None listed
Conditions
Brief summary
Chronic kidney disease (CKD) is an important global health issue, the leading causes being diabetes mellitus and hypertension. Early detection and effective management of risk factors have the potential to delay CKD progression to end stage kidney disease (ESKD), and decrease mortality and morbidity from cardiovascular (CV) disease. We will evaluated a nurse-led intervention utilizing specialist renal nursing in the primary care setting to reduce accepted risk factors for CKD progression and CV disease.
Interventions
The intervention involves a series of sessions in GP practices led by a nephrology Nurse Practitioner with the assistance of a practice nurse, to deliver medical care based on best practice guidelines through tailored education and the development of individualised care plans, and using self-management and patient-centered theory utilizing the Flinders Chronic Care model. Participants will be seen fortnightly for 30 minutes for 12 weeks by the NP and the practice nurse in an intense induction p
The intervention involves a series of sessions in GP practices led by a nephrology Nurse Practitioner with the assistance of a practice nurse, to deliver medical care based on best practice guidelines through tailored education and the development of individualised care plans, and using self-management and patient-centered theory utilizing the Flinders Chronic Care model. Participants will be seen fortnightly for 30 minutes for 12 weeks by the NP and the practice nurse in an intense induction phase, and then for 30 minutes monthly in a maintenance and monitoring phase to 12 months. A detailed patient education package was developed for the study and included information on diabetes and its complications, blood pressure management, lifestyle modifications, medication adherence, smoking cessation and dietary advice including low salt intake (dietary sodium intake less than 2.3 g/day). All patients were also given a booklet on self-management developed for the study where they could record all clinical results, self-care goals, individualised medication charts and other important information. Adherence to intervention will be monitored through self-reporting using self-management survey instruments, GP attendance records, and clinical and laboratory parameters. Outcomes will all be ascertained as 3 monthly repeated measures.
Sponsors
New Zealand Ministry of Health
Study design
Allocation
Non-randomised trial
Intervention model
Single group
Primary purpose
Treatment
Masking
Open (masking not used)
Eligibility
Sex/Gender
All
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
1. Age >= 18 years 2. Diagnosis of type 2 diabetes mellitus 3. Diagnosis of hypertension 3. Proteinuria defined as an albumin to creatinine ratio (ACR) > 30 mg/mmol on at least three occasions separated by at least 1 week 4. At ‘high risk of CKD progression’ as defined by a) at least 12 months of uncontrolled diabetes, defined as HbA1c consistently >8%, AND/OR b) at least 12 months of uncontrolled hypertension, defined as BP consistently >140/90 mmHg, AND c) a history of poor attendance and engagement with their GP (history of unplanned non-attendance of 25% or more of scheduled appointments over the course of 12 months).
Exclusion criteria
1. CKD due to renal parenchymal disease other than diabetic nephropathy 2. Unsuitable for the intervention in the view of their treating GP 3. Unwilling or unable to provide consent
Outcome results
None listed