Effect of Multi-Dimensional Education on Disease Progression in Pre-Dialysis Patients in China

Abstract

Background: There is an increasing body of evidence showing that educational interventions aiming at empowering patients are successful in chronic disease management. The aim of this study was to conduct an evaluation of the systematic effectiveness of a multi-dimensional education intervention program in a group of pre-dialysis chronic kidney disease (CKD) patients. In addition, we investigated whether the outcome of the program was related with the amount of education. Methods: We collected data retrospectively from 302 patients with CKD stages 3, 4, and 5, who were followed up from February 2006 to March 2008. The patients were divided into long-time education group and short-time education group depending on the number of provided hours of education. Survival analysis was undertaken to see if the progression of the kidney function differed between these two groups. Results: The percentage of patients receiving long-time education was highest with severe degree of impairment of renal function (45.5%, 61.3%, and 66.7% in CKD stages 3, 4, and 5 groups, respectively). In a multivariate regression analysis, adjusting for age, gender, Charlson comorbidity index, and other traditional risk factors of renal failure, such as smoking, hypertension, and renal function (glomerular filtration rate), the length of time until a decline of renal function by 25% was noted and was significantly shorter in the short-time education group as compared to the long-time education group (p = 0.0334). Conclusion: Multi-component structured empowerment intervention is effective in pre-dialysis CKD patients and may lead to a delay in the progression of kidney disease.

• chronic kidney disease
• education
• kidney disease progression

INTRODUCTION

Chronic kidney disease (CKD) is a significant and growing medical, social, and economic problem worldwide as an increasing number of patients develop end-stage renal disease (ESRD) and require renal replacement therapy (RRT). China is a developing country with a vast population of 1.3 billion. There were 41,755 patients undergoing maintenance dialysis in 1999,¹ and this figure has increased dramatically in recent years. It is thus no doubt that great efforts should be made to develop and implement strategies aiming at stopping progression or even inducing remission/regression of CKD to reduce the number of patients with ESRD.

It has been clearly demonstrated that lifestyle-related factors and diseases such as diet, hypertension, hyperglycemia, and also medicine abuse play important roles in the deterioration of kidney function. As patient empowerment is an essential step to help the patients to change their lifestyle, we hypothesized that patient empowerment education may have some positive effects on the progression of CKD. Helping patients to develop necessary skill by coaching and motivation is an essential component in patient empowerment education. Therefore, in this study, we developed a multi-dimensional education intervention program (MIP) based on three components (education, skills, and motivation) for our CKD patients and investigated the efficacy of this educational program on the progression of kidney function in this patient population.

MATERIALS AND METHOD

Subject

Total 302 CKD stages 3, 4, and 5 patients were recruited from our CKD program and received training from February 2006 to March 2008 and the outcome of these patients was then studied retrospectively. The inclusion criteria were glomerular filtration rate (GFR) <60 mL/min, pre-dialysis CKD (transplant, hemodialysis, and peritoneal dialysis patients were excluded), and could be followed up regularly. The measurement at the first CKD clinic visit was treated as the baseline. All patients had been followed up for at least 3 months. We provided education program on disease knowledge, lifestyle change skills, group community activities, and group discussion. The time the patients had taken part in those courses and activities was calculated by a primary nurse according to patient’s file. The patients were divided into long-time education group (L-MIP) and short-time education group (S-MIP) according to the total time of education, using a cut-off value of 12 h of education during the study period (L-MIP ≥12 h; S-MIP < 12 h). The event was defined as the occurrence of GFR decrease by 25% compared with baseline, initiation of dialysis, or transplantation. The study protocol was approved by the Ethic Committee of Peking University, and all patients gave their written informed consent.

Education Program

The MIP was built on knowledge, skills, and motivation that CKD patients require as recommended by K/DOQI guideline.² We provided various programs to those patients: (1) The core curriculum is about CKD-related knowledge taught by nephrologists and nurses once a week; the core curriculum comprised eight parts (1.5 h per part) as shown in Table 1. This course provided patient education in a traditional way. (2) Skills coaching program on how to change lifestyle was taught by dietician and volunteers once a week (2 h per session). Skills such as how to adjust diet menu into 0.6 g protein/kg/day, how to calculate daily protein intake, how to control salt and water balance, how to calculate amount of exercise, how to control blood glucose, and so on (Table 2), were shared among the team including the patients and their family members. (3) Motivational activities were organized by the team. The activities included patient group discussion, story-telling, expert patient lecture provided by experienced CKD patients, CKD patient committee, patient’s journal to display patients’ story that failed or succeeded with comments from nephrologists.

Table 1. Core curriculums provided to CKD patients.

