Improving Late-Stage CKD Care

Advanced chronic kidney disease (CKD) planning to prep for renal replacement therapies, subsequent access planning, and preemptive transplant can be overwhelming. Data suggests that outcomes for patients with advanced CKD stages 4 to 5 in the United States are suboptimal.

In a recent AJKD article, Fishbane et al conducted a 2-arm randomized trial comparing augmented nurse care management (nurse care manager coordination aided by a disease-based informatics system) to a control group of usual care. The study showed a reduction in hospitalizations and improved ESRD preparation in the intervention arm.

Hitesh Shah (HS), one of the authors (and an AJKDBlog contributor), discusses the findings in this interview with Timothy Yau (AJKDBlog)AJKD’s Social Media Editor.

AJKDBlog: Can you tell us briefly about the control arm that received usual care? What are the standard tools utilized to educate patients about their advanced CKD?

HS: There were 65 patients with late-stage CKD who were assigned to the control arm, and they were well-matched to the intervention group with regards to baseline characteristics. While no other care management resources were provided to this group, no existing services were withheld from the usual nephrology care. Education for advanced CKD varies greatly between programs and institutions, but standard services such as dialysis modality and transplant education, access discussions, dietary counseling, and lifestyle modifications to address modifiable risk factors are provided to patients with late-stage CKD.

AJKDBlog: The Healthy Transitions in Late-Stage Kidney Disease program, developed in 2011, utilizes nurse care managers and an informatics system that helps guide care between nephrologist visits. How does this system interact with the patient to produce meaningful communication?

HS: Our augmented nurse care management program in late-stage CKD was designed to reduce hospitalizations and to enhance patient education and preparation for renal replacement treatment.

After the patient is enrolled in the program, the nurse care manager makes an initial visit to the patient’s home. In addition to meeting the patient and caregivers, the nurse manager also provides health-literate, patient-centered education on CKD. Discussion on various options for renal replacement treatment is also provided to all appropriate patients. While the initial home visit does not focus on immediate renal replacement therapy (RRT) decisions, this decision is considered an important critical step for participants of this program.

In addition, dietary education, medication reconciliation, and home safety assessment are key components of home visits. Dietary education is primarily focused on consistently maintaining low sodium intake and providing greater skill in reading food labels. A visit to the patient’s kitchen helps the nurse manager assess the types of food the patient has available and offers an opportunity for further discussion on nutrition. Medication reconciliation consists of a review of the patient’s medicine bottles to determine which agents are actually being taken. This information is reconciled to the medication list from the nephrology practice. Home safety is evaluated with a focus on factors that create risk for falls.

The patient is also provided with a weighing scale that has a large numeric readout, wide profile, and low height. The patient utilizes this scale to call in daily weights to an automated recording service. The daily weights become part of the informatics system that assesses weight changes to generate alerts.

The ultimate desired outcome of the home visit is to build a collaborative relationship with patients, which is followed by a goal-specific and patient-centered plan of care.

AJKDBlog: What are the primary results of your study? How long did you follow the 2 arms, and in what ways did the augmented nursing care improve patient outcomes?

HS: The primary outcome studied was the rate of hospitalization in both (intervention and control) groups. Several secondary outcomes were also studied. After randomization, patients remained in their assigned study group for 18 months. After 18 months, both groups received usual nephrology care. Patients continued to be followed for end-stage kidney disease related outcomes for an additional 6 months after the end of the randomization period.

Our findings show that there were significantly fewer hospitalizations in the intervention group. While there were several reasons for hospitalization in both groups, volume overload/congestive heart failure (CHF) remained the most frequent cause, and this was significantly reduced in the patients that received augmented nursing care. In the control group, 15 patients were hospitalized for volume overload/CHF, but in the intervention group, only 5 patients were hospitalized for volume overload/CHF.

Number of Hospitalizations by Causes. Table 4 from Fishbane et al, AJKD © National Kidney Foundation.

Secondary outcomes of the study included the percentage of peritoneal dialysis (PD) starts and the type of access present on hemodialysis (HD) initiation. Our study showed an increased number of PD starts in the intervention group. The percentage of patients initiating HD with a dialysis catheter alone was much higher in the control group (69%) than the intervention group (37%).

End-Stage Kidney Disease Preparation Outcomes. Table 5 from Fishbane et al, AJKD © National Kidney Foundation.

Another exploratory outcome, the percentage of patients receiving preemptive kidney transplantation, although higher in the intervention group, was not statistically significant compared to the control group.

One final observed benefit of this care management program was that a higher percentage (58%) of patients in the intervention group started their HD treatment in the outpatient dialysis facility compared to 23% in the control group.

Hence, a care management program in late-stage kidney disease such as ours had multiple benefits outside of hospitalizations alone.

AJKDBlog: Were the modalities of dialysis ultimately chosen between the 2 groups different?

HS: While the rate of RRT treatment initiation was similar in both (intervention and control) groups, an increased number of patients (7 of 30) in the intervention group were initiated on PD compared to 1 of 29 patients in the control group.

AJKDBlog: Are there barriers to implementing this model in other hospitals or institutions?

HS: While the financial costs associated with implementing this informatics-driven care management program can be considered a barrier, it is very important that late-stage kidney disease care be improved. Several factors such as poor patient education, fragmented patient care, inadequate communication among medical care providers, and delayed decision making have been implicated for suboptimal care in this patient population. If adequate financial compensation is made available, the care model can be implemented by most nephrology practices across the United States. Of note, the reduced number of hospitalizations and the increased number of PD starts as seen in our study could also lead to significant cost savings in this patient population.

AJKDBlog: Thank you for taking the time for this interview!


To view the Fishbane et al article abstract or full-text (subscription required), please visit

Title: Augmented Nurse Care Management in CKD Stages 4 to 5: A Randomized Trial
Authors: S. Fishbane, S. Agoritsas, A. Bellucci, C. Halinski, H.H. Shah, V. Sakhiya, and L. Balsam
DOI: 10.1053/j.ajkd.2017.02.366



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