Effect of behavioral stage-based nutrition education on management of osteodystrophy among hemodialysis patients, Lebanon

Promoting self-management in chronic disease: a systematic review and meta-analysis of behaviour change interventions for patients on dialysis

Given the importance of patients' ability to effectively self-manage their kidney disease, researchers have developed interventions focused on improving self-management for patients on dialysis. The review and meta-analysis aimed to evaluate the efficacy of these interventions and identify the characteristics of more effective interventions in this domain. A meta-analysis of randomised controlled trials to promote self-management in patients on dialysis (N = 4201, k = 45) evaluated: the effect of the interventions on psychological, behavioural, and physiological outcomes; the relationships between changes in outcomes; the moderation of outcomes by behaviour change techniques employed in the interventions; and intervention duration. The meta-analysis obtained moderate effect sizes, demonstrating improvement in behavioural (g = 0.50 to 0.65) and physiological health outcomes (g = -0.32 to -0.57). Fewer studies assessed psychological intervention targets, but large effects were obtained for knowledge change and quality of life (g = 0.65 and 1.17, respectively). Improved knowledge was positively associated with improved medication adherence, which in turn was associated with one physiological outcome. Interventions incorporating psychotherapeutic techniques such as CBT or rational emotive therapy achieved superior physiological outcomes, particularly when used in isolation. The findings support the interpretation that intervention strategies to enhance emotional self-management are effective in optimising outcomes for patients on dialysis.

Knowledge, attitudes, and practices of Lebanese licensed dietitians regarding hyperphosphatemia management in patients undergoing hemodialysis in a Lebanese Governorate

BACKGROUND

Hyperphosphatemia is deemed to be an asymptomatic silent killer, its high prevalence in patients undergoing hemodialysis (HD) is correlated mainly with malnutrition and mortality. Dietitian's renal nutrition education has a major impact on chronic kidney disease patients' knowledge, and attitude towards nutrition guidelines. However, a large number of factors are acting as barriers to the appropriate practices of Lebanese dietitians in renal therapy. This study evaluated the knowledge, attitudes, and practices (KAP) of licensed dietitians (LDs) regarding hyperphosphatemia management in patients undergoing HD.

METHODS

A total of 408 LDs from Mount-Lebanon Governorate in Lebanon participated in this study. A 52-item online questionnaire was used to assess nutritional phosphorus' KAP of all LDs, in compliance with dietetic practices with KDOQI guidelines updated version 2020 and identified the factors preventing dietitians from dealing with renal patients undergoing HD, e.g., nutrition care. The data was analyzed using SPSS version 25.

RESULTS

There was a significant association between KAP levels, and almost all sociodemographic characteristics evaluated. Only 2% of dietitians applied all KDOQI guidelines, 64% attained poor and moderate knowledge, and 60% had a positive attitude towards renal care. Working in a clinical field was a common predictor of positive knowledge (adjusted OR = 2.453, 95% CI 1.244-4.836), positive attitude (adjusted OR = 1.900, 95% CI 1.300-2.541) and positive practice (adjusted OR = 0.192, 95% CI 0.184-0.491) while HD/hospital-based field increased the odds for positive knowledge (adjusted OR = 4.520, 95% CI 1.189-17.182). LDs, compared to registered dietitians, had lower odds of positive knowledge (adjusted OR = 0.390, 95% CI 0.231-0.658) and positive attitude (adjusted OR = 0.270, 95% CI 0.154-0.471). Lack of training was the main reason preventing the appropriate dietetic practices regarding hyperphosphatemia management in patients undergoing HD.

CONCLUSION

The Ministry of Public Health (MOPH) should be asked to endorse the integration of renal nutrition programs in the Lebanese curriculum, to aid in the empowerment of dietitians from different backgrounds towards renal therapy, in order to enhance the knowledge and attitude regarding nutritional guidelines of poorly supported Lebanese patients undergoing HDhemodialysis. Other stakeholders may include the Syndicate of Dietitians in Lebanon.

Effect of a transtheoretical model-based intervention and motivational interviewing on hyperphosphatemia management via telehealth (TMT program) among hemodialysis patients during the COVID-19 pandemic

Background

Hyperphosphatemia poses a significant risk for cardiovascular diseases and mortality in hemodialysis patients. Non-adherence to phosphate binders and a low-phosphate diet behavior contribute to this issue. Leveraging psychological and behavior change theories has proven effective in addressing many health risks. During the COVID-19 pandemic, face-to-face communication was limited, and telehealth served as a bridge to address healthcare gaps. This study aimed to determine the effect of a transtheoretical model-based intervention and motivational interviewing on hyperphosphatemia management via telehealth (TMT program) among hemodialysis patients during the COVID-19 pandemic.

Method

A two-arm parallel randomized controlled trial with assessors blinding involved 80 participants who were stratified block-randomized into either the TMT program group (n = 40) or the control group (Usual care; n = 40). Linear regression was used to compare the two groups on serum phosphorus levels, knowledge of hyperphosphatemia management, and dietary consumption behavior at the 24-week endpoint. The readiness to change (stage of change), self-efficacy, and phosphate binder adherence were assessed using Fisher's test.

Result

The TMT program demonstrated a significant reduction in serum phosphorus levels compared to usual care (mean difference = -1.03, 95% CI = -1.77, -0.29). Additionally, improvement in dietary consumption behavior related to phosphorus-containing foods was also observed (mean difference = 13.48, 95% CI = 8.41, 18.57). Positive effects emerged in the readiness to change (p < 0.001), self-efficacy in the appropriate use of phosphate binders (p = 0.025), and adherence to phosphate binders (p = 0.001) at the 24-week endpoint. However, groups did not differ in knowledge of hyperphosphatemia management (mean difference = 7.02, 95% CI = -1.03, 15.07).

