Implementing nurse-led, multi-disciplinary, cardio-kidney-metabolic care in an integrated community care program for fluid overload in CKD and heart failure

Q: What is the clinical evidence from this study?

Study design: Letter. Population: Fluid overload in chronic kidney disease and heart failure (n=32). Intervention: Nurse-led integrated community care program.

Q: What does this research mean for the field?

A nurse-led, multidisciplinary cardio-kidney-metabolic care program can be implemented within integrated community care to manage fluid overload in patients with chronic kidney disease and heart failure. Novelty: ClaimNovelty.METHODOLOGICAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Cynthia Ciwei Lim; Hooi Khee Teo; Stephanie Swee Hong Teo; Hairil Rizal Bin Abdullah; Shan Yin Audry Lee

doi:10.1093/ckj/sfag276

August 14, 2026Clinical Kidney JournalOpen Access

Implementing nurse-led, multi-disciplinary, cardio-kidney-metabolic care in an integrated community care program for fluid overload in CKD and heart failure

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Key result

A survey of 32 stakeholders identified developing educational materials, involving patients and family, and intervening to enhance treatment uptake as top strategies for implementing a nurse-led care program.

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Key Points

To establish and prioritize implementation strategies for an integrated, nurse-led community care program managing fluid overload in chronic kidney disease and heart failure.
Surveyed 32 multidisciplinary stakeholders—including community nurses, hospital-based nurses, physicians, care coordinators, and administrators—using the Expert Recommendations for Implementing Change taxonomy.
Applied the Practical, Robust Implementation and Sustainability Model (PRISM) framework to construct a logic model integrating remote symptom monitoring, multidisciplinary care plans, and escalation pathways.
Identified cardiorenal fluid overload as a high healthcare burden, accounting for over 9300 emergency department visits, 6200 hospitalizations, 42 000 bed-days, and USD 55 million in hospital bills in 2025 across four acute hospitals in the SingHealth cluster.
Prioritized three primary implementation strategies among surveyed stakeholders: developing educational materials, involving patients and family members, and intervening with patients to enhance treatment uptake and adherence.

Structured PICO

P

Population

32 multidisciplinary stakeholders were surveyed to prioritize implementation strategies for a nurse-led community care program for fluid overload in cardiorenal disease.

I

Intervention

Integrated, nurse-led, multi-disciplinary community care program (incorporating remote symptom monitoring, patient-reported outcome measures, individualized self-management support, patient nudges, protocolized escalation pathways, and shared multidisciplinary care plans)

C

Comparator

Conventional reactive models of care relying on scheduled outpatient reviews

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Implication

A proposed integrated, nurse-led community care program aims to proactively manage fluid overload in cardiorenal disease, aligning with recent cardiovascular-kidney-metabolic (CKM) guidelines.

Abstract

Cynthia Ciwei Lim, Hooi Khee Teo, Stephanie Swee Hong Teo, Hairil Rizal Bin Abdullah, Audry Shan Yin Lee; Implementing nurse-led, multi-disciplinary, cardi

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Cite This Study

Lim et al. (2026) conducted a letter in Fluid overload in chronic kidney disease and heart failure (n=32). Nurse-led integrated community care program was evaluated. A survey of 32 stakeholders identified developing educational materials, involving patients and family, and intervening to enhance treatment uptake as top strategies for implementing a nurse-led care program.

synapsesocial.com/papers/6a817a01f2fb91fc834ad857 https://doi.org/10.1093/ckj/sfag276

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Implementing nurse-led, multi-disciplinary, cardio-kidney-metabolic care in an integrated community care program for fluid overload in CKD and heart failure

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Key Points

Structured PICO

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Implication

Abstract

Discussion

Cite This Study

Implementing nurse-led, multi-disciplinary, cardio-kidney-metabolic care in an integrated community care program for fluid overload in CKD and heart failure

Figures

Key Points

Structured PICO

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Implication

Abstract

Discussion

Cite This Study

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