The Role of Nurse Case Managers in Slowing Progression of Chronic Kidney Disease

Introduction

Chronic kidney disease (CKD) affects a substantial proportion of the adult population and follows a heterogeneous but often progressive clinical course, with a meaningful subset of patients advancing over time toward end-stage kidney disease requiring dialysis or transplantation (United States Renal Data System, 2023). While the underlying pathophysiology of CKD progression varies by etiology, a substantial body of evidence has established that the rate of decline in kidney function is strongly influenced by the consistency with which modifiable risk factors, including blood pressure control, glycemic management in patients with diabetic kidney disease, proteinuria reduction through renin-angiotensin system blockade, and avoidance of nephrotoxic medication exposure, are managed over the course of the disease (KDIGO, 2021).

Ambulatory nephrology care is typically structured around periodic physician office visits, occurring at intervals ranging from every three to twelve months depending on disease stage, a cadence that may be insufficient to ensure timely identification and correction of gaps in modifiable risk factor management as they emerge between visits. Nurse case management has been proposed as a complementary care delivery model capable of providing more continuous, proactive monitoring and intervention between physician visits, a model that has demonstrated benefit in other chronic disease contexts, including heart failure and diabetes, through mechanisms including more timely medication titration, earlier identification of clinical deterioration, and sustained reinforcement of lifestyle and dietary recommendations (Peikes et al., 2019).

Existing research examining nurse case management specifically within CKD populations has predominantly focused on process-oriented outcomes, such as the proportion of patients achieving guideline-concordant antihypertensive prescribing or attainment of target blood pressure at a single time point, with comparatively fewer studies directly examining the effect of nurse case management on the primary clinical outcome of greatest long-term relevance to patients and health systems: the trajectory of kidney function decline over time (Thomas et al., 2018). This gap is clinically significant, as improvement in intermediate process measures does not necessarily translate into a measurable difference in the ultimate disease trajectory, and health systems considering investment in nephrology case management infrastructure require outcome-level evidence to support this investment decision.

Given the substantial burden of CKD progression and the plausible but incompletely confirmed benefit of nurse case management on kidney function trajectory specifically, this study aimed to evaluate the effect of a structured nurse case management program on the rate of eGFR decline among adults with stage 3–4 chronic kidney disease, in comparison to standard nephrology clinic follow-up, and to examine associated secondary clinical outcomes including blood pressure control, proteinuria, and CKD-related hospitalization.

Methods

This study employed a prospective, controlled cohort design conducted across two nephrology clinics affiliated with a single regional health system, over an 18-month observation period. Adults aged 18 years or older with a confirmed diagnosis of stage 3 or stage 4 CKD, defined as an eGFR between 15 and 59 mL/min/1.73m² sustained over at least three months, who were established patients at a participating clinic, were eligible for inclusion. Patients receiving dialysis, those with a functioning kidney transplant, and those with a life expectancy of less than 12 months were excluded. Clinic assignment, rather than individual patient randomization, determined study arm: one participating clinic implemented the structured nurse case management program for all eligible patients, while the second clinic continued standard nephrology follow-up without dedicated case management, allowing for controlled comparison while avoiding contamination between conditions within a shared clinic setting. A total of 268 patients were enrolled: 134 in the nurse case management clinic and 134 in the standard follow-up clinic.

Patients at the nurse case management clinic were assigned a dedicated registered nurse case manager, credentialed in chronic kidney disease management, who provided structured, proactive monitoring and intervention between scheduled physician visits, including the following core components:

1.Proactive laboratory and blood pressure monitoring, with the case manager reviewing interval home blood pressure logs and laboratory results and directly contacting patients whose values fell outside pre-specified target ranges, rather than awaiting the next scheduled physician visit to identify and address such deviations.

2.Medication reconciliation and titration support, in which the case manager, operating under a nephrologist-approved standing protocol, adjusted antihypertensive dosing within pre-defined parameters and flagged nephrotoxic medication exposures, such as nonsteroidal anti-inflammatory drug use, identified during interval contact.

3.Structured dietary and lifestyle counseling, delivered through scheduled telephone or in-person contact at a minimum monthly interval, addressing sodium and protein intake, fluid management, and smoking cessation as clinically indicated.

Patients at the standard follow-up clinic continued to receive nephrology care exclusively through scheduled physician office visits, without dedicated nurse case management or structured interval monitoring beyond usual clinic practice. The primary outcome was the annualized rate of eGFR decline, calculated for each patient using linear mixed-effects modeling of all available serial eGFR measurements recorded during the study period, expressed in mL/min/1.73m² per year. Secondary outcomes included the proportion of patients achieving guideline-concordant blood pressure targets at study end, change in urine albumin-to-creatinine ratio, and the incidence of CKD-related hospitalization. Between-group comparison of annualized eGFR decline was conducted using a linear mixed-effects model with a group-by-time interaction term, adjusting for baseline eGFR, diabetes status, and baseline proteinuria. Statistical significance was set at p < .05, and analyses were conducted using Stata version 18.