Section	Courses in eight core curriculums
I	ABC of chronic kidney disease (CKD)
II	How to prevent aggravation of kidney function
III	Life style and CKD
IV	Complications of CKD
V	Medicine, detection, and clinic service of CKD
VI	Self-management and rehabilitation of CKD
VII	Rational diet of CKD
VIII	Replacement treat on CKD

Table 2. Multi-dimensional education intervention about salt intake control.

Component	Content
Knowledge	• Importance of salt intake
	• Salt <3 g every day
Skill	• How to calculate the salt intake
	• Which food is hypersaline? Aginomoto, oyster sauce, soy sauce . . .
	• Seasoning without salt: vinegar, onion, garlic, pepper, mustard . . .
	• Individual serving in dinner
	• Replace 3 g salt by 15 mL soy sauce
	• Less dining in restaurants
Encourage	• Experiences shared by expert patients
	• Questionnaire in salt intake

Data Collection

Patient demographic data were collected at baseline. Serum albumin (sALB), serum creatinine, hemoglobin (Hb) concentrations, and 24 h urinary protein were analyzed using standard methods at the Department of Laboratory Medicine, Peking University Third Hospital. Body mass index (BMI) was calculated by the formula of weight (kg) divided by height squared (m²). Systolic blood pressure (SBP) and diastolic blood pressure (DBP) levels were measured at the routine visit. The Charlson comorbidity index was scored at the baseline using the definitions of Charlson et al.³

GFR was estimated by a modified formula for Chinese:

According to the estimated GFR, patients’ CKD stages were established: stage 3 with GFR of 30–59 mL/min, stage 4 with GFR of 15–29 mL/min, and stage 5 with GFR of <15 mL/min.⁵

The smoking status was defined as years of smoking × packages of cigarette/day >1⁶; alcohol drinking status was defined as drinking alcohol more than two times monthly.⁷ The low protein intake status was defined as <0.6 g/kg/day based on 3-day dietary records (including 1 weekend day and 2 weekdays). Education level was assigned a score from 0 to 5 indicating if the patients received education in primary school and below, junior middle school, high school, junior college, bachelor and master, respectively.

Statistical Analysis

Comparisons of data between patients in different groups were performed using the Student’s t-tests for parametric variables or the Mann–Whitney U-test for nonparametric variables. Continuous variables were expressed as mean ± standard deviation, while categorical variables were expressed as percentage or ratio. Comparisons of continuous variables among these groups were performed using ANOVA or Kruskal–Wallis tests. Comparisons of nominal variables among these groups were performed using χ² test. Spearman’s rank correlation (ρ) was used to determine the correlations of time of renal function by 25% decrease or to dialysis with other variables. Comparison of kidney function survival between two groups was performed using the Kaplan–Meier analysis with Logrank test. A p-value of less than 0.05 was considered statistically significant. All the statistical analyses were performed using SPSS version 15.0 (SPSS, Inc., Chicago, IL, USA), and SAS version 9.2 (SAS Institute, Inc., Cary, NC, USA).

RESULTS

Demographic Characteristics

Total 302 patients were recruited in this study according to inclusion criteria. All of them were followed up for more than 3 months. The etiology of CKD was analyzed and the primary diagnoses of CKD of patients were glomerulonephritis (62/20.5%), interstitial nephritis (80/26.5%), diabetes (36/11.9%), hypertension (77/25.5%), and others (47/15.5%). The clinical characteristics and causes of kidney disease did not differ significantly between the two groups. Ten patients entered into RRT until the end of follow-up, two patients into center hemodialysis, and eight patients into continuous ambulatory peritoneal dialysis; three patients died because of cardiovascular disease (n = 2) and cancer (n = 1). Gender distribution, age, height, and several traditional factors which could influence the progression of kidney disease, such as BMI, albumin, Hb, 24 h urinary protein, anti-hypertension medications, smoking, drinking, and education level were not significantly different between the two groups at baseline (p > 0.05). The proportion of patients who received L-MIP (vs. S-MIP) was lower among patients with CKD stage 3 and higher among CKD stage 5 patients as shown in Tables 3 and 4.

Table 3. Comparisons of demographic and clinical parameters between pre-dialysis CKD patients receiving more (N = 162) or less (N = 140) formalized education.

