The impact of nurse-led care in chronic kidney disease management: a systematic review and meta-analysis

Chronic Kidney Disease (CKD), one of the leading health issues throughout the world, affects more than 10% of the global population[1]. CKD is diagnosed when a patient’s estimated glomerular filtration rate (eGFR) falls below 60 ml/min per 1.73 square meters for at least 3 months [2]. The increasing prevalence of risk factors [3], has led to a corresponding rise in CKD prevalence and morbidity, contributing to higher mortality rates globally [4]. From 1990 to 2017, the global mortality rate increased by 41.5% [5]. CKD is one of the very few non-communicable diseases leading to death, and it is expected that it will be the fifth-highest cause of mortality in the world by 2040 [6]. This growing burden highlights the urgent need for effective and accessible management strategies. Nurse-led care has emerged as a promising approach to address the clinical and psychosocial challenges faced by CKD patients, particularly in improving quality of life, symptom management, and patient outcomes.

Prompt diagnosis and effective management are critical for CKD patients. However, CKD is often diagnosed in later stages [7], leaving patients with limited treatment options. Renal Replacement Therapy (RRT) including hemodialysis (HD), peritoneal dialysis (PD), and renal transplant, becomes the primary management approach. Unfortunately, RRT is not a definitive cure and comes with somatic symptoms and complications [8]. The patient's quality of life is severely impacted, leading to depression, anxiety, stress, and cognitive issues [9].

Damage to kidneys in CKD is irreversible so the ultimate goal is to delay the progression and compensate for the loss via medication, dialysis, or transplant. As nurses work closely with patients, studies prove that they are effective in raising awareness among patients regarding their disease status and possible complications if left unmanaged [10]. Moreover, nurses can also provide individualized patient care and psychosocial support that can improve cognitive behavior and quality of life in such patients [11]. The trial led by Wong et al. [12] in 2010, demonstrated that nurse-led care shows improvement in diet and fluid restriction, patient satisfaction, symptom control, complication control, and quality of life. However, the study didn’t conclusively determine its impact on health service utilization. Subsequent studies in 2014 [13] and 2015 [14] confirmed these findings but shared the limitation of being solely conducted in China, raising concerns about the generalizability of the results to more diverse populations. Additionally, Barret et al. [15] conducted a trial focusing on specific treatment goals like HbA1c control in diabetics, serum bicarbonate management in acidosis, serum LDL levels, vitamin D control, and the use of antiplatelet therapy. These findings indicated no significant differences between the nurse-led and standard care groups, with some other studies even highlighting potential risks to patient safety and cardiac health [16]. Moreover, a meta-analysis was conducted by Chen et el., 2016 [17] that included 8 studies and reported outcomes like symptoms, sleep, pain, staff encouragement, general health, energy/fatigue, and overall health. It concluded nurse-led care to be beneficial in improving certain domains of quality of life (like symptoms, sleep, staff encouragement, and energy/fatigue) but it didn’t take into account the loss of follow-up and mistakenly considered sample size of [13] to be 80 instead of 69 and 66 in the intervention and control groups respectively. This inconsistency in outcomes and serious mistakes in existing literature necessitates the need for further research to establish the true efficacy of nurse-led care in CKD management.

This systematic review and meta-analysis aims to compare the effects of nurse-led care with routine care to provide a foundation for implementing nurse-led care models in the management of patients with CKD. By critically evaluating existing evidence, we seek to determine whether nurse-led care is genuinely helpful in improving CKD management or merely an unproven concept awaiting validation.

The characteristics of the included studies are available in Table 1, and the baseline characteristics of the individuals included in these studies are available in Table 2. The following outcomes were analyzed.

This study specifically explores the effectiveness of nurse-led care in managing chronic kidney disease (CKD), focusing not only on the clinical outcomes but also on the broader impact on patients’ physical, social, and mental well-being, their coping strategies, and overall quality of life. Our investigation seeks to delve into several key inquiries. We aim to ascertain the extent to which nurse-led care interventions influence the progression of CKD and contribute to achieving desirable clinical outcomes, including physical and mental well-being.

Our analysis revealed that, although no significant improvements were observed in certain components of quality of life (such as work status, cognitive function, social interactions, sexual function, patient satisfaction, general health problems, and burden of kidney disease), nurse-led care interventions resulted in notable improvements in symptoms and issues directly associated with kidney disease. These findings are consistent with those of Chen et al., 2016 [17], who reported similar results in a smaller sample of three RCTs. Our study extends this evidence by incorporating additional trials, such as those by Halloran et al., 2020 [31] and Tao et al., 2015 [14], further supporting the positive impact of nurse-led care on managing CKD symptoms.

