treated patients . Although blood pressure decreased in both atorvastatin and placebo-treated groups there were no differences between groups . In addition , there was no difference in concomitant medication intake including angiotensin converting enzyme inhibitors and angiotensin receptor blockers between groups . CONCLUSIONS There was a trend toward a slower eGFR decline in the atorvastatin-treated group that did not reach statistical significance . This may have been due to the lack of power of the study . However , atorvastatin may have a renoprotective effect in those patients with chronic kidney disease and cardiovascular disease . This needs to be assessed in further studies BACKGROUND Diabetic nephropathy is the single most common cause of chronic renal failure requiring dialysis . Effective treatment exists , but no clinical audit or large trial has reduced the rate of loss of renal function as effectively as in small groups of intensively managed patients . AIM To determine the effect of intensive vs. st and ard medical management on the rate of progression of renal failure in patients with diabetic nephropathy . DESIGN Prospect i ve r and omized controlled study . METHODS Patients with type 2 diabetes and nephropathy were r and omly allocated to an intensive group ( n = 47 ) or control group ( n = 43 ) . Treatment targets were the same for both groups , but the intensive group were seen as often as required to meet the targets ; controls were seen at their normal clinics . The primary end-point was the rate 
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Risks for mortality , end-stage renal disease , or other clinical outcomes did not significantly differ between strict and usual blood pressure control .
The strength of evidence was rated high for angiotensin II-receptor blockers and statins , moderate for angiotensin-converting enzyme inhibitors and β-blockers , and low for strict blood pressure control .
The role of CKD screening or monitoring in improving clinical outcomes is uncertain .
Evidence for CKD treatment benefit is strongest for angiotensin-converting enzyme inhibitors and angiotensin II-receptor blockers , and in patients with albuminuria combined with diabetes or cardiovascular disease .