Effect of Structured Pre-dialysis Education on the Clinical Outcomes of Kidney Patients

doi:10.21203/rs.3.rs-5290079/v1

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Effect of Structured Pre-dialysis Education on the Clinical Outcomes of Kidney Patients

https://doi.org/10.21203/rs.3.rs-5290079/v1

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Background: The aim of this study was to evaluate the effect of pre-dialysis education on clinical, laboratory, quality of life and self-care ability of patient started dialysis treatment.

Methods: In this observational study we recruited 202 patients. 108 of them were patients who received systematic pre-dialysis education-(education group), 94 patients who were started on dialysis without education (non-education group). Quality of life, self-care, ability, psychological/depressive status, biochemical parameters were evaluated and compared between groups.

Results: The education group had a significantly higher selfcare score (98.3 ± 8.5) (82.4 ± 21.5, p<0.001). The depressive symptoms were lower in the education group (2,8%, 0.9%, and 0.9%; respectively) compared with the non-education group (31.9%,20.2%,2.8%; respectively, p<0.001). Quality of life scale results were significantly higher in the education group than those in the non-education group (p<0.001 for each). Phosphate, parathormone, BUN and residual renal function level was significantly lower (p<0.01) and hemoglobin was significantly higher (p<0.01) in the education group compared to those in the non-education group.

Conclusion: Our study shows that systematic education practices in the pre-dialysis period appear to a associated with improved quality of life, increased self-care ability, increased psychosocial well-being and positive effects on clinical outcomes in dialysis patients.

Pre-dialysis education programs give patients the chance to involve decision making on a treatment option.

Predialysis education improves patients' self-care ability

Predialysis education provides psychosocial well-being in patients

Predialysis education has a positive impact on clinical outcome

End Stage Renal Disease is an important public health problem and because of the rapid increased incidence and prevalence, has become an epidemic in the world and in our country. It is a disease that has a large social burden due, high morbidity and mortality rates, serious effects on quality of life, low awareness and high costs for treatment [1–3]

Several factors can affect therapeutic success in ESRD. These include the time of referral to the nephrology team, training about treatment, supporting patients to adapt for treatment regimen [4].

Optimal management of CKD may improve clinical outcome and decrease mortality, thus resulting in reduced hospitalization and medical cost. Aggressive approaches are needed. Pre-dialysis follow-up policies have been established to prevent the disease, to control and manage progression with early diagnosis and appropriate treatment methods, to prolong the life span of patients and to increase their quality of life. Therefore, early referral to the nephrology team and multidisciplinary pre-dialysis education has been accepted as a fundamental and complementary practice in nephrology [5, 6]

It should be aimed and ensured that the patient reaches the appropriate RRT option at the appropriate time and under appropriate conditions. Patients must be adequately informed about the types of dialysis and kidney transplantation before starting dialysis treatment. The Pre-Dialysis Training Program is a systematic training program designed to enable patients to benefit optimally from End Stage Renal Failure treatment options, to start treatment at the scheduled time, and to provide patients with the opportunity to choose their own treatments. Studies that evaluate initiation status of dialysis treatment reported that half of all patients started renal replacement therapy (RRT) in a planned manner compared to the remaining where dialysis therapy was initiated in an emergent setting due to late referral to the nephrology team. All research in this area emphasizes the importance of early referral to the nephrology team and pre-dialysis education [7].

Recent trials and studies also have proven the efficacy of several interventions such as early detection of CKD, prevention of kidney disease progression, early referral to nephrologists, promotion of pre-dialysis educations, timely preparation of renal replacement therapy (RRT), and care by a comprehensive, nephrology-based, multi-disciplinary team.

Purpose

This study aimed to evaluate and compare clinical outcomes, self-care capability, QoL and psychological status in dialysis patients who had been started on therapy in an “planned” manner with education vs. those who start in dialysis without education.

The universe of this descriptive and correlational controlled study consisted of patients who received peritoneal dialysis (PD) and hemodialysis (HD) treatments.

The sample size was determined as 200 by taking into account of medium effect, 95% power and 0.05 error probability by power analysis.