Conclusion

The study demonstrated that the TMT program has positive effects on reducing serum phosphorus levels, providing a hyperphosphatemia management strategy for ESRD patients undergoing hemodialysis via telehealth.

Clinical trial registration

TCTR20230628003, https://www.thaiclinicaltrials.org.

Impact of Nutrition Education on Various Health-Related Components of Hemodialysis Patients: A Systematic Review

This study aimed to identify the impact of nutrition education on various health-related components of hemodialysis patients. A systematic review was conducted according to the PRISMA guidelines. Relevant literature published between 2013 and 2023 was identified across two databases (PubMed and Science Direct). The protocol was registered in PROSPERO (CRD42023460681). Two independent reviewers retrieved the data, and 41 studies were selected. Nine components related to the impact of nutrition education in hemodialysis patients were identified. Each component was clarified by mentioning each study and its results. This study enabled us to characterize the various components of the impact of nutritional education in hemodialysis patients, namely biological markers, quality of life, cost of care, adherence to dietary recommendations, knowledge, malnutrition inflammation, dietary intake, weight change, and behavior change. This systematic review enables healthcare providers to assess the impact of nutritional education on hemodialysis patients. Also, it gives professionals an exact idea of the impact of nutrition education on hemodialysis patients, with knowledge of new methods using behavior change theories and innovative technological tools.

Effect of Educational Intervention on Knowledge and Level of Adherence among Hemodialysis Patients: A Randomized Controlled Trial

Purpose. The purpose of the study was to assess the impact of an educational intervention on the level of knowledge and adherence to the treatment regimen among hemodialysis (HD) patients as well as to describe the association between these variables. Methods. In this randomized controlled trial, 160 HD patients at an HD centre of a 2030-bed tertiary teaching hospital in Southern India were randomly assigned into intervention (N = 80, received education and a booklet) and control (N = 80, received standard care) groups. Knowledge and adherence were measured preintervention and postintervention using a validated questionnaire for knowledge and the ESRD-AQ (End-Stage Renal Disease Questionnaire) for the level of adherence. The statistical analysis of the data was performed with the help of the Statistical Program SPSS version 19.0. The statistical significance level was set at 0.05. Results. The increase in knowledge on disease management, fluid adherence, and dietary adherence in the intervention group was significantly higher compared to the control group. There was no significant correlation between knowledge and adherence. Adherence improved for all the domains, i.e., dialysis attendance, episodes of shortening, adherence to medication, fluid restriction, and dietary restriction. Adherence to fluid and dietary restriction was statistically significant. This trail is registered with https://clinicaltrials.gov/ct2/show/CTRI/2018/05/014166.

Interventions for improving health literacy in people with chronic kidney disease

BACKGROUND

Low health literacy affects 25% of people with chronic kidney disease (CKD) and is associated with increased morbidity and death. Improving health literacy is a recognised priority, but effective interventions are not clear.

OBJECTIVES

This review looked the benefits and harms of interventions for improving health literacy in people with CKD.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 12 July 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. We also searched MEDLINE (OVID) and EMBASE (OVID) for non-randomised studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and non-randomised studies that assessed interventions aimed at improving health literacy in people with CKD.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for eligibility and performed risk of bias analysis. We classified studies as either interventions aimed at improving aspects of health literacy or interventions targeting a population of people with poor health literacy. The interventions were further sub-classified in terms of the type of intervention (educational, self-management training, or educational with self-management training). Results were expressed as mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals (CI) for continuous outcomes and risk ratios (RR) with 95% CI for dichotomous outcomes.

MAIN RESULTS

We identified 120 studies (21,149 participants) which aimed to improve health literacy. There were 107 RCTs and 13 non-randomised studies. No studies targeted low literacy populations. For the RCTs, selection bias was low or unclear in 94% of studies, performance bias was high in 86% of studies, detection bias was high in 86% of studies reporting subjective outcomes and low in 93% of studies reporting objective outcomes. Attrition and other biases were low or unclear in 86% and 78% of studies, respectively. Compared to usual care, low certainty evidence showed educational interventions may increase kidney-related knowledge (14 RCTs, 2632 participants: SMD 0.99, 95% CI 0.69 to 1.32; I² = 94%). Data for self-care, self-efficacy, quality of life (QoL), death, estimated glomerular filtration rate (eGFR) and hospitalisations could not be pooled or was not reported. Compared to usual care, low-certainty evidence showed self-management interventions may improve self-efficacy (5 RCTs, 417 participants: SMD 0.58, 95% CI 0.13 to 1.03; I² = 74%) and QoL physical component score (3 RCTs, 131 participants: MD 4.02, 95% CI 1.09 to 6.94; I² = 0%). There was moderate-certainty evidence that self-management interventions probably did not slow the decline in eGFR after one year (3 RCTs, 855 participants: MD 1.53 mL/min/1.73 m², 95% CI -1.41 to 4.46; I² = 33%). Data for knowledge, self-care behaviour, death and hospitalisations could not be pooled or was not reported. Compared to usual care, low-certainty evidence showed educational with self-management interventions may increase knowledge (15 RCTs, 2185 participants: SMD 0.65, 95% CI 0.36 to 0.93; I² = 90%), improve self-care behaviour scores (4 RCTs, 913 participants: SMD 0.91, 95% CI 0.00 to 1.82; I² =97%), self-efficacy (8 RCTs, 687 participants: SMD 0.50, 95% CI 0.10 to 0.89; I² = 82%), improve QoL physical component score (3 RCTs, 2771 participants: MD 2.56, 95% CI 1.73 to 3.38; I² = 0%) and may make little or no difference to slowing the decline of eGFR (4 RCTs, 618 participants: MD 4.28 mL/min/1.73 m², 95% CI -0.03 to 8.85; I² = 43%). Moderate-certainty evidence shows educational with self-management interventions probably decreases the risk of death (any cause) (4 RCTs, 2801 participants: RR 0.73, 95% CI 0.53 to 1.02; I² = 0%). Data for hospitalisation could not be pooled.

