***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: Background —Microalbuminuria is associated with increased risk of cardiovascular events . We assessed whether therapeutic intervention aim ed at lowering urinary albumin excretion would reduce cardiovascular events in microalbuminuric subjects ( 15 to 300 mg/24 hours ) . Methods and Results —From the Prevention of Renal and Vascular Endstage Disease ( PREVEND ) cohort ( n=8592 ) , 1439 subjects fulfilled the inclusion criteria of the PREVEND Intervention Trial ( PREVEND IT ) . Of these subjects , 864 were r and omized to fosinopril 20 mg or matching placebo and to pravastatin 40 mg or matching placebo . The mean follow-up was 46 months , and the primary end point was cardiovascular mortality and hospitalization for cardiovascular morbidity . Mean age was 51±12 years ; 65 % of subjects were male , and 3.4 % had a previous cardiovascular event . Mean cholesterol level was 5.8±1.0 mmol/L , mean systolic/diastolic blood pressure was 130±18/76±10 mm Hg , and median urinary albumin excretion was 22.8 ( 15.8 to 41.3 ) mg/24 hours . The primary end point occurred in 45 subjects ( 5.2 % ) . Fosinopril  reduced urinary albumin excretion by 26 % ( P<0.001 ) . Subjects treated with fosinopril showed a 40 % lower incidence of the primary end point ( hazard ratio 0.60 [ 95 % CI 0.33 to 1.10 ] , P=0.098 , log-rank ) . Pravastatin did not reduce urinary albumin excretion , and subjects treated with pravastatin showed a 13 % lower incidence of the primary end point than subjects in the placebo group ( 0.87 [ 0.49 to 1.57 ] , P=0.649 , log-rank ) . Conclusions —In microalbuminuric subjects , treatment with fosinopril had a significant effect on urinary albumin excretion . In addition , fosinopril treatment was associated with a trend in reducing cardiovascular events  . Treatment with pravastatin did not result in a significant reduction in urinary albumin excretion or cardiovascular events OBJECTIVES Chronic kidney disease is , increasingly , both a contributor to premature deaths and a financial burden to the health system , and is estimated to affect between 10 % and 15 % of the adult population in Western countries . Hypertension and , in particular diabetes , are significant contributors to the global burden of chronic kidney disease . Although it might increase costs , screening for , and improved management of , persons at increased risk of progressive kidney disease could improve health outcomes . We therefore sought to estimate the costs and health outcomes of alternative strategies to prevent end-stage kidney disease , compared with usual care . METHODS A Markov model comparing : 1 ) intensive management versus usual care for patients with suboptimally managed diabetes and hypertension ; and 2 ) screening for and intensive treatment of diabetes , hypertension , and proteinuria versus usual care was developed . Intervention effectiveness was based on published meta-analyses and r and omized controlled trial data ; costs were measured from a central health-care funder perspective in 2008 Australian dollars ( $ A ) , and outcomes were reported in quality -adjusted life-years ( QALYs ) . RESULTS Intensive treatment of inadequately controlled diabetes was both less costly ( an average lifetime saving of $ A133 ) and more effective ( with an additional 0.075 QALYs per patients ) than conventional management . Intensive management of hypertension had an incremental cost-effectiveness ratio ( ICER ) $ A2588 per QALY gained . Treating all known diabetics with angiotensin-converting enzyme ( ACE ) inhibitors was both less costly ( an average lifetime saving of $ A825 per patient ) and more effective than current treatment ( result ing in 0.124 additional QALYs per patient ) . Primary care screening for 50- to 69-year-olds plus intensive treatment of diabetes had an ICER of $ A13,781 per QALY gained . Primary care screening for hypertension ( between ages 50 and 69 years ) plus intensive blood pressure management had an ICER of $ A491 per QALY gained . Primary care screening for proteinuria ( between