Adult patients (> 18 years old) who were on dialysis at least three months were included to the study after received written consent. Those with psychological disorders, malignancy, decompensated heart or hepatic failure, visual or hearing problems were not included. Three patients did not agree to give informed written consent.

The study population was categorized as the “education group” who had had pre-dialysis education (n = 108) and as the “control group” who started dialysis urgenttly and had not received any education before dialysis initiation (n = 94).

Data Collection

Patient Information form contained several items that collected patient data on socio-demographic (sex, age, and marital/ educational status) type of RRT characteristics.

Self-care ability was evaluated through “Self-Care Ability Scale (SCAS). This 43-item scale, which was used for assessment of the individuals’ self-care ability (8). The validity and reliability of the scale was adapted by Nahcivan for Turkish adolescents and reduced to 35 items. The levels of self-care ability are defined as: 24–64, poor; 65–100, moderate; 101–112, good; and113–140, very good. Cronbach’s alpha value for the self-care ability scale was found 0.913 for this study, which indicated its reliability for this research [9]

Patient Health Questionnaire (PHQ-9) is a nine-item tool used for diagnosis, treatment selection, and monitoring depression. It identifies psychological problems experienced by the patients and assesses the extent of the patient’s disturbance by these problems. It is commonly used by healthcare professionals as it usually facilitates psychological diagnosing [10]

The Quality of Life (QoL) was determined by SF-36 Scale. Developed by Ware in 1987, SF-36 QoL Scale is a self-assessment scale designed for use in clinical practice and research, health policy assessments, and general population surveys. All statements in the scale are responded by taking into consideration the last four weeks [11–12].

Clinical and biochemical parameters including blood pressure, hemoglobin, albumin, C-reactive protein, calcium, phosphate, parathormone, creatinine, blood urea nitrogen, and residual renal function (RRF) were collected from medical records of the patients; no additional tests were performed.

Patients gave written consent after being informed about the purpose of the study and agreed to participate. HD patients were interviewed after dialysis sessions whereas PD patients at routine outpatient monthly visits. Questionnaires were filled by patients themselves or via face-to-face interviews during 40 to 45 minutes. Clinical and laboratory parameters obtained from most recent information from patien files. The study was performed after being approved by the ethics committee and relevant institutional permissions.

Statistical analysis

The data were analyzed through SPSS (Statistical Package for Social Sciences) for Windows 17.0 software. Socio-demographic and disease-related variables were expressed as number, percentage, mean and median. The comparisons of socio-demographic characteristics between the study groups, in terms of SF-36, PHQ and SCAS scores, were analyzed with t-test. Analysis of variance (univariate ANOVA) for normally distributed data or with Kruskal-Wallis and Mann-Whitney U tests for non-normally distributed data. Categorical variables between the groups were compared via chi-square test. Significance was established at the p < 0.05 level.

Socio-demographics characteristics; Among 202 patients of the study population, women constituted 52.6% and the median age was 52 years (range: 19–80 years). More than half (57.4%) of the patients were found to be primary school graduates, 24.3% illiterate, and 15.3% high school graduates. Married patients constituted 61.9% of the study population. Age distribution of the study groups was found to be similar (median age: 50 years in the education group vs. 52 years in the non-education group.

Treatment Modality Decision: Patients who never educated had found to be used of HD (77,7%). It is noteworthy that education and pre-dialysis management had a big impact on the probability of PD as final RRT (54,6%) (Fig. 1).

Clinical and Laboratory Parameters; Analysis of biochemical parameters showed that hemoglobin, calcium, creatinine levels and RRF were significantly higher in the education group compared with those in the non-education group (p = 0.002, p < 0.001, p < 0.001, and p < 0.001; respectively). On the other hand, the education group had significantly lower levels of CRP, phosphate, PTH, and BUN compared to those in the non-education group (p < 0.001 for each), (Table 1).