AUTHORS' CONCLUSIONS

Interventions to improve aspects of health literacy are a very broad category, including educational interventions, self-management interventions and educational with self-management interventions. Overall, this type of health literacy intervention is probably beneficial in this cohort however, due to methodological limitations and high heterogeneity in interventions and outcomes, the evidence is of low certainty.

Dietary advice with or without oral nutritional supplements for disease-related malnutrition in adults

BACKGROUND

Disease-related malnutrition has been reported in 10% to 55% of people in hospital and the community and is associated with significant health and social-care costs. Dietary advice (DA) encouraging consumption of energy- and nutrient-rich foods rather than oral nutritional supplements (ONS) may be an initial treatment.

OBJECTIVES

To examine evidence that DA with/without ONS in adults with disease-related malnutrition improves survival, weight, anthropometry and quality of life (QoL).

SEARCH METHODS

We identified relevant publications from comprehensive electronic database searches and handsearching. Last search: 01 March 2021.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of DA with/without ONS in adults with disease-related malnutrition in any healthcare setting compared with no advice, ONS or DA alone.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study eligibility, risk of bias, extracted data and graded evidence.

MAIN RESULTS

We included 94, mostly parallel, RCTs (102 comparisons; 10,284 adults) across many conditions possibly explaining the high heterogeneity.  Participants were mostly older people in hospital, residential care and the community, with limited reporting on their sex. Studies lasted from one month to 6.5 years.  DA versus no advice - 24 RCTs (3523 participants) Most outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.87 (95% confidence interval (CI) 0.26 to 2.96), or at later time points. We had no three-month data, but advice may make little or no difference to hospitalisations, or days in hospital after four to six months and up to 12 months. A similar effect was seen for complications at up to three months, MD 0.00 (95% CI -0.32 to 0.32) and between four and six months. Advice may improve weight after three months, MD 0.97 kg (95% CI 0.06 to 1.87) continuing at four to six months and up to 12 months; and may result in a greater gain in fat-free mass (FFM) after 12 months, but not earlier. It may also improve global QoL at up to three months, MD 3.30 (95% CI 1.47 to 5.13), but not later. DA versus ONS - 12 RCTs (852 participants) All outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.66 (95% CI 0.34 to 1.26), or at later time points. Either intervention may make little or no difference to hospitalisations at three months, RR 0.36 (95% CI 0.04 to 3.24), but ONS may reduce hospitalisations up to six months. There was little or no difference between groups in weight change at three months, MD -0.14 kg (95% CI -2.01 to 1.74), or between four to six months. Advice (one study) may lead to better global QoL scores but only after 12 months. No study reported days in hospital, complications or FFM. DA versus DA plus ONS - 22 RCTs (1286 participants) Most outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.92 (95% CI 0.47 to 1.80) or at later time points. At three months advice may lead to fewer hospitalisations, RR 1.70 (95% CI 1.04 to 2.77), but not at up to six months. There may be little or no effect on length of hospital stay at up to three months, MD -1.07 (95% CI -4.10 to 1.97). At three months DA plus ONS may lead to fewer complications, RR 0.75 (95% CI o.56 to 0.99); greater weight gain, MD 1.15 kg (95% CI 0.42 to 1.87); and better global QoL scores, MD 0.33 (95% CI 0.09 to 0.57), but this was not seen at other time points. There was no effect on FFM at three months. DA plus ONS if required versus no advice or ONS - 31 RCTs (3308 participants) Evidence was moderate- to low-certainty. There may be little or no effect on mortality at three months, RR 0.82 (95% CI 0.58 to 1.16) or at later time points. Similarly, little or no effect on hospitalisations at three months, RR 0.83 (95% CI 0.59 to 1.15), at four to six months and up to 12 months; on days in hospital at three months, MD -0.12 (95% CI -2.48 to 2.25) or for complications at any time point. At three months, advice plus ONS probably improve weight, MD 1.25 kg (95% CI 0.73 to 1.76) and may improve FFM, 0.82 (95% CI 0.35 to 1.29), but these effects were not seen later. There may be little or no effect of either intervention on global QoL scores at three months, but advice plus ONS may improve scores at up to 12 months. DA plus ONS versus no advice or ONS - 13 RCTs (1315 participants) Evidence was low- to very low-certainty. There may be little or no effect on mortality after three months, RR 0.91 (95% CI 0.55 to 1.52) or at later time points. No study reported hospitalisations and there may be little or no effect on days in hospital after three months, MD -1.81 (95% CI -3.65 to 0.04) or six months. Advice plus ONS may lead to fewer complications up to three months, MD 0.42 (95% CI 0.20 to 0.89) (one study). Interventions may make little or no difference to weight at three months, MD 1.08 kg (95% CI -0.17 to 2.33); however, advice plus ONS may improve weight at four to six months and up to 12 months. Interventions may make little or no difference in FFM or global QoL scores at any time point.

AUTHORS' CONCLUSIONS

We found no evidence of an effect of any intervention on mortality. There may be weight gain with DA and with DA plus ONS in the short term, but the benefits of DA when compared with ONS are uncertain. The size and direction of effect and the length of intervention and follow-up required for benefits to emerge were inconsistent for all other outcomes.  There were too few data for many outcomes to allow meaningful conclusions. Studies focusing on both patient-centred and healthcare outcomes are needed to address the questions in this review.