There was a consistent positive correlation observed between nurse-led care and improved sleep among CKD patients (Fig. 7). The systematic review by Chen et al., 2016 [17] reported a similar outcome, though it didn’t incorporate the findings from Tsai et al., 2015 [22] as this RCT was published after their review. This highlights the ongoing relevance of new studies and suggests that including more recent data could further strengthen the understanding of nurse-led care’s impact on sleep. All four studies included in this meta-analysis unanimously proved the efficacy of nurse-led interventions in addressing sleep disturbances commonly experienced by CKD patients. It’s also important to note that the effects of interventions increased over time. The most recent study by Hu et al., 2022 [34] also supported these findings; however, it was later retracted and therefore not included in this meta-analysis. Sleep quality is a critical aspect of overall health and well-being, with improvements in this area potentially leading to significant implications for patient outcomes, including enhanced quality of life and better disease management.

This meta-analysis did not reveal any statistically significant improvement in physical functioning and role-physical by nurse-led care administration (Figs. 8 and 9). These findings suggest that while nurse-led interventions may play a crucial role in addressing certain aspects of CKD management, they may not have a substantial impact on improving physical role functioning or overall physical functioning in CKD patients. An RCT by Hu et al., 2022 [34] reported a significant improvement in physical functioning after the nurse-led care intervention in the experimental group but its retraction leaves the results questionable and opens the room for further exploration.

No statistically significant correlation could be noted between nurse-led care administration and emotional well-being (Fig. 10) or satisfaction levels (Fig. 12) among CKD patients. However, statistically significant reductions in Self-Rating Anxiety (SAS) and Self-Rating Depression (SDS) scores were reported by Hu et al., 2022 [34] and Chen et al., 2022 [35] after the administration of nurse-led psychological care. Despite these studies initially demonstrating substantial improvements in the psychological well-being of CKD patients, their subsequent retraction has invalidated these findings. Further research is necessary to comprehensively investigate the impact of nurse-led interventions on psychological and emotional well-being among CKD patients.

Significant improvements in energy levels/fatigue, and overall health outcomes were observed (Figs. 11 and 13), as reported earlier by Chen et al., 2016 [17] as well. However, Chen et al., 2016 [17] did not take into account the loss to follow-up in Li et al., 2014 [13] and mistakenly considered the sample size to be 80 instead of 69 and 66 in intervention and control groups respectively. This highlights the potential of nurse-led care models to positively impact the holistic health of CKD patients by providing comprehensive care, lifestyle modifications, and patient education.

Although the results indicate nurse-led intervention practices to be effective in improving quality of life, different studies reported it to negatively impact kidney function. According to Haan et al., 2013 [32] and Nguyens et al., 2019 [27], standardized nephrologist-led care is more impactful than nurse-led care in lowering BP among CKD patients. These studies provided a follow-up of 1 year and 16 weeks respectively but Major et al., 2019 [23] followed patients for 42 months and reported the opposite. It is not clear that the problem lies in the intervention, or the follow-up period was not adequate to draw a significant conclusion. Further investigation is necessary to clarify these inconsistencies and determine the most effective approach for managing CKD patients.

This study represents a significant breakthrough in uncovering a previously unexplored outcome: depression. The research consistently observed a notable decrease in depression scores among patients under nurse-led care (Fig. 15). However, the effectiveness varied across different measurement scales used in the studies. For instance, Lii et al., 2007 [33]; and Tsai et al., 2015 [22] utilized Beck’s Depression Inventory (BDI and BDI-II), and showed a non-significant improvement in depression by the intervention of nurse-led care. In contrast, studies by Kauric-Klein et al., 2007 [19] and Weisbord et al., 2013 [21] used the Patient Health Questionnaire (PHQ-9) and they concluded no significant association. Halloran et al., 2020 [31] found no significant difference between both groups using Clinical Outcomes in Routine Evaluation (CORE-34), while Jahromi et al., 2016 [25] concluded an extreme level of statistically significant improvement in depression by the nurse-led care intervention. The inconsistency among assessment tools highlights the intricacy of evaluating depression and indicates a need for a more uniform methodology.

Notwithstanding these discrepancies, it's crucial to examine why interventions led by nurses may have such beneficial effects on mental well-being. Care provided by nurses typically encompasses a comprehensive strategy, not only managing the physical aspects of long-term illnesses but also offering emotional backing, instruction, and empowerment, which are vital in addressing depression. The regular patient interactions and personalized care in nurse-directed models may cultivate a therapeutic bond that motivates patients to become more engaged in their treatment, potentially enhancing mood and diminishing feelings of powerlessness. Moreover, nurses' involvement in mental health education and the application of coping techniques may assist patients in handling stress, a significant factor contributing to depression in chronic conditions. This integrated approach could account for the noted improvements in depression scores, though additional research is necessary to pinpoint the specific components of nurse-led care that are most effective in alleviating depressive symptoms.

