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The Effects of Self-Management on the Progression of Chronic Kidney Disease

Keywords: Chronic kidney disease, self-management, patient education, end-stage renal disease

The Effects of Self-Management on the Progression of Chronic Kidney Disease

Kidney disease is one of the leading causes of death in the United States and was the 8th leading cause in 2010 (Arialdi M. Miniño, 2012). Approximately 20 million U.S. adults who are over 20 years of age have chronic kidney disease (CKD), and most of them are unaware of their condition ("CDC, National chronic kidney disease "). This number continues to grow every year due to an increase in the incidence of hypertension, diabetes, obesity, and the aging population. CKD can develop into end-stage renal disease (ESRD) rapidly without intervention, and the only treatment currently available is renal replacement therapy or kidney transplant. The cost of treating those in the United States with ESRD in 2009 was approximately $40 billion dollars, and this cost continues to grow each year ("National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) "). Moreover, patients who develop kidney disease pay an even higher price with their life. Studies have shown that CKD is associated with a higher rate of cardiovascular disease as well as all other related mortalities (Kurth, de Jong, Cook, Buring, & Ridker, 2009). An adult with CKD is 16-40 times more likely to die before reaching ESRD than an adult without the disease ("CDC, National chronic kidney disease "). The rate of CKD is on the rise and could potentially be the largest source of health care expenditures in the United States annually. If we do not develop an intervention approach to delay the progression of CKD, ESRD could become an epidemic, and it is therefore imperative that an effective approach for slowing the progression of kidney disease is explored, developed, and practiced for improving the physical and economic health of our country. With more people developing CKD every year, it is essential that we find better approaches for the early detection or prevention of kidney disease as well as the prevention of uremia comorbidities from kidney disease, as early interventions have been shown to delay progression to ESRD (Bastos & Kirsztajn, 2011). In return, this will slow the progression of kidney disease and decrease the need for renal replacement therapy. However, delaying the progression of CKD will only be accomplished through the improvement of care and outcomes for those with kidney disease. Studies have shown that self-management is not only inexpensive, but beneficial in the prevention or delay of complications related to chronic diseases (Haas et al., 2012). Therefore, this systematic review will focus on adults with CKD and the use of self-management to delay the progression to ESRD compared to patients who receive standard of care. The search strategy used to identify studies published in English from January 2007-July 2012 consisted of searching four databases (Ovid, Pubmed, Web of Science, and Science Direct) using the following keywords: chronic kidney disease, self-management, patient education, and end-stage renal disease. PICO was used to establish inclusion criteria as follows: P- an adult over the age of 18 with CKD and a glomerular filtration rate (GFR) of less then 60 mL/min/1.73m2; I- self-management education, including the full range of activities undertaken by a person with a chronic condition, ranging from the preventive activities undertaken by healthy people at home to the day-to-day tasks undertaken by an individual for managing symptoms, treatments, consequences, and lifestyle changes associated with chronic conditions (Lin, Wu, Wu, Chen, & Chang, 2012); C- compared to those who receive standard care; and O- the progression of a patient’s kidney disease. CKD is not a well-studied topic, and this research only found 26 studies related to this aspect of the disease. Studies that did not focus on CKD were eliminated, resulting in eight studies. Furthermore, studies that were more then 5 years old were eliminated, which left three studies for analysis. The reference sections of these identified articles were then manually searched for additional compatible studies. The articles in which the studies cited were also searched, which identified a total of five studies that met the criteria of the PICO criteria set for this review. For this first draft of this paper, three identified studies will be discussed.

(Chen et al., 2011) The purpose of this small, open-label randomized control study enrolling 54 volunteers was to assess the impact of standardized self-management support programs on disease progression and morbidity in CKD patients. All participants were interviewed to obtain baseline information at the first medical visit. The patients were then randomized into self-management support and non-self-management support study arms at a 1:1 ratio. Those placed into the self-management support program group were educated on the important role that patients can play in actively managing their disease. The participants were given information through multiple sources, including verbal, visual, and written materials. They also received support through multiple disciplinary areas (i.e. nursing, dietitian peers, and volunteers). The participants also had monthly one-on-one meetings in person with nurse, weekly telephone-based support, and support groups held twice a month. The non-self-management support group patients received standard of care from their nephrologists, which h included evaluation of laboratory data and clinical indicators of CKD as well as an explanation of general principles of dialysis. All participants were followed for 12 months. All data obtained were analyzed using the Statistical Package for Social Sciences (SPSS) for Windows (IBM, NY, USA). An analysis of the time to dialysis and patient survival was performed using the Kaplan-Meier method. The results of this study found that a standardized self-management support program slowed the progression of CKD in patients with the disease. The strength of the study was that it shows that standardized self-management support education can slow the progression of kidney disease and reduces hospitalization. One limitation was the sample size of the study.