Association between the transtheoretical model approach and sustained intradialytic pedaling exercise: A retrospective cohort study

The transtheoretical model (TTM) is a promising approach to the promotion of behavior change, but it remains to be established whether there is an association between the TTM approach and intradialytic exercise among patients on hemodialysis (HD) with low motivation to exercise in a real-world setting.This retrospective cohort study, conducted in a regional hospital in Japan, included adult outpatients receiving HD 3 times per week who had never participated in intradialytic pedaling exercise despite the encouragement of the HD personnel. Patients were divided into 2 groups according to HD weekday. Patients undergoing HD on Tuesday, Thursday, and Saturday were encouraged by the HD unit team to exercise during HD based on the TTM (exposure group) and those receiving HD on Monday, Wednesday, and Friday were encouraged to exercise as usual (control group). The primary outcome was sustained intradialytic exercise using a leg ergometer, defined as a total of 72 sessions of 30-minute pedaling exercise (duration of at least 6 months).Overall, 85 patients were included in the analysis (mean age: 67.1 ± 11.9 years, 22% female). Of 33 patients in the exposure group, 10 (30%) maintained intradialytic exercise, compared with 2 of 52 patients (4%) in the control group. Log-binomial regression models with stabilized inverse probability of treatment weighting showed a significant association between the TTM approach and sustained intradialytic exercise (adjusted risk ratio 9.23 [95% confidence interval 2.13-40.00]). There were no exercise-related cardiovascular events.Among patients with low motivation to exercise during HD, use of the TTM approach in clinical practice was associated with sustained intradialytic exercise compared with usual care.

Adequate Management of Phosphorus in Patients Undergoing Hemodialysis Using a Dietary Smartphone App: Prospective Pilot Study

Background

The renal diet is complex and requires alterations of the diet and careful monitoring of various nutrients. Elevated serum phosphorus is common among patients undergoing hemodialysis, and it is associated with many complications. Smartphone technology could be used to support both dietitians and patients by providing a source of accessible and reliable information.

Objective

The aim of this pilot is to assess the potential efficacy of an intervention using the educational and self-monitoring mobile app KELA.AE on the phosphorous management in hemodialysis patients. Results will be used to improve both the app and a planned, rigorous large-scale trial intended to assess app efficacy.

Methods

This is a prospective pilot study performed at the hemodialysis unit of Al Qassimi Hospital (Emirate of Sharjah, United Arab Emirates). All patients were assessed for eligibility and, based on inclusion criteria, considered for enrollment. Participants met with a dietitian once a week and used the mobile app regularly for 2 weeks. Outcomes (knowledge, self-reported nonadherence, dietary intake, anthropometry, and biochemical data) were measured. This pilot is reported as per guidelines for nonrandomized pilot and feasibility studies and in line with the CONSORT (Consolidated Standards of Reporting Trials) 2010 checklist for reporting pilot or feasibility trials.

Results

Of 26 subjects, 23 successfully completed the pilot. Patient dietary knowledge about phosphorous management improved from 51.4% (SD 13.9) to 68.1% (SD 13.3) after intervention with a large effect size (d=1.22, 95% CI 0.59 to 1.85). Dietary protein intake increased from a mean of 0.9 g/kg (SD 0.3) per day to a mean of 1.3 g/kg (SD 0.5) per day with a large effect size (d=1.07, 95% CI 0.45 to 1.69). Phosphorus to protein ratio dropped from a mean of 18.4 mg/g protein to 13.5 mg/g protein with a large effect size (d=0.83, 95% CI 0.22 to 1.43). There was no evidence of change in phosphorous intake, self-reported nonadherence, and serum phosphorus.

Conclusions

The findings of this prospective pilot reveal the potential efficacy of a smartphone app as a supportive nutrition education tool for phosphorus management in patients undergoing hemodialysis. This pilot study showed that the KELA.AE app has the potential to improve knowledge and dietary choices. A rigorous randomized controlled trial should be performed to evaluate the efficacy, assessing app use of a long-term intervention.

Comparison of the effect of educational and self-management interventions on adherence to treatment in hemodialysis patients: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Adherence to fluid intake, diet, and drug management is very important in hemodialysis patients. Educational and self-management interventions are frequently used to improve adherence to treatment in hemodialysis patients.

OBJECTIVES

To synthesize a comparison of the effect of educational and self-management interventions on adherence to treatment in hemodialysis patients in randomized controlled trials.

METHODS

Systematic searches were conducted using 11 multidisciplinary databases in June 2020. The PRISMA checklist was used. The subgroup analysis was used to compare the effect of educational and self-management interventions on adherence to fluid intake, diet, and drug management.

RESULTS

In the included studies, educational interventions were performed ranging from 15 to 60 minutes, in 1-72 sessions. Self-management interventions were performed ranging from 10 to 120 minutes, in 1-84 sessions. The overall effect of educational interventions was small on adherence to fluid intake (P = .019, Hedges' g = -0.39), diet in serum phosphorus level (P = .001, Hedges' g = -0.35), drug management (P = .002, Hedges' g = -0.44), and not significant on adherence to diet in serum potassium level (P = .181). The overall effect of self-management interventions was small on adherence to fluid intake (P = .001, Hedges' g = -0.19) and diet in serum phosphorus level (P < .001, Hedges' g = -0.42). Additionally, the overall effect of self-management interventions was moderate on adherence to diet in serum potassium level (P = .002, Hedges' g = -0.75) and drug management (P < .001, Hedges' g = -0.55). There was no difference between the educational and self-management interventions on adherence to fluid intake, diet, and drug management (P > .05).