Table 1

Clinical and laboratory characteristics of the study groups.
	Pre-dialysis education (n = 108)		No pre-dialysis education (n = 94)		p
Characteristics	Mean	SD	Mean	SD	p
Hemoglobin (mg/dl)	11.19	0.83	10.59	1.64	0.002*
Albumin (mg/dl)	3.86	0.27	3.72	0.49	0.096
CRP (mg/l)	14.61	11.15	24.63	46.82	< 0.001*
Calcium (mg/dl)	9.22	0.40	8.59	0.88	< 0.001*
Phosphate (mg/dl)	4.46	0.69	5.60	1.58	< 0.001*
PTH (pg/ml)	208.59	94.75	417.54	232.53	< 0.001*
Systolic blood pressure (mmHg)	124.31	11.42	125.00	27.50	0.105
Diastolic blood pressure (mmHg)	75.47	7.72	75.00	14.65	0.008*
RRF (ml/day)	545.73	339.94	38.17	110.19	< 0.001*
Creatinine (mg/dl)	8.52	2.03	10.13	13.39	< 0.001*
BUN (mg/dl)	66.12	13.18	96.28	37.13	< 0.001*
* Kruskal-Wallis Test

BUN, blood urea nitrogen; CRP, C-reactive protein; PTH, parathormone; RRF, residual renal function

Self-care Ability: Patients in the education group were evaluated to have a higher mean SCAS score (98.3 ± 8.5) compared to that of patients in the non-education group (82.4 ± 21.5; p < 0,001), (Table 2).

Table 2

Comparison of the study groups in terms of SF-36 and SCAS scores.
	Pre-dialysis education (n = 108)		No pre-dialysis education (n = 94)		F	p
SF-36	Mean	SD	Mean	SD	F	p
Physical function	78.94	10.37	35.59	28.07	88.84	< 0.001*
Physical role	83.33	22.24	25.00	37.39	66.37	< 0.001*
Pain	18.71	15.18	54.20	26.59	40.20	< 0.001*
General health	37.78	9.64	51.46	12.40	25.57	< 0.001*
Energy/vitality	54.24	8.49	51.91	12.79	0.93	0.398
Social function	48.86	7.88	47.01	16.03	0.73	0.484
Emotional function	81.82	23.71	27.34	38.51	57.94	< 0.001*
Mental health	74.18	8.84	55.06	15.49	30.38	< 0.001*
SCAS	98.04	11.38	82.35	21.48	22.731	< 0.001*

*ANOVA Test

SCAS, Exercise of Self-Care Agency Scale; SF-36, Short Form-36 Health Survey

Psychosocial Assessment: The psychosocial evaluation measured by PHQ-9 showed that patients in the education group have minimal and mild depressive symptoms, (45.4% and 50.0%) respectively. On the other hand, the frequency of moderate, moderately severe, and severe depressive symptoms was lower in the education group (2,8%, 0.9%, and 0.9%; respectively) compared to that in the non-education group (31.9%, 20.2%, 12.8%; respectively, p < 0.001 for each), (Fig. 2).

Quality of Life; SF-36 QoL scale showed that the mean scores of physical function, physical role, pain, general health, emotional function, and mental health subscales were significantly higher in the education group when compared to the non-education group (p < 0.001 for each) (Table 2).

There is strong evidence in the literature reporting that timely referral of chronic kidney disease (CKD) patients to nephrology team for optimal management and care is associated with reduced morbidity and mortality [13–14]

Several studies reported that more than half of patients were late referred to the nephrology team and these patients started dialysis treatment without any education [15–16]. A multicenter study with 1488 patients reported that 53% of dialysis patients were started on therapy in acute/emergency settings due to late referral to the nephrology team [7, 16]. Our study showed that 46.5% of the patients were late referred to the nephrology team and did not receive any education.

A study investigating the association between education and treatment option reported that 41.5% of those who received multidisciplinary pre-dialysis education preferred home-treatment and 55% of them were started on dialysis therapy in a planned manner [17]. Another study with 573 cases reported that 35% of patients receiving multidisciplinary education preferred PD whereas 80% of patients who did not receive education preferred HD [18]. Research suggests that pre-dialysis education program has impact on the choice of dialysis treatment and education is associated with a higher likelihood of home-treatment [19]. Consistent with these findings, our study indicated higher preference for PD in the education group compared to that of HD in the non-education group.