Results

Baseline characteristics, including age, baseline eGFR, CKD etiology distribution, diabetes prevalence, and baseline proteinuria, did not differ significantly between the nurse case management and standard follow-up cohorts (all p > .05), supporting comparability between groups. A mean of 5.8 eGFR measurements per patient were available for analysis over the 18-month study period, with no significant difference in measurement frequency between groups.

The annualized rate of eGFR decline was significantly slower in the nurse case management group compared to the standard follow-up group. In the adjusted linear mixed-effects model, mean annualized eGFR decline was 2.1 mL/min/1.73m² per year in the nurse case management group, compared to 4.6 mL/min/1.73m² per year in the standard follow-up group, an adjusted between-group difference of 2.5 mL/min/1.73m² per year (95% CI 1.6–3.4, p < .001), after adjusting for baseline eGFR, diabetes status, and baseline proteinuria.

Secondary outcomes similarly favored the nurse case management group. At study end, 61.9% of patients in the case management group had achieved guideline-concordant blood pressure targets, compared to 38.1% in the standard follow-up group (χ² = 15.42, p < .001). Mean reduction in urine albumin-to-creatinine ratio over the study period was significantly greater in the case management group, consistent with more effective renin-angiotensin system blockade optimization achieved through the case manager’s proactive medication titration protocol. CKD-related hospitalization, encompassing admissions for volume overload, uncontrolled hypertension, or acute kidney injury superimposed on chronic disease, occurred in 9.7% of case management patients compared to 19.4% of standard follow-up patients over the 18-month study period (p = .014). Subgroup analysis indicated that the magnitude of benefit in eGFR decline rate was numerically greatest among patients with diabetic kidney disease and among those with stage 4 disease at baseline, populations in which the consequences of unaddressed risk factor drift between physician visits may be most clinically consequential, though these subgroup comparisons were exploratory and the study was not powered for formal subgroup interaction testing.

Discussion

The findings of this study demonstrate that structured nurse case management was associated with a significantly slower rate of eGFR decline among patients with stage 3–4 CKD, with an adjusted between-group difference in annualized decline rate of 2.5 mL/min/1.73m² per year, a magnitude of effect that, if sustained over a multi-year time horizon, would be expected to meaningfully delay progression toward end-stage kidney disease for a substantial proportion of affected patients. This finding extends prior CKD case management research, which has predominantly examined process measures such as guideline-concordant prescribing, by directly demonstrating a benefit on the primary clinical outcome of kidney function trajectory itself (Thomas et al., 2018).

The parallel improvement observed in blood pressure target attainment and proteinuria reduction offers a plausible mechanistic explanation for the observed effect on eGFR decline, consistent with established evidence linking blood pressure control and renin-angiotensin system blockade optimization to slowed CKD progression (KDIGO, 2021). The case manager’s capacity to proactively identify and address risk factor drift between scheduled physician visits, rather than awaiting the next periodic visit to detect and correct such drift, likely represents the central mechanism through which this benefit was achieved, consistent with the broader chronic disease case management literature demonstrating that the value of case management often derives from continuity and timeliness of intervention rather than from the delivery of fundamentally different clinical content (Peikes et al., 2019).

The significant reduction in CKD-related hospitalization observed in the case management group carries additional practical and economic relevance beyond the primary eGFR outcome, suggesting that the case management model’s benefit extended to averting acute clinical deterioration events, not solely to modifying the chronic disease trajectory. This finding, considered alongside the observed reduction in eGFR decline, suggests that structured nurse case management may offer a favorable return on investment for health systems, both through the deferred cost of end-stage kidney disease care associated with slowed progression and through the more immediate reduction in acute hospitalization-related expenditure, though formal cost-effectiveness analysis was beyond the scope of this study and represents an important direction for future research.

This study has several limitations. The clinic-level, rather than individual patient-level, assignment of study condition introduces the possibility of residual clinic-level confounding related to patient population characteristics, provider practice patterns, or other unmeasured site-level factors not fully addressed through the statistical adjustments applied. The two-site, single regional health system setting may limit generalizability to nephrology practices with different staffing models, patient populations, or existing care coordination infrastructure. The 18-month observation period, while sufficient to detect a significant between-group difference in eGFR decline rate, does not establish whether this benefit persists over a longer, multi-year time horizon more directly relevant to ultimate progression to end-stage kidney disease. Future research employing multi-site, patient-level randomized designs with extended follow-up, and incorporating formal cost-effectiveness analysis, would further strengthen the evidence base supporting broader implementation of nurse case management in CKD care. Despite these limitations, the magnitude and clinical coherence of the findings support integration of structured, proactive nurse case management into ambulatory nephrology care for patients with stage 3–4 CKD, particularly those with diabetic kidney disease or more advanced baseline disease stage.

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