CONCLUSIONS

The analysis shows that educational and self-management interventions had a beneficial effect on adherence to fluid intake, diet, and drug management and no difference between these interventions. Therefore, these interventions can be used by healthcare professionals. It is also recommended that these interventions be well defined and transferable to routine clinical practice.

Dietary interventions with dietitian involvement in adults with chronic kidney disease: A systematic review

BACKGROUND

A comprehensive evidence base is needed to support recommendations for the dietetic management of adults with chronic kidney disease (CKD). The present study aimed to determine the effect of dietary interventions with dietitian involvement on nutritional status, well-being, kidney risk factors and clinical outcomes in adults with CKD.

METHODS

Cochrane Central Register of Controlled Trials, CINAHL, MEDLINE, PsycINFO and EMBASE.com were searched from January 2000 to November 2019. Intentional weight loss and single nutrient studies were excluded. Risk of bias was assessed using the Cochrane risk-of-bias tool. Effectiveness was summarised using the mean difference between groups for each outcome per study.

RESULTS

Twelve controlled trials (1906 participants) were included. High fruit and vegetable intake, as well as a multidisciplinary hospital and community care programme, slowed the decline in glomerular filtration rate in adults with stage 3-4 CKD. Interventions addressing nutrition-related barriers increased protein and energy intake in haemodialysis patients. A Mediterranean diet and a diet with high n-3 polyunsaturated fatty acids improved the lipid profile in kidney transplant recipients.

CONCLUSIONS

A limited number of studies suggest benefits as a result of dietary interventions that are delivered by dietitians and focus on diet quality. We did not identify any studies that focussed on our primary outcome of nutritional status or studies that examined the timing or frequency of the nutritional assessment. This review emphasises the need for a wider body of high-quality evidence to support recommendations on what and how dietetic interventions are delivered by dietitians for adults with CKD.

Evaluation of first-person storytelling on changing health-related attitudes, knowledge, behaviors, and outcomes: A scoping review

OBJECTIVES

First-person storytelling (FPS) has the potential to engage patients in changing behavior differently than didactic education. We assessed the prevalence of FPS in health education interventions; whether published FPS research has shown improvements in attitudinal, knowledge, behavioral, or clinical outcomes; and whether randomized controlled trials (RCTs) including FPS have shown more effectiveness than non-FPS interventions.

METHODS

A scoping review of FPS studies published before October 2019 in five medical databases was conducted.

RESULTS

22 out of 10,363 identified studies met eligibility criteria. FPS has been studied primarily in cancer, diabetes, and hypertension. Of the 12 RCTs, compared to controls, patients receiving FPS interventions improved attitudes (N = 6 studies) and knowledge (N = 1), improved health behaviors like quitting smoking (N = 6), and improved clinical outcomes like lowering A1C levels (N = 3). Of the 10 non-RCT studies, compared to baseline assessments, patients who received FPS interventions had improved knowledge (N = 1), attitudes (N = 3), clinical outcomes (N = 4), and improved health behaviors (N = 7).

CONCLUSION

While rarely used, FPS interventions can improve patient health attitudes and outcomes. Future research should expand FPS to new health areas and determine best practices for developing FPS interventions.

PRACTICE IMPLICATIONS

FPS may be particularly effective with low income patients and racial/ethnic minorities.

Reporting of key methodological and ethical aspects of cluster trials in hemodialysis require improvement: a systematic review

Background

The hemodialysis setting is suitable for trials that use cluster randomization, where intact groups of individuals are randomized. However, cluster randomized trials (CRTs) are complicated in their design, analysis, and reporting and can pose ethical challenges. We reviewed CRTs in the hemodialysis setting with respect to reporting of key methodological and ethical issues.

Methods

We conducted a systematic review of CRTs in the hemodialysis setting, published in English, between 2000 and 2019, and indexed in MEDLINE or Embase. Two reviewers extracted data, and study results were summarized using descriptive statistics.

Results

We identified 26 completed CRTs and five study protocols of CRTs. These studies randomized hemodialysis centers (n = 17, 55%), hemodialysis shifts (n = 12, 39%), healthcare providers (n = 1, 3%), and nephrology units (n = 1, 3%). Trials included a median of 28 clusters with a median cluster size of 20 patients. Justification for using a clustered design was provided by 15 trials (48%). Methods that accounted for clustering were used during sample size calculation in 14 (45%), during analyses in 22 (71%), and during both sample size calculation and analyses in 13 trials (42%). Among all CRTs, 26 (84%) reported receiving research ethics committee approval; patient consent was reported in 22 trials: 10 (32%) reported the method of consent for trial participation and 12 (39%) reported no details about how consent was obtained or its purpose. Four trials (13%) reported receiving waivers of consent, and the remaining 5 (16%) provided no or unclear information about the consent process.

Conclusion

There is an opportunity to improve the conduct and reporting of essential methodological and ethical issues in future CRTs in hemodialysis.

Review Registration

We conducted this systematic review using a pre-specified protocol that was not registered.

Effect of a Nutritional Intervention, Based on Transtheoretical Model, on Metabolic Markers and Food Consumption of Individuals Undergoing Hemodialysis

OBJECTIVE

This study aimed to evaluate the effect of a nutritional intervention, based on the transtheoretical model, on the metabolic markers and dietary intake of individuals undergoing hemodialysis (HD).

METHODS

Intervention study at a nephrology clinic includes 83 individuals undergoing HD, over a period of 4 months. The nutritional intervention based on the transtheoretical model was composed of two group meetings and three individual ones, with delivery of personalized food plans and nutritional education activities. Anthropometry, dietary intake, metabolic markers, and stage of behavior change were evaluated before and after nutritional intervention.