(Wu et al., 2009) The purpose of this open-labeled, controlled cohort study was to look at the impact of multidisciplinary predialysis education on the incidence of dialysis and outcomes of CKD patients in accordance with the guidelines of the National Kidney Foundation Dialysis Outcomes Quality Initiative. There were a total of 573 participants involved in the study. The participants were divided into two cohorts according to sites: the multidisciplinary predialysis education group was located at the Keelung Center and the non-multidisciplinary predialysis education group was located at the Taipei Center. Both groups were seen by the same group of nephrologists. The education team for the multidisciplinary predialysis education included a nephrologist, nurse, pharmacist, dietitian, and social worker. The multidisciplinary predialysis education program consisted of an integrated course involving individual lectures on renal health that was delivered according to the guidelines in a standardized booklet. The patients were contacted for follow-up by phone. Interactive education sessions were given based on the disease stage. All patients also received biannual dietary counseling. In addition to phone calls to reinforce the importance of the medical visit, the non- multidisciplinary predialysis education received standard of care from their nephrologists, which included instructions regarding renal function, evaluation of laboratory data, and explanation of general principles of hemodialysis and peritoneal dialysis. All participants were followed for 12 months. Analysis of the time to dialysis and patient survival was conducted using the Cox-Mantel log-rank test. This study found that a standardized multidisciplinary predialysis education program slowed the progression of CKD in these patients. The strength of the study was that it found that a multidisciplinary predialysis education program slowed the progression of CKD. A limitation was that proteinuria levels were not recorded, and proteinuria has been shown to be an independent marker for the progression of kidney disease.

(Cho et al., 2012) The object of this cohort study was to retrospectively assess the incidence of renal replacement therapy, mortality, cardiovascular events, and infection in a group of patients with CKD who received multidisciplinary predialysis education compared to those who had not. A total of 1218 patients with CKD were assessed in the study, and 149 of them had been involved in the multidisciplinary predialysis education program. The characteristics of the patients receiving a multidisciplinary predialysis education were matched to patients in the non-multidisciplinary predialysis education group for a total of 298 matched patients. The education team for the multidisciplinary predialysis education group was comprised of a nephrologists, nurse, pharmacist, dietitian, and social worker. The multidisciplinary predialysis education group received group and individualized sessions that lasted for approximately 2 hours each month. Participants were educated on kidney function nutrition, medical treatment for CKD, and renal replacement therapy. The education approach was standardized for all patients. The participants met with a dietician and each participant was given an educational booklet. The non-multidisciplinary predialysis education group received standard of care, and all participants were followed for 30 months. The propensity score was calculated for each multidisciplinary predialysis education group participant. The score were matched to the non-multidisciplinary predialysis education group participants using the Greedy matching algorithms at a ratio of 1:1. The effectiveness of bias reduction after matching was assessed with paired student’s t-test and McNemar’s test. All data obtained were analyzed using SPSS for Windows. Analysis of the time to dialysis and survival was carried out using the Kaplan-Meier survival method and log-rank test. The strength of the study was that it found that a multidisciplinary predialysis education program reduces the incidence of unplanned renal replacement therapy as well as cardiovascular and infectious events. One limitation of the study was that the mean age of the participants was 58 years, and these individuals were healthier and had a lower risk of mortality.

References

Arialdi M. Miniño, S. L. M. (2012). Death in the United States, 2010. [statistical publications that provide information about current public health topics ]. NCHS Data Brief(No. 99).
Bastos, M. G., & Kirsztajn, G. M. (2011). Chronic kidney disease: importance of early diagnosis, immediate referral and structured interdisciplinary approach to improve outcomes in patients not yet on dialysis. J Bras Nefrol, 33(1), 93-108.
. CDC, National chronic kidney disease Retrieved September 27, 2012, from http://www.cdc.gov/diabetes/projects/kidney/
Chen, S. H., Tsai, Y. F., Sun, C. Y., Wu, I. W., Lee, C. C., & Wu, M. S. (2011). The impact of self-management support on the progression of chronic kidney disease--a prospective randomized controlled trial. Nephrol Dial Transplant, 26(11), 3560-3566. doi: 10.1093/ndt/gfr047
Cho, E. J., Park, H. C., Yoon, H. B., Ju, K. D., Kim, H., Oh, Y. K., . . . Oh, K. H. (2012). Effect of multidisciplinary pre-dialysis education in advanced chronic kidney disease: Propensity score matched cohort analysis. Nephrology (Carlton), 17(5), 472-479. doi: 10.1111/j.1440-1797.2012.01598.x
Haas, L., Maryniuk, M., Beck, J., Cox, C. E., Duker, P., Edwards, L., . . . Youssef, G. (2012). National standards for diabetes self-management education and support. Diabetes Educ, 38(5), 619-629. doi: 10.1177/0145721712455997
Kurth, T., de Jong, P. E., Cook, N. R., Buring, J. E., & Ridker, P. M. (2009). Kidney function and risk of cardiovascular disease and mortality in women: a prospective cohort study. BMJ, 338, b2392. doi: 10.1136/bmj.b2392
Lin, C. C., Wu, C. C., Wu, L. M., Chen, H. M., & Chang, S. C. (2012). Psychometric evaluation of a new instrument to measure disease self-management of the early stage chronic kidney disease patients. J Clin Nurs. doi: 10.1111/j.1365-2702.2011.04048.x
. National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) from http://kidney.niddk.nih.gov/kudiseases/pubs/kustats/#1
Wu, I. W., Wang, S. Y., Hsu, K. H., Lee, C. C., Sun, C. Y., Tsai, C. J., & Wu, M. S. (2009). Multidisciplinary predialysis education decreases the incidence of dialysis and reduces mortality--a controlled cohort study based on the NKF/DOQI guidelines. Nephrol Dial Transplant, 24(11), 3426-3433. doi: 10.1093/ndt/gfp259

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