ages 50 and 69 years ) combined with prescription of an ACE inhibitor for all persons showing proteinuria and all known diabetics had an ICER of $ A4793 per QALY gained . CONCLUSIONS Strategies combining primary care screening of 50- to 69-year-olds for proteinuria , diabetes , and hypertension followed by the routine use of ACE inhibitors , and optimal treatment of diabetes and hypertension , respectively , have the potential to reduce death and end-stage kidney disease and are likely to represent good value for money CONTEXT A triple-marker approach for chronic kidney disease ( CKD ) evaluation has not been well studied . OBJECTIVE To evaluate whether combining creatinine , cystatin C , and urine albumin-to-creatinine ratio ( ACR ) would improve identification of risks associated with CKD compared with creatinine alone . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve cohort study involving 26,643 US adults enrolled in the Reasons for Geographic and Racial Differences in Stroke ( REGARDS ) study from January 2003 to June 2010 . Participants were categorized into 8 groups defined by estimated glomerular filtration rate ( GFR ) determined by creatinine and by cystatin C of either < 60 or ≥60 mL/min/1.73 m(2 ) and ACR of either < 30 or ≥30 mg/g . MAIN OUTCOME MEASURES All-cause mortality and incident end-stage renal disease with median follow-up of 4.6 years . RESULTS Participants had a mean age of 65 years , 40 % were black , and 54 % were women . Of 26,643 participants , 1940 died and 177 developed end-stage renal disease  . Among participants without CKD defined by creatinine , 24 % did not have CKD by either ACR or cystatin C. Compared with those with CKD defined by creatinine alone , the hazard ratio for death in multivariable-adjusted models was 3.3 ( 95 % confidence interval [ CI ] , 2.0 - 5.6 ) for participants with CKD defined by creatinine and ACR ; 3.2 ( 95 % CI , 2.2 - 4.7 ) for those with CKD defined by creatinine and cystatin C , and 5.6 ( 95 % CI , 3.9 - 8.2 ) for those with CKD defined by all biomarkers . Among participants without CKD defined by creatinine , 3863 ( 16 % ) had CKD detected by ACR or cystatin C. Compared with participants who did not have CKD by any measure , the HRs for mortality were 1.7 ( 95 % CI , 1.4 - 1.9 ) for participants with CKD defined by ACR alone , 2.2 ( 95 % CI , 1.9 - 2.7 ) for participants with CKD defined by cystatin C alone , and 3.0 ( 95 % CI , 2.4 - 3.7 ) for participants with CKD defined by both measures . Risk of incident end-stage renal disease was higher among those with CKD defined by all markers ( 34.1 per 1000 person-years ; 95 % CI , 28.7 - 40.5 vs 0.33 per 1000 person-years ; 95 % CI , 0.05 - 2.3 ) for those with CKD defined by creatinine alone . The second highest end-stage renal disease rate was among persons missed by the creatinine measure but detected by both ACR and cystatin C ( rate per 1000 person-years , 6.4 ; 95 % CI , 3.6 - 11.3 ) . Net reclassification improvement for death was 13.3 % ( P < .001 ) and for end-stage renal disease was 6.4 % ( P < .001 ) after adding estimated GFR cystatin C in fully adjusted models with estimated GFR creatinine and ACR . CONCLUSION Adding cystatin C to the combination of creatinine and ACR measures improved the predictive accuracy for all-cause mortality and end-stage renal disease BACKGROUND AND OBJECTIVES CKD is common among older patients . This article assesses long-term renal and cardiovascular outcomes in older high-risk hypertensive patients , stratified by baseline estimated GFR ( eGFR ) , and long-term outcome efficacy of 5-year first-step treatment with amlodipine or lisinopril , each compared with chlorthalidone . DESIGN , SETTING , PARTICIPANTS , & MEASUREMENTS This was a long-term post-trial follow-up of hypertensive participants ( n=31,350 ) , aged ≥55 years , r and omized to receive chlorthalidone , amlodipine , or lisinopril for 4 - 8 years at 593 centers . Participants were stratified by baseline eGFR ( ml/min per 1.73 m(2 ) ) as follows : normal/increased ( ≥90 ; n=8027 ) , mild reduction ( 60 - 89 ; n=17,778 ) , and moderate/severe reduction ( < 60 ; n=5545 ) . Outcomes were cardiovascular mortality ( primary outcome ) , total mortality , coronary heart disease , cardiovascular disease , stroke , heart failure , and ESRD . RESULTS After an average 8.8-year follow-up , total mortality was significantly higher in participants with moderate/severe eGFR reduction compared with those with normal and mildly reduced eGFR ( P<0.001 ) . In participants with an eGFR < 60 , there was no significant difference in cardiovascular mortality  between chlorthalidone and amlodipine ( P=0.64 ) , or chlorthalidone and lisinopril ( P=0.56 ) . Likewise , no significant differences were observed for total mortality , coronary heart disease , cardiovascular disease , stroke , or ESRD . CONCLUSIONS CKD is associated with significantly higher long-term risk of cardiovascular events and mortality in older hypertensive patients . By eGFR stratum , 5-year treatment with amlodipine or lisinopril was not superior to chlorthalidone in preventing cardiovascular events , mortality , or ESRD during 9-year follow-up . Because data on proteinuria were not available , these findings may not be extrapolated to proteinuric CKD The incidence of ESRD is increasing dramatically . Progression to end-stage may be halted or slowed when kidney damage is detected at an early stage . Kidney damage is frequently asymptomatic but is indicated by the presence of proteinuria , hematuria , or reduced GFR . Population -based studies relating to the prevalence of kidney damage in the community are limited , particularly outside of the United States . Therefore , the prevalence of proteinuria , hematuria , and reduced GFR in the Australian adult population was determined using a cross-sectional study of 11,247 noninstitutionalized Australians aged 25 yr or over , r and omly selected using a stratified , cluster method . Subjects were interviewed and tested for  proteinuria-spot urine protein  to  creatinine ratio  ( abnormal : > /=0.20 mg/mg ) ; hematuria-spot urine dipstick ( abnormal : 1 + or greater ) confirmed by urine microscopy ( abnormal : > 10,000 red blood cells per milliliter ) or dipstick ( abnormal : 1 + or greater ) on midstream urine sample ; and reduced GFR-Cockcroft-Gault estimated GFR ( abnormal : < 60 ml/min per 1.73 m(2 ) ) . The associations between age , gender , diabetes mellitus , and hypertension , and indicators of kidney damage were examined . Proteinuria was detected in 2.4 % of cases ( 95 % CI : 1.6 % , 3.1 % ) , hematuria in 4.6 % ( 95 % CI : 3.8 % , 5.4 % ) , and reduced GFR in 11.2 % ( 95 % CI : 8.6 % , 13.8 % ) . Approximately 16 % had at least one indicator of kidney damage . Age , diabetes mellitus , and hypertension were independently associated with proteinuria ; age , gender , and hypertension with hematuria ; and age , gender , and hypertension with reduced GFR . Approximately 16 % of the Australian adult population has either proteinuria , hematuria , and /or reduced GFR , indicating the presence of kidney damage . Identifying and targeting this section of the population may provide a means to reduce the burden of ESRD BACKGROUND Microalbuminuria is a common diagnosis in the clinical care of patients with type 1 diabetes mellitus . Long-term outcomes after the development of microalbuminuria are variable . METHODS We quantified the incidence of and risk factors for long-term renal outcomes after the development of microalbuminuria in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications ( DCCT/EDIC ) 
    Output:
    
The incidence of CKD , rate of progression , and effectiveness of drug therapy were major drivers of cost-effectiveness .
Performance of a quantitative meta- analysis on influential assumptions was not conducted because of few available studies and heterogeneity in model design s. CONCLUSIONS Screening for CKD is suggested to be cost-effective in patients with diabetes and hypertension .
CKD screening may be cost-effective in population s with higher incidences of CKD , rapid rates of progression , and more effective drug therapy