RESULTS

There was a significant change from the stage of contemplation to the stage of action, after the intervention (P < .001). There was a significant reduction in serum concentrations of creatinine and predialysis and postdialysis urea (P < .001). Hyperphosphataemia and hyperkalemia in the group were also significantly reduced as were markers related to bone metabolism (P < .001). The markers of iron metabolism (P < .001), protein (P = .042), and globulin (P < .001) showed a significant increase. Regarding food consumption, the caloric intakes (P = .034), cholesterol (P = .034), protein, and lipid as well as intake of iron, phosphorus, potassium, copper, and vitamin C (P < .001) were significantly higher after intervention.

CONCLUSIONS

The nutritional intervention based on the transtheoretical model promoted a change in the behavior of individuals undergoing HD, with an important improvement in their metabolic control. This can be explained by the significant change in the intake of calories, macronutrients, and micronutrients, as well as adequate use of phosphorus binders, indicating the crucial role of nutrition in this group.

Mineral and bone disorder in hemodialysis patients in the Tibetan Plateau: a multicenter cross-sectional study

Background: Mineral and bone disorder (MBD) in hemodialysis patients is associated with increased morbidity and mortality. Studies on the MBD status of hemodialysis patients at high altitudes are extremely limited. Methods: A total of 146 hemodialysis patients from 5 local hospitals across all districts with hemodialysis centers in the Tibetan Plateau were enrolled in this cross-sectional study. Parameters related to MBD, including serum phosphorus (P), calcium (Ca), and intact parathyroid hormone (iPTH) levels, were measured. The achievement of MBD goals was compared with the achievement in the Dialysis Outcomes and Practice Study (DOPPS) 3, DOPPS 4 and a multicenter study of MBD in China. Factors associated with hyperphosphatemia were examined. Results: Altogether, 146 hemodialysis patients were recruited from the Tibetan Plateau. According to the K/DIGO guidelines, there were low achievement rates for serum Ca (40.4%), P (29.7%), and iPTH (47.1%). As for the (KDOQI) guidelines, the rates of achievement of defined targets were 38.4%, 33.7% and 16.4% for serum Ca, P and iPTH, respectively. The percentages of patients reaching the KDOQI targets for corrected Ca, P, and iPTH were significantly lower for Tibetan patients than the percentages found in DOPPS 3 (38.4% vs. 50.4%, 33.7% vs. 49.8%, and 16.4% vs. 31.4%, respectively, all p < .001) and DOPPS 4 (38.4% vs. 56.0%, 33.7% vs. 54.5%, and 16.4% vs. 35.3%, respectively, all p < .001). The percentage of patients reaching the KDOQI targets for iPTH was significantly lower in Tibet than in the plain areas of China (16.4% vs. 26.5%, p < .001). The proportion of patients with hypocalcemia was higher in Tibet than in the plain areas (44.5% vs. 19.4%, p < .001). The percentage of local patients with optimal P was significantly higher for patients with an activated vitamin D prescription than for patients without an activated vitamin D prescription (45.3% vs. 19.3%, p < .001). Age and the activated vitamin D prescription were independently associated with hyperphosphatemia. Conclusion: The MBD status of hemodialysis patients in Tibet is far from the ideal level. High altitude is one of the possible causes of the differences found, but not the principal one. It is necessary for medical staff in Tibet to improve the detection and treatment of MBD.

Dietary Application for the Management of Patients with Hemodialysis: A Formative Development Study

Objectives

To describe the step-by-step person-centered, theory-based development of the KELA.AE app for Arabic speaking hemodialysis patients.

Methods

A step-by-step person-driven theory-based approach was conducted to develop a self-monitoring and educational dietary app for hemodialysis patients. The development follows the Integration, Design, Assessment, and Sharing (IDEAS) framework. Qualitative, semi-structured interviews with 6 hemodialysis patients and 6 healthcare practitioners (dietitians and nephrologists) were performed to assess the need for an app, the willingness to use an app, and features desired in an app.

Results

The KELA.AE app, which includes a self-monitoring feature, CKD-friendly recipes, and a theory-based, evidence-based educational feature was developed. Qualitative analysis of interviews revealed two predominant themes from patient interviews ‘Experience with the diet’, ‘App evaluation’, and one theme from interviews with healthcare practitioners ‘App evaluation’. Patients expressed frustration with current accessibility of dietary information along with the need for educational materials in the app. The review of the KELA.AE prototype was positive overall, and patients reported a willingness to use the app. Healthcare practitioners considered the app accurate, simple, and culturally sensitive but expressed concerns about app misuse and the replacement of healthcare practitioners.

Conclusions

The KELA.AE app was found to be satisfactory and supportive of the participants' needs. Changes were made to the app as suggested during the interviews.

Strategies to improve dietary, fluid, dialysis or medication adherence in patients with end stage kidney disease on dialysis: A systematic review and meta-analysis of randomized intervention trials

Background

In patients with end stage kidney disease (ESKD) on dialysis, treatment non-adherence is common and results in poor health outcomes. However, the clinical benefits of interventions to improve adherence in dialysis patients are difficult to evaluate since trialled interventions and reported outcomes are highly diverse/ heterogeneous. This review summarizes existing literature on randomized controlled trials (RCTs) evaluating adherence interventions in ESKD patients focusing on the intervention category, outcome efficacy and persistence of benefit beyond the intervention.

Methods

We performed electronic database searches in Medline, Embase & Cochrane CENTRAL upto 1^st July 2018 for RCTs evaluating interventions to improve diet, fluid, medication or dialysis adherence in ESKD patients. Study characteristics including category of interventions, outcomes, efficacy and follow-up were assessed. Meta-analysis was used to compute pooled estimates of the effects on the commonest reported outcome measures.

