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A prospective clinical trial of specialist renal nursing in the primary care setting to prevent progression of chronic kidney: a quality improvement report.

Walker RC, Marshall MR, Polaschek NR - BMC Fam Pract (2014)

Bottom Line: There was a small but significant decrease in eGFR and a reduction in 5 year absolute CV risk.Adherence to lifestyle advice improved with a significant reduction in prevalence of active smoking, although there was no significant change in BMI.Self-management significantly improved across all relevant domains.

View Article: PubMed Central - PubMed

Affiliation: Counties Manukau District Health Board, Auckland, New Zealand. mrmarsh@woosh.co.nz.

ABSTRACT

Background: Early detection and effective management of risk factors can potentially delay progression of chronic kidney disease (CKD) to end-stage kidney disease, and decrease mortality and morbidity from cardiovascular (CV) disease. We evaluated a specialist nurse-led intervention in the primary care setting to address accepted risk factors in a study sample of adults at 'high risk of CKD progression', defined as uncontrolled type II diabetes and/or hypertension and a history of poor clinic attendance.

Methods: The study was a non-controlled quality improvement study with pre- and post- intervention comparisons to test feasibility and potential effectiveness. Patients within two primary care practices were screened and recruited to the study. Fifty-two patients were enrolled, with 36 completing 12-months follow-up. The intervention involved a series of sessions led by the nephrology Nurse Practitioner with assistance from practice nurses. These sessions included assessment, education and planned medication and lifestyle changes. The primary outcome measured was proteinuria (ACR), and the secondary outcomes estimated glomerular filtration rate (eGFR) and 5-year absolute CV risk. Several 'intermediary' secondary outcomes were also measured including: blood pressure, serum total cholesterol, glycosylated haemoglobin (HbA1c), body mass index (BMI), prevalence of active smoking, a variety of self-management domains, and medication prescription. Analysis of data was performed using linear and logistic regression as appropriate.

Results: There was a significant improvement in ACR (average decrease of -6.75 mg/mmol per month) over the course of the study. There was a small but significant decrease in eGFR and a reduction in 5 year absolute CV risk. Blood pressure, serum total cholesterol, and HbA1c all decreased significantly. Adherence to lifestyle advice improved with a significant reduction in prevalence of active smoking, although there was no significant change in BMI. Self-management significantly improved across all relevant domains.

Conclusions: The results suggest that a collaborative model of care between specialist renal nurses and primary care clinicians may improve the management of risk factors for progression of CKD and CV death. Further larger, controlled studies are warranted to definitively determine the effectiveness and costs of this intervention.

Trial registration: Australian and New Zealand Clinical Trials Registry number: ACTRN12613000791730.

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Related in: MedlinePlus

Primary and secondary outcomes: albumin to creatinine ratio (mg/mmol), estimated GFR (mL/min/1.73 m2) and 5 year absolute cardiovascular risk (%) over the period of observation. Individual participant trajectories are illustrated in the overlaid line plots in the left panels, and the trajectory for the cohort in the boxplots in the right panels (the central line represents the median, the box the first and third quartile, and the whiskers 1.5 × the interquartile range).
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Fig2: Primary and secondary outcomes: albumin to creatinine ratio (mg/mmol), estimated GFR (mL/min/1.73 m2) and 5 year absolute cardiovascular risk (%) over the period of observation. Individual participant trajectories are illustrated in the overlaid line plots in the left panels, and the trajectory for the cohort in the boxplots in the right panels (the central line represents the median, the box the first and third quartile, and the whiskers 1.5 × the interquartile range).

Mentions: There was a significant change in the primary outcome, ACR, over the course of the study, amounting to an average decrease of −6.75 mg/mmol per month over the period of observation. There were also significant changes in the secondary outcomes. There was a significance decrease in estimated GFR of −0.3 mL/min/1.73 m2 per month, indicating that progression of CKD was still occurring within the study cohort amounting to a loss of 3–4 mL/min/1.73 m2 per annum. There was a significant decrease in the 5 year absolute cardiovascular risk by −0.2% per month. Changes in these primary and secondary outcomes are illustrated in Figure 2.Figure 2


A prospective clinical trial of specialist renal nursing in the primary care setting to prevent progression of chronic kidney: a quality improvement report.

