title: A prospective clinical trial of specialist renal nursing in the primary care setting to prevent progression of chronic kidney: a quality improvement report.
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.
  
  
  BACKGROUND
  Australian and New Zealand Clinical Trials Registry number: ACTRN12613000791730.
authors.forename: Rachael C
authors.initials: RC
authors.lastname: Walker
authors.affiliation: Counties Manukau District Health Board, Auckland, New Zealand. mrmarsh@woosh.co.nz.
authors.forename: Mark R
authors.initials: MR
authors.lastname: Marshall
authors.forename: Nick R
authors.initials: NR
authors.lastname: Polaschek
mesh_terms: D000419:Albuminuria / Q000378:metabolism*; D001794:Blood Pressure; D015992:Body Mass Index; D002784:Cholesterol / Q000097:blood; D003924:Diabetes Mellitus, Type 2 / Q000150:complications / Q000378:metabolism / Q000451:nursing*; D018450:Disease Progression; D005260:Female; D005919:Glomerular Filtration Rate; D006442:Glycated Hemoglobin; D006801:Humans; D008297:Male; D008875:Middle Aged; D064647:Nephrology Nursing / Q000379:methods*; D009520:New Zealand; D010353:Patient Education as Topic / Q000379:methods; D057184:Practice Patterns, Nurses'; D011320:Primary Health Care / Q000379:methods*; D011446:Prospective Studies; D011507:Proteinuria / Q000378:metabolism; D058996:Quality Improvement; D051436:Renal Insufficiency, Chronic / Q000150:complications / Q000378:metabolism / Q000451:nursing*; D040242:Risk Reduction Behavior; D055502:Secondary Prevention / Q000379:methods; D012648:Self Care; D012907:Smoking / Q000453:epidemiology / Q000628:therapy
chemical_list: D002784:Cholesterol; D006442:Glycated Hemoglobin; C517652:hemoglobin A1c protein, human