***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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    ***EXAMPLES*** 
    Input: Treatment goals for patients with CKD are often unrealized for many reasons , but support by nurse practitioners may improve risk factor levels in these patients . Here , we analyzed renal endpoints of the Multifactorial Approach and Superior Treatment Efficacy in Renal Patients with the Aid of Nurse Practitioners ( MASTERPLAN ) study after extended follow-up to determine whether strict implementation of current CKD guidelines through the aid of nurse practitioners improves renal outcome . In total , 788 patients with moderate to severe CKD were r and omized to receive nurse practitioner support added to physician care ( intervention group ) or physician care alone ( control group ) . Median follow-up was 5.7 years . Renal outcome was a secondary endpoint of the MASTERPLAN study . We used a composite renal endpoint of death , ESRD , and 50 % increase in serum creatinine . Event rates were compared with adjustment for baseline serum creatinine concentration and changes in estimated GFR were determined . During the r and omized phase , there were small but significant differences between the groups in BP , proteinuria , LDL cholesterol , and use of aspirin , statins , active vitamin D , and antihypertensive medications  , in favor of the intervention group . The intervention reduced the incidence of the composite renal endpoint by 20 % ( hazard ratio , 0.80 ; 95 % confidence interval , 0.66 to 0.98 ; P=0.03 ) . In the intervention group , the decrease in estimated GFR was 0.45 ml/min per 1.73 m(2 ) per year less than in the control group ( P=0.01 ) . In conclusion , additional support by nurse practitioners attenuated the decline of kidney function and improved renal outcome in patients with CKD 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 The multidisciplinary pre-dialysis education ( MPE ) retards renal progression , reduce incidence of dialysis and mortality of CKD patients . However , the financial benefit of this intervention on patients starting hemodialysis has not yet been evaluated in prospect i ve and r and omized trial . Methods We studied the medical expenditure and utilization incurred in the first 6 months of dialysis initiation in 425 incident hemodialysis patients who were r and omized into MPE and non-MPE groups before reaching end-stage renal disease . The content of the MPE was st and ardized in accordance with the National Kidney Foundation Dialysis Outcomes Quality Initiative guidelines . Results The mean age of study patients was 63.8±13.2 years , and 221 ( 49.7 % ) of them were men .  The mean serum creatinine level and estimated glomerular filtration rate was 6.1±4.0 mg/dL and 7.6±2.9 mL⋅min−1⋅1.73 m−2 , respectively , at dialysis initiation . MPE patients tended to have lower total medical cost in the first 6 months after hemodialysis initiation ( 9147.6±0.1 USD/patient vs. 11190.6±0.1 USD/patient , p = 0.003 ) , fewer in numbers [ 0 ( 1 ) vs. 1 ( 2 ) , p<0.001 ] and length of hospitalization [ 0 ( 15 ) vs. 8 ( 27 ) days , p<0.001 ] , and also lower inpatient cost [ 0 ( 2617.4 ) vs. 1559,4 ( 5019.6 ) USD/patient , p<0.001 ] than non-MPE patients , principally owing to reduced cardiovascular hospitalization and vascular access – related surgeries . The decreased inpatient and total medical cost associated with MPE were independent of patients ' demographic characteristics , concomitant disease , baseline biochemistry and use of double-lumen catheter at initiation of hemodialysis . Conclusions Participation of multidisciplinary education in pre-dialysis period was independently associated with reduction in the inpatient and total medical expenditures of the first 6 months post-dialysis owing to decreased inpatient service utilization secondary to cardiovascular causes and vascular access – related surgeries . Trial Registration Clinical Trials.gov Background . A well-functioning vascular access ( VA ) is essential to efficient dialysis therapy . Guidelines have been implemented improving care , yet access use varies widely across countries and VA complications remain a problem . This study took advantage of the unique opportunity to utilize data from the Dialysis Outcomes and Practice Patterns Study ( DOPPS ) to examine international trends in VA use and trends in patient characteristics and practice s associated with VA use from 1996 to 2007 . DOPPS is a prospect i ve , observational study of  haemodialysis ( HD )  practice s and patient outcomes at > 300 HD units from 12 countries and has collected data thus far from > 35 000 r and omly selected patients . Methods .  