Results

From 1311 citations, we included 36 RCTs (13 cluster-randomized trials), recruiting a total of 3510 dialysis patients (mean age 55.1 ± 5.8 years, males 58.1%). Overall risk of bias was ‘high’ for 24 and of ‘some concern’ for 12 studies. Most interventions (33 trials, 92%) addressed patient related factors, and included educational/cognitive (N = 11), behavioural / counselling (N = 4), psychological/affective (N = 4) interventions or a combination (N = 14) of the above. A majority of (28/36) RCTs showed improvement in some reported outcomes. Surrogate measures like changes in phosphate (N = 19) and inter-dialytic weight gain (N = 15) were the most common reported outcomes and both showed significant improvement in the meta-analysis. Sixteen trials reported follow-up (1–12 months) beyond intervention and the benefits waned or were absent in nine trials within 12 months post-intervention.

Conclusions

Interventions to improve treatment adherence result in modest short-term benefits in surrogate outcome measures in dialysis patients, but significant improvements in trial design and outcome reporting are warranted to identify strategies that would achieve meaningful and sustainable clinical benefits.

Limitations

Poor methodological quality of trials. Frequent use of surrogate outcomes measures. Low certainly of evidence.

Bone and mineral disorders in chronic kidney disease: implications for cardiovascular health and ageing in the general population

The patient with chronic kidney disease (CKD) represents an extreme model for arteriosclerosis, vascular calcification, and bone disorders, all of which are also associated with ageing in the general population. These pathological features are also relevant to other common chronic health disorders such as diabetes, and chronic inflammatory and cardiovascular diseases. Although management and interventions for these major risk factors are now incorporated into most public health guidelines (eg, smoking cessation and control of bodyweight and blood pressure, as well as glucose and cholesterol concentrations), some residual cardiovascular risk is not reduced by implementation of these interventions. CKD should be regarded as an atypical disease in which both traditional and novel cardiovascular risk factors have effects on outcomes. But CKD can also be viewed conceptually as an accelerator of traditional cardiovascular risk factors. Findings from research into mineral bone disorder associated with CKD (CKD-MBD) could help the medical community to better understand the vascular actions of certain molecules, such as phosphates, fibroblast growth factor 23, parathyroid hormone, sclerostin, or vitamin D and their relevance to the management of different pathologies in the general population. Importantly, these components, which are recognised in nephrology, could help to explain residual risk of cardiovascular events in the general population. Thus, achieving a better understanding of CKD-MBDs could provide substantial insight into future treatments for arteriosclerosis and osteoporosis, which are strongly associated with ageing and morbidity in the general population.

Cost-effectiveness of dedicated dietitians for hyperphosphatemia management among hemodialysis patients in Lebanon: results from the Nutrition Education for Management of Osteodystrophy trial

AIM

To assess the cost-effectiveness of nutrition education by dedicated dietitians (DD) for hyperphosphatemia management among hemodialysis patients.

MATERIALS AND METHODS

This was a trial-based economic evaluation in 12 Lebanese hospital-based units. In total, 545 prevalent patients were cluster randomized to DD, trained hospital dietitian (THD), and existing practice (EP) groups. During Phase I (6 months), DD (n = 116) received intensive education by DD trained on renal nutrition, THD (n = 299) received care from trained hospital dietitians, and EP (n = 130) received usual care from untrained hospital dietitians. Patients were followed-up during Phase II (6 months).

RESULTS

At baseline, EP had the lowest weekly hemodialysis time, and DD had the highest serum phosphorus and malnutrition-inflammation score. The additional costs of the intervention were low compared with the societal costs (DD: $76.7, $21,007.7; EP: $4.6, $18,675.4; THD: $17.4, $20,078.6, respectively). Between Phases I and II, DD showed the greatest decline in services use and societal costs (DD: -$2,364.0; EP: -$1,727.7; THD: -$1,105.7). At endline, DD experienced the highest decrease in adjusted serum phosphorus (DD: -0.32; EP: +0.16; THD: +0.04 mg/dL), no difference in quality-adjusted life-years (QALY), and the highest societal costs. DD had a cost-effectiveness ratio of $7,853.6 per 1 mg decrease in phosphorus, compared with EP; and was dominated by THD. Regarding QALY, DD was dominated by EP and THD. The results were sensitive to changes in key parameters.

LIMITATIONS

The analysis depended on numerous assumptions. Interpreting the results is limited by the significant baseline differences in key parameters, suggestive of higher baseline societal costs in DD.

CONCLUSIONS

DD yielded the greatest effectiveness and decrease in societal costs, but did not affect QALY. Regarding serum phosphorus, DD was likely to be cost-effective compared with EP, but had a low cost-effectiveness probability compared with THD. Regarding QALY, DD was not likely to be cost-effective. Assessing the long-term cost-effectiveness of DD, on similar groups, is recommended.

Effectiveness of educational or behavioral interventions on adherence to phosphate control in adults receiving hemodialysis: a systematic review

BACKGROUND

People with end-stage kidney disease (ESKD) develop impaired excretion of phosphate. Hyperphosphatemia develops in ESKD as a result of the kidney's reduced ability to excrete ingested phosphate load and is characterized by high bone turnover and increased musculoskeletal morbidity including bone pain and muscle weakness. Increased serum phosphate levels are also associated with cardiovascular disease and associated mortality. These effects are significant considering that cardiovascular disease is the leading cause of death in ESKD, making phosphate control a crucial treatment goal.

OBJECTIVES

To determine the effectiveness of education or behavioral interventions on adherence to phosphate control in adults with ESKD receiving hemodialysis (HD).