In patients with CKD, psychosocial problems, including physical insufficiency, dependence on healthcare team, changing roles in the family, restricted working life and social relations, internal conflicts, impaired sexual functions, fatigue, change in body image, fluid restriction, diet limitations, fear of future, and reduced life expectancy, might increase the disability of the patients, causing changes in daily living activities, and thereby leading to a decrease in self-care ability [20]. Several studies reported that CKD patients who received appropriate education had improved self-competence and self-care [21], and that self-care ability was higher and preferred home-treatment options [22–24]. Our findings revealed a higher self-care ability of the education group as compared to that of the non-education group. We further suggest the preference of home-treatment in the education group to be a positive key factor for the success of the home-treatment as they have higher self-care ability.

About a quarter of patients with ESRD who have been hospitalized for medical reasons have a psychiatric problem. Depression is the most important psychological problem as it can lead to the termination of dialysis, if not recognized and untreated [25]. A study that evaluated the impact of HD patients’ education on their QoL, anxiety, and depression level reported that such education was associated with improved QoL scores at all subdomains as well as reduced level of anxiety and depression. The authors concluded that educational interventions targeting improved QoL and psychiatric conditions, needed to be continued [26]. Consistently, we also showed that depressive symptoms were less pronounced in patients who had received pre-dialysis education.

There are a limited number of studies evaluating health-related QoL of patients in the pre-dialysis period. A study regarding these patients reported a rapidly decreased QoL, which was associated with increased serum creatinine and decreased hematocrit value [27]. In our study, SF-36 QoL scale showed better scores for physical function, physical role, pain, general health, emotional function and mental health subscales in the education group with no difference on energy/vitality and social function. The lack of impact on the latter two subdomains could be attributed to the limitations due to overall disease burden and the need for time spent on the treatment itself.

Multidisciplinary management and care in the pre-dialysis period is associated with improved clinical outcomes [18, 27–28]. In addition, a study evaluating patients with or without multidisciplinary education prior to dialysis treatment reported that those receiving multidisciplinary approach had better clinical outcomes [16, 29]. In our study, the education group was found to have higher hemoglobin and calcium and lower phosphate levels. A close follow-up of these parameters as well as PTH is regarded as critical for the treatment and prevention of complications and potential comorbidities in ESRD (28, 30). A prospective study reported that iPTH was better controlled in patients who received pre-dialysis education [29, 30]. Consistently, we also detected lower PTH level in the education group.

Education group revealed higher RRF and lower creatinine values in our study. Parallel to these results, patients receiving education were reported to be associated with a better preserved RRF [16, 29, 30].

CRP levels in our study were found as lower in the education group with no difference in albumin levels. The study by Wu et al. reported higher albumin and lower CRP levels in subset of patients who received education [18, 30].

Limitations

There are some limitations to this research. Firstly, some of collected data are based solely on the patients’ self-reporting. Secondly, patients from only one hospital enrolled to study which, by being a nonprobability sampling method, may not adequately represent the population. Finally, the cross-sectional study did not assess the changes in the respondents’ results over time.

Most of patients with ESRD tend to start on dialysis treatment without any pre-dialysis education. Patients who received education such in our study were more likely to prefer PD, to have higher self-care ability, lower level of moderate and severe depressive symptoms, higher QoL, and to exhibit improved clinical and laboratory outcomes. It seems that pre-dialysis education is associated with better clinical outcomes and hence it has a potential impact on improving patient results.

Author Contribution

Z.A. collected the data, analysed the data, wrote the main manuscript text, prepared figures and tables and reviewed the manuscript S.O. analysed the dataand reviewed the manuscript

Acknowledgement

The authors gratefully acknowledge the Nephrology Units, patients and staff who contributed data to the study

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No competing interests reported.

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Effect of Structured Pre-dialysis Education on the Clinical Outcomes of Kidney Patients

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Purpose

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Results

*ANOVA Test

Discussion

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Author Contribution

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