Walker RC, Marshall MR, Polaschek NR - BMC Fam Pract (2014)

Primary and secondary outcomes: albumin to creatinine ratio (mg/mmol), estimated GFR (mL/min/1.73 m2) and 5 year absolute cardiovascular risk (%) over the period of observation. Individual participant trajectories are illustrated in the overlaid line plots in the left panels, and the trajectory for the cohort in the boxplots in the right panels (the central line represents the median, the box the first and third quartile, and the whiskers 1.5 × the interquartile range).
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4263018&req=5

Fig2: Primary and secondary outcomes: albumin to creatinine ratio (mg/mmol), estimated GFR (mL/min/1.73 m2) and 5 year absolute cardiovascular risk (%) over the period of observation. Individual participant trajectories are illustrated in the overlaid line plots in the left panels, and the trajectory for the cohort in the boxplots in the right panels (the central line represents the median, the box the first and third quartile, and the whiskers 1.5 × the interquartile range).
Mentions: There was a significant change in the primary outcome, ACR, over the course of the study, amounting to an average decrease of −6.75 mg/mmol per month over the period of observation. There were also significant changes in the secondary outcomes. There was a significance decrease in estimated GFR of −0.3 mL/min/1.73 m2 per month, indicating that progression of CKD was still occurring within the study cohort amounting to a loss of 3–4 mL/min/1.73 m2 per annum. There was a significant decrease in the 5 year absolute cardiovascular risk by −0.2% per month. Changes in these primary and secondary outcomes are illustrated in Figure 2.Figure 2

Bottom Line: There was a small but significant decrease in eGFR and a reduction in 5 year absolute CV risk.Adherence to lifestyle advice improved with a significant reduction in prevalence of active smoking, although there was no significant change in BMI.Self-management significantly improved across all relevant domains.

View Article: PubMed Central - PubMed

Affiliation: Counties Manukau District Health Board, Auckland, New Zealand. mrmarsh@woosh.co.nz.

ABSTRACT

Background: Early detection and effective management of risk factors can potentially delay progression of chronic kidney disease (CKD) to end-stage kidney disease, and decrease mortality and morbidity from cardiovascular (CV) disease. We evaluated a specialist nurse-led intervention in the primary care setting to address accepted risk factors in a study sample of adults at 'high risk of CKD progression', defined as uncontrolled type II diabetes and/or hypertension and a history of poor clinic attendance.

Methods: The study was a non-controlled quality improvement study with pre- and post- intervention comparisons to test feasibility and potential effectiveness. Patients within two primary care practices were screened and recruited to the study. Fifty-two patients were enrolled, with 36 completing 12-months follow-up. The intervention involved a series of sessions led by the nephrology Nurse Practitioner with assistance from practice nurses. These sessions included assessment, education and planned medication and lifestyle changes. The primary outcome measured was proteinuria (ACR), and the secondary outcomes estimated glomerular filtration rate (eGFR) and 5-year absolute CV risk. Several 'intermediary' secondary outcomes were also measured including: blood pressure, serum total cholesterol, glycosylated haemoglobin (HbA1c), body mass index (BMI), prevalence of active smoking, a variety of self-management domains, and medication prescription. Analysis of data was performed using linear and logistic regression as appropriate.

Results: There was a significant improvement in ACR (average decrease of -6.75 mg/mmol per month) over the course of the study. There was a small but significant decrease in eGFR and a reduction in 5 year absolute CV risk. Blood pressure, serum total cholesterol, and HbA1c all decreased significantly. Adherence to lifestyle advice improved with a significant reduction in prevalence of active smoking, although there was no significant change in BMI. Self-management significantly improved across all relevant domains.

Conclusions: The results suggest that a collaborative model of care between specialist renal nurses and primary care clinicians may improve the management of risk factors for progression of CKD and CV death. Further larger, controlled studies are warranted to definitively determine the effectiveness and costs of this intervention.

Trial registration: Australian and New Zealand Clinical Trials Registry number: ACTRN12613000791730.

Show MeSH
Related in: MedlinePlus