Implementing the Nurse-led Optimization of Volume and blood pressure - Enabling at multi-Levels using TechnologY (NOVELTY) program for Chronic Kidney Disease: a prospective cohort study.

Abstract

Background: Fluid overload is a common manifestation of chronic kidney disease (CKD) and is associated with increased hospitalizations and death. However, severe symptomatic fluid overload is potentially preventable with early recognition of mild fluid overload and timely institution of appropriate pharmacotherapy and fluid restriction. We implemented and evaluated the outcomes of a nurse-led clinic that incorporated objective fluid volume assessment using body impedance analysis (BIA) into structured patient education and action plan coaching to patients with CKD and fluid overload.

Methods: Single-center prospective pre- post implementation study of adults who participated in the program (Table 1) between August 2022 and April 2024. Patients were eligible if they had CKD not requiring dialysis and had fluid overload and/or systolic blood pressure (BP) >160 mmHg or diastolic BP >100 mmHg. The clinical effectiveness outcomes were symptoms and signs of fluid overload and improvement in blood pressure. The patient-reported effectiveness outcomes were chronic disease self-management assessed using the Partner in Health (PIH) questionnaire and health-related quality of life (HrQOL) assessed by the EuroQOL-5 Dimension (EQ5D5L) survey. The clinical safety outcomes were hypotension and worsening kidney function.

Results: Among 107 patients referred to the nurse-led program, 96 attended the first visit. median age was 68.5 (IQR 60.2, 77.3) years and eGFR was 21.6 (14.0, 39.7) ml/min/1.73 m2. Almost all participants (93.8%) had symptoms of fluid overload within the past 1 month before the first review. BIA was performed for 52 (54.2%) patients and the median overhydration was 2.4 (1.3, 3.6) liters. The second and third visits were attended by 38 (39.6%) and 28 (29.2%) patients, respectively. At program completion, patients had reduced symptoms and signs of fluid overload and had improved systolic BP [137 (121, 143) versus 151 (132, 166) mmHg, p=0.03] and self-management [PIH score 96 (89, 104) versus 72 (57, 88), p=0.001] compared to their baseline visit. EQ5D5L scores were significantly different. None experienced hypotension (systolic BP <90 mmHg) and kidney function did not change significantly during follow-up.

Conclusions: A nurse-led program that incorporated objective fluid volume assessment, structured patient education and action plan coaching for patients with CKD and fluid overload improved BP and self-management.