Supplementary Material for: 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

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.

背景：液体超负荷是慢性肾脏病（chronic kidney disease, CKD）的常见临床表现，与住院率升高及死亡风险增加相关。然而，通过早期识别轻度液体超负荷并及时启动恰当的药物治疗与液体限制，严重有症状的液体超负荷是可预防的。本研究实施并评估了一项由护士主导的门诊项目的结局，该项目将体阻抗分析（body impedance analysis, BIA）这一客观体液容量评估手段纳入慢性肾脏病合并液体超负荷患者的结构化患者教育与行动计划辅导流程。方法：本研究为单中心前瞻性前后对照研究，纳入2022年8月至2024年4月期间参与该项目的成年患者（详见表1）。患者入组标准为：无需透析的慢性肾脏病患者，且合并液体超负荷，和/或收缩压＞160 mmHg或舒张压＞100 mmHg。临床有效性结局指标包括液体超负荷的症状与体征，以及血压改善情况。患者报告的有效性结局指标包括采用《健康伙伴》（Partner in Health, PIH）问卷评估的慢性病自我管理能力，以及采用欧洲五维健康量表（EuroQOL-5 Dimension, EQ5D5L）调查评估的健康相关生活质量（health-related quality of life, HrQOL）。临床安全性结局指标包括低血压与肾功能恶化。结果：共计107名患者被转诊至该护士主导的项目，其中96名完成首次就诊。患者中位年龄为68.5岁（四分位距IQR：60.2~77.3岁），估算肾小球滤过率（estimated glomerular filtration rate, eGFR）中位值为21.6（14.0~39.7）ml/min/1.73 m²。93.8%的受试者在首次就诊前1个月内出现液体超负荷症状。其中52名（54.2%）患者接受了体阻抗分析检测，中位体液超负荷量为2.4（1.3~3.6）升。分别有38名（39.6%）与28名（29.2%）患者完成了第二次与第三次就诊。项目结束时，与基线就诊时相比，患者的液体超负荷症状与体征有所减轻，收缩压得到改善[137（121~143）mmHg vs 151（132~166）mmHg，p=0.03]，自我管理能力也有所提升[PIH评分：96（89~104）vs 72（57~88），p=0.001]。EQ5D5L评分存在显著差异。随访期间无患者出现低血压（收缩压＜90 mmHg），肾功能亦无显著变化。结论：针对慢性肾脏病合并液体超负荷患者，将客观体液容量评估、结构化患者教育与行动计划辅导相结合的护士主导项目，可改善患者血压与自我管理能力。