Moreover, some other outcomes have also been reported by various studies. Even those not eligible for meta-analyses provide valuable insights. Fishbane et al., 2017 [30] reported that nurse-led interventions were effective in reducing hospitalization rates. Arad et al., 2021 [20] and Jadhav et al., 2018 [28] successfully developed nurse-led patient education programs that improved treatment and medication adherence among CKD patients. Shi et al., 2013 [24] demonstrated better control of hyperphosphatemia in the experimental group. Conversely, Zuilen et al., 2012 [16] and Barrett et al., 2011 [15] concluded that nurse-led interventions did not significantly impact cardiovascular outcomes and eGFR (estimated glomerular filtration rate) in CKD patients, respectively.

Our study did not specifically aim to assess patient empowerment as a primary outcome. However, we acknowledge that nurse-led care often includes empowering patients to take an active role in managing their condition. While our results demonstrated significant improvements in symptoms and problems associated with kidney disease (Fig. 3), sleep quality (Fig. 7), energy/fatigue (Fig. 11), pain (Fig. 14), depression (Fig. 15), and overall health (Fig. 13), no significant improvements were found in certain components of quality of life, such as work status, cognitive function, quality of social interactions, sexual function, patient satisfaction, social function etc. These findings suggest that nurse-led care may have a positive impact on symptom management, but further research is warranted to explore its role in enhancing patient empowerment and other psychosocial aspects of CKD management.

Our findings align with previous systematic reviews [36], which have consistently shown that the inclusion of advanced practice nurse practitioners (ANPs) in healthcare management has positive effects on various health parameters.

This systematic review and meta-analysis was initiated to evaluate recent RCTs to better define the pros and cons of nurse-led interventions among CKD patients. However, the retraction of some studies was a major setback, limiting the pool of available data. Zheng et al., 2022 (37) found nurse-led care to help improve self-efficacy, medication adherence, and quality of life among CKD patients. Chen et al., 2022 [36] reported its efficacy in enhancing vitality, quality of life, patient satisfaction and treatment compliance. Additionally, they found it useful in reducing physical pain, postoperative complications, anxiety, and depression. Hu et al., 2022 [35] observed that while nurse-led care improved the nutritional status of CKD patients, it severely compromised renal function.

Our findings provide important insights into nurse-led care impact on patient well-being. We found that nurse-led care significantly improved symptoms and problems commonly associated with CKD, including sleep quality, energy levels, and depression. Additionally, the overall health of patients showed notable improvement. However, nurse-led care did not significantly impact kidney disease burden, physical functioning, or emotional well-being. Variability in depression outcomes suggests potential heterogeneity across studies. While some trials reported improvements in hospitalization rates and treatment adherence, the results were inconsistent, highlighting the need for more rigorous research to better define the comprehensive efficacy of nurse-led care. Although our study did not measure outcomes such as blood pressure (BP), low-density lipoprotein (LDL) levels, parathyroid hormone (PTH) levels, or phosphate control, previous research has demonstrated that ANP involvement has led to improvements in these areas. Thus, our results, in conjunction with prior findings, reinforce the beneficial role of ANPs in healthcare management.

The timing of intervention is a critical factor that can influence outcomes in patients with CKD. In this study, we did not stratify interventions based on the stage of disease progression, which may affect the comparability of results. Future research should aim to analyze interventions across different stages of CKD, including at the point of diagnosis, during long-term management, and at end-of-life care. Less evidence is available for certain outcomes like mortality, hospitalization rate, self-efficacy, compliance, and renal parameters. The majority of studies included were conducted in Eastern countries, particularly Asia, where healthcare systems and cultural norms differ significantly from those in Western regions. This geographic concentration may limit the generalizability of findings, as the effectiveness and implementation of nurse-led care models could vary in different healthcare contexts. Future research should explore these interventions in diverse regions to validate their broader applicability. Only a few studies could follow-up for the long term and that too reported results at variable times. 5 out of 10 studies included in meta-analysis had a high risk of bias which might affect the reliability of findings. Moreover, future research should incorporate clinical relevance measures to better understand the practical impact of nurse-led care interventions on patient outcomes, ensuring that observed improvements translate into meaningful benefits for patients’ daily lives.

Our findings contribute to the growing body of evidence supporting the effectiveness of nurse-led care in improving patient outcomes and enhancing the quality of life for CKD patients. These results have important implications for clinical practice, emphasizing the integration of nurse-led interventions into CKD care pathways to optimize patient-centered care and improve health outcomes. A comprehensive nurse-led intervention program should be devised for CKD patients. Telephone follow-up, social support, and patient education should be the main focus of this holistic approach to improving the health and quality of life of this population. Adequate training and continuous professional development are imperative for nurses to effectively manage chronic kidney disease, thereby ensuring that the quality of care aligns with established healthcare standards.

Although a great deal of evidence supports the effectiveness of nurse-led care in improving quality of life, sleep, pain, overall health and depressive symptoms among CKD patients. Certain domains such as hospitalization rates, mortality, and compliance remain under-investigated. More trials and qualitative studies are required to fully understand the overall effects of nurse-led interventions in CKD care, as their impact on renal function remains in question.