Improving the detection and treatment of malnutrition for people with chronic kidney disease: co-design and validation of a novel outpatient nutrition screening tool.

Background Protein energy malnutrition affects up to 50% people with chronic kidney disease (CKD). Risk of malnutrition increases with disease progression. This can reduce quality of life, mobility and independence and cause poor wound healing and increased frailty, complications, ill health and time in hospital. Guidelines recommend nutrition screening for timely detection and treatment of malnutrition for patient benefit and to reduce costs. However, this is widely missing in renal services due to a lack of suitable screening tools. Therefore, malnutrition goes unrecognised, without intervention or referral to dietitians. Nurses have responsibility for nutrition screening but little involvement in screening tool development and the patient perspective has been lacking. We previously developed the only nurse-led validated nutrition screening tool for specialist renal wards. It is cited in guidelines and used across the UK and worldwide. Adaptation for outpatients using codesign would provide a practical, consistent evidence-based approach to nutrition screening for renal units, and emphasise the importance of involving nurses and people living with CKD. Aim: To determine if a codesigned adaptation of a nutrition tool, training and self-management resources is feasible, acceptable and valid for use within outpatient services for people with advanced CKD (stages 4-5) in three large renal units Method: There are three studies within the proposal: 1: A scoping methodology will be used to review the barriers and facilitators for delivering nurse-led nutrition screening within renal outpatient services and the characteristics of existing tools, with an emphasis on the nurse and patient perspective. 2: Codesign A multi-stage accelerated form of experienced -based codesign will involve group and individual meetings with renal nurses and people living with CKD. There is a need to establish appropriate terminology, adapt the ward-based screening tool, design training and self-management resources. 3.Validation and Implementation The codesigned nutrition screening tool and nurse-led screening will be implemented in selected renal outpatient services. A multicentre validation of the screening tool will be conducted in 139 adult consenting participants with advanced CKD (eGFR This includes testing concurrent, construct and face validity, sensitivity, specificity. The nurse-led tool and a patient self-screening version will be compared against a comprehensive extended dietetic assessment, using the validated subjective global assessment as the reference method, and against handgrip strength. A generic Malnutrition Universal Screening Tool (MUST) will be completed for comparison. Inter-rater reliability will be tested in a subsample of 52 consenting participants. Recorded data will include indices of co-morbidity, frailty and social deprivation, communication barriers and demographics. Participant and nurse feedback will be obtained by questionnaire. Conclusion A valid screening tool for CKD outpatient services, codesigned with people with CKD and specialist renal nurses, offers a new way of integrating screening for malnutrition at an earlier stage and in collaboration with the key people involved. It provides opportunity for earlier detection of malnutrition risk, better cost-effectiveness and more efficient use of dietitians. This will improve patient care and support technological and research advances.