VA data were collected for each patient at study entry ( 1996–2007 ) . Practice pattern data from the facility medical director , nurse manager and VA surgeon were also analysed . Results . Since 2005 , a native arteriovenous fistula ( AVF ) was used by 67–91 % of prevalent patients in Japan , Italy , Germany , France , Spain , the UK , Australia and New Zeal and , and 50–59 % in Belgium , Sweden and Canada . From 1996 to 2007 , AVF use rose from 24 % to 47 % in the USA but declined in Italy , Germany and Spain . Moreover , graft use fell by 50 % in the USA from 58 % use in 1996 to 28 % by 2007 . Across three phases of data collection , patients consistently were less likely to use an AVF versus other VA types if female , of older age , having greater body mass index , diabetes , peripheral vascular disease or recurrent cellulitis/gangrene . In addition , countries with a greater prevalence of diabetes in HD patients had a significantly lower percentage of patients using an AVF . Despite poorer outcomes for central vein catheters , catheter use rose 1.5- to 3-fold among prevalent patients in many countries from 1996 to 2007 , even among non-diabetic patients 18–70 years old . Furthermore , 58–73 % of patients new to end-stage renal disease ( ESRD )  used a catheter  for the initiation of HD in five countries despite 60–79 % of patients having been seen by a nephrologist > 4 months prior to ESRD . Patients were significantly ( P < 0.05 ) less likely to start dialysis with a permanent VA if treated in a faciity that ( 1 ) had a longer time from referral to access surgery evaluation or from evaluation to access creation and ( 2 ) had longer time from access creation until first AVF cannulation . The median time from referral until access creation varied from 5–6 days in Italy , Japan and Germany to 40–43 days in the UK and Canada . Compared to patients using an AVF , patients with a catheter displayed significantly lower mean Kt/V levels . Conclusions . Most countries meet the contemporary National Kidney Foundation 's Kidney Disease Outcomes Quality Initiative goal for AVF use ; however , there is still a wide variation in VA preference . Delays between the creation and cannulation must be improved to enhance the chances of a future permanent VA . Native arteriovenous fistula is the VA of choice ensuring dialysis adequacy and better patient outcomes . Graft is , however , a better alternative than catheter for patients where the creation of an attempted AVF failed or could not be created for different reasons A 1993 National Institutes of Health Consensus statement stressed the importance of early medical intervention in predialysis population s. Given the need for evidence -based practice , we report the outcomes of  predialysis programs in two major Canadian cities . The purpose of this report was to determine whether the institution of a multidisciplinary predialysis program is of benefit to patients , and to analyze those factors that are important in actualizing those benefits . Data from two different studies is presented : ( 1 ) a prospect i ve , nonr and omized cohort study comparing patients who were or were not exposed to an ongoing multidisciplinary predialysis team ( St Paul 's Hospital ) and ( 2 ) a retrospective review of outcomes before and after the institution of a predialysis program  ( The Toronto Hospital ) . Although created independently in major academic centers in Canada , the programs both aim ed to reduce urgent dialysis starts , improve preparedness for dialysis , and improve re source utilization . The Vancouver study was able to demonstrate significantly fewer urgent dialysis starts ( 13 % v 35 % ; P < 0.05 ) , more outpatient training ( 76 % v 43 % ; P < 0.05 ) , and less hospital days in the first month of dialysis ( 6.5 days v 13.5 days ; P < 0.05 ) . Cost savings of the program patients in 1993 are conservatively estimated to be $ 173,000 ( Canadian dollars ) or over $ 4,000 per patient . The Toronto study demonstrated success in predialysis access creation ( 86.3 % of patients ) , but could not realize any benefit in terms of elective dialysis initiation due to well-documented hemodialysis re source constraints . We conclude that an approach to predialysis patients involving a multidisciplinary team can have a positive impact on quantitative outcomes , but essential elements for success include ( 1 ) early referral to a nephrology center , ( 2 ) adequate re sources for dedicated predialysis program staff and infrastructure , and ( 3 ) available re sources for patients with end-stage renal disease ( ESRD ) ( dialysis stations ) . In times of economic constraints , objective data are necessary to justify re source 
    Output:
    
Compared with the non-MDC group , MDC was associated with a lower risk of all-cause mortality and lower hospitalization rates for patients with CKD .
In addition , MDC also result ed in a slower eGFR decline and reduced temporary catheterization for patients receiving dialysis .
However , according to the subgroup analysis , the lower rates of all-cause mortality in the MDC group were observed only in patients in stage 4–5 and when the staff of the MDC consisted of nephrologists , nurse specialists and professionals from other fields .
The most prominent effect of reducing the hospitalization rates was also observed in patients with stage 4–5 but not in patients with stage 4–5 CKD .
Conclusions MDC can lower the all-cause mortality of patients with CKD , reduce temporary catheterization for patients receiving dialysis , decrease the hospitalization rate , and slow the eGFR decline .
Moreover , the reduction in all-cause mortality crucially depends on the professionals comprising the MDC staff and the stage of CKD in patients .
In addition , the CKD stage influences the hospitalization rates