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Adults aged over 18 years with ESKD undergoing HD, attending dialysis facilities regardless of frequency and duration of treatment sessions per week. Studies with participants receiving hemodiafiltration were excluded.

TYPES OF INTERVENTION(S)/PHENOMENA OF INTEREST

All types of educational and behavioral interventions aimed at improving adherence to dietary phosphate restriction, phosphate binder medication and HD.

TYPES OF STUDIES

Randomized controlled trials (RCTs), non-RCTs, before and after and cohort studies.

OUTCOMES

Outcome measures included serum phosphate levels, patient knowledge and adherence to phosphate control methods, chronic kidney disease (CKD) self-management behavior and perceived self-efficacy for CKD related to phosphate control.

SEARCH STRATEGY

A search was conducted in CINAHL, MEDLINE, The Cochrane Library, Embase, Web of Science, PsycINFO and ProQuest Dissertations and Theses Global to find published studies between January 2005 and December 2015.

METHODOLOGICAL QUALITY

Risk of bias was assessed by three reviewers prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI).

DATA EXTRACTION

Data were extracted using the standardized data extraction tool from JBI-MAStARI.

DATA SYNTHESIS

Data were pooled using JBI software. Mean differences (95% confidence interval [CI]) and effect size estimates were calculated for continuous outcomes. Meta-analysis using a random-effects model was performed for serum phosphate levels, and where the findings could not be pooled using meta-analysis, results have been presented in a narrative form. Standard GRADE (Grading of Recommendations Assessment, Development and Evaluation) evidence assessment of outcomes has been reported.

RESULTS

A total of 18 studies were included in the review: seven studies focused on dietary phosphate, four studies focused on medications (phosphate binders) and six studies focused on dietary phosphate and medications. Only one study taught patients about diet, medications and HD to control phosphate. Sixteen studies showed significant improvements in phosphate levels. Meta-analysis of eight RCTs favored educational or behavioral interventions over standard care for serum phosphate control, with a weighted mean reduction of -0.23 mmol/l (95% CI -0.37, -0.08) in treatment groups.

CONCLUSION

Overall, educational or behavioral interventions increase adherence to phosphate control. Studies in this systematic review revealed improved outcomes on serum phosphate levels, patient knowledge and adherence to phosphate control methods, CKD self-management behavior and perceived self-efficacy for CKD related to phosphate control. However, there is a lack of sufficient data on how some of the studies implemented their interventions, suggesting that further research is required. Successful strategies that improve and optimize long-term adherence to phosphate control still need to be formulated.

Nutritional education for management of osteodystrophy: Impact on serum phosphorus, quality of life, and malnutrition

Introduction Osteodystrophy management includes dietary phosphorus restriction, which may limit protein intake, exacerbate malnutrition-inflammation syndrome and mortality among hemodialysis patients. Methods A multicenter randomized controlled trial was conducted in Lebanon, to test the hypothesis that intensive nutrition education focused on phosphorus-to-protein balance will improve patient outcomes. Six hemodialysis units were randomly assigned to the trained hospital dietitian (THD) protocol (210 patients). Six others (184 patients) were divided equally according to the patients' dialysis shifts and assigned to Dedicated Dietitian (DD) and Control protocols. Patients in the THD group received nutrition education from hospital dietitians who were trained by the study team on renal dietetics, but had limited time for hemodialysis patients. Patients in the DD group received individualized nutritional education on dietary phosphorus and protein management for 6 months (2-hour/patient/month) from study renal dietitians. Patients in the control group continued receiving routine care from hospital dietitians who had limited time for these patients and were blinded to the study. Serum phosphorus (mmol/L), malnutrition-inflammation score (MIS), health-related quality of life (HRQOL) index and length of hospital stay (LOS) were assessed at T0 (baseline), T1 (postintervention) and T2 (post6 month follow up). Findings Only the DD protocol significantly improved serum phosphorus (T0:1.78 ± 0.5, T1:1.63 ± 0.46, T2:1.69 ± 0.53), 3 domains of the HRQOL and maintained MIS at T1, but this protective effect resolved at T2. The LOS significantly dropped for all groups. Discussion The presence of competent renal dietitians fully dedicated to hemodialysis units was superior over the other protocols in temporarily improving patient outcomes.

Development and evaluation of continuing education course in renal nutrition

BACKGROUND/OBJECTIVE

Competent renal dietitians are crucial for better patient compliance and clinical outcomes, specifically in critical settings. The aim of this study was to develop and evaluate an evidence-based course in renal dietetics for dietitians working in health care systems where dietetic specialization is absent.

SUBJECTS/METHODS

Fifteen licensed dietitians working with hemodialysis patients in Lebanon were randomly recruited to participate in the course. The latter was developed by the study's primary investigator, according to evidence-based practice guidelines, and focused on all aspects of renal nutrition. Total course duration was 28 hours spread over a 2 month period. Dietitians' knowledge in renal nutrition was tested pre- and post-training through a 23-item questionnaire; the total score was expressed in percentage (< 60% score indicated insufficient knowledge). Paired-samples t test was used for statistical analysis.

RESULTS

Overall knowledge of the dietitians significantly improved post-training and reached satisfactory levels (pre: 38.75 ± 17.20%, post: 62.08 ± 21.85%). Sub-analysis of the change in the knowledge showed significant and satisfactory improvement only in 3 topics: 1) correct body weight use in calculations, 2) energy estimation method and 3) phosphorus management. Knowledge in the fluid management significantly improved but did not achieve a satisfactory level.

CONCLUSION

The course significantly improved dietitians' knowledge in renal nutrition. If adopted as part of the continuing education of dietitians in countries that lack dietetic specializations, it may serve the first step towards improving health care practice.