	S-MIP (N = 140)	L-MIP (N = 162)	p-Value
Age	65 ± 13	65 ± 12	NS
Sex (female)	50.7% (81)	50% (81)	NS
Diabetes (%)	28.4	24.8	NS
eGFR (mL/min)	38 ± 15	37 ± 16	NS
CKD stage
CKD3	65.0% (91)	46.9% (76)	<0.01
CKD4	20.7% (29)	28.4% (46)	NS
CKD5	14.3% (20)	24.7% (40)	<0.01
Creatinine (mol/L)	219 ± 130	235 ± 121	NS
Height (cm)	163.6 ± 8.2	164 ± 8.4	NS
24h albuminuria (g/day)	1.68 ± 1.83	1.53 ± 1.71	NS
CCI	2.59 ± 1.03	2.65 ± 0.99	NS
Education level	3.38 ± 1.69	3.11 ± 1.81	NS
AHM
ACEI (%)	16.1	15.6	NS
ARB (%)	26.3	26.6	NS
Calcium antagonist (%)	51.8	45.8	NS
β-blocker (%)	27.1	27.3	NS

Note: S-MIP, short-time multi-dimensional education intervention program; L-MIP, long-time multi-dimensional education intervention program; eGFR, estimated glomerular filtration rate; CCI, Charlson comorbidity index; AHM, antihypertensive medication; ACEI, angiotensin-converting enzyme inhibitors; ARB, angiotensin receptor antagonist; NS, no significant difference between the two groups.

Table 4. Comparisons of clinical parameters between pre-dialysis CKD patients receiving S-MIP (N = 162) or L-MIP (N = 140) formalized education on the baseline and endpoint.

		Baseline			Endpoint
	S-MIP	L-MIP	p-Value	S-MIP	L-MIP	p-Value
BMI (kg/m^2)	24.04 ± 3.65	24.13 ± 3.84	NS	23.59 ± 2.99	24.01 ± 3.14	NS
BP
SBP (mm Hg)	135 ± 16	132 ± 16	NS	131 ± 15	128 ± 15	0.05
DBP (mm Hg)	79 ± 11	78 ± 11	NS	77 ± 10	72 ± 9	0.03
PP (mm Hg)	55 ± 15	54 ± 17	NS	55 ± 15	54 ± 14	NS
BW (kg)	64.9 ± 12.3	64.8 ± 12.6	NS	65.6 ± 12.9	65.1 ± 11.9	NS
Hb (g/L)	116.5 ± 20.5	116.7 ± 27.2	NS	115.6 ± 21.2	119.2 ± 26.6	0.03
sALB (g/L)	42.8 ± 3.52	42.6 ± 3.66	NS	40.9 ± 4.01	43.3 ± 3.78	0.04
DP (g/kg/day)	0.76 ± 0.21	0.78 ± 0.20	NS	0.74 ± 0.18	0.68 ± 0.15	0.02
Life style
AHM (%)	80	78	NS	74	72	NS
LPI (%)	56	59	NS	60	73	<0.001
Smoking	16.8% (21)	12.2% (20)	NS	12.8% (15)	3.1% (5)	0.01
Drinking wine	10.9% (15)	6.1% (10)	NS	4.2% (8)	0.5% (1)	<0.001

Note: S-MIP, short-time multi-dimensional education intervention program; L-MIP, long-time multi-dimensional education intervention program; BMI, body mass index; BW, body weight; SBP, systolic blood pressure; DBP, diastolic blood pressure; PP, pulse pressure; Hb, hemoglobin; sALB, serum albumin level; DPI, dietary protein intake (n = 102); AHM, anti-hypertension medicine; LPI, low protein intake; NS, no significant difference between the two groups.

Table 5. Multivariate regression model predicting time to significant renal function decline: decrease by 25% or initiation of dialysis in pre-dialysis patients.

Parameter	Parameter estimate	Standard error	p-Value
Intercept	147.41	53.92	0.006
Age (years)	0.17	0.59	0.771
Gender (female)	5.99	9.11	0.517
CKD multi-education	106.60	16.78	<0.001
CCI	26.37	8.86	0.003
Smoking	33.18	24.93	0.184
Hypertension, presence	6.92	16.69	0.679
BMI	−15.23	10.68	0.155
eGFR (MDRD China)	3.04	0.56	<0.001

Notes: The adjusted R² of the model is 0.25. CKD, chronic kidney disease; BMI, body mass index; CCI, Charlson comorbidity index; BMI, body mass index; eGFR, estimated glomerular filtration rate.

As shown in Table 4, there were no significant differences between the two groups in BMI, blood pressure, Hb, sALB, and lifestyle-related factors (antihypertension medications, low protein intake, smoking, and alcohol drinking) at baseline. During the follow-up, BMI and body weight were stable in both the groups. At the end of follow-up, the high education group had a lower level of SBP (p = 0.05) and DBP (p = 0.03), and a higher level of Hb (p = 0.03) and sALB (p = 0.04). In the lifestyle section, antihypertension medication usage was the same during the whole intervention period, while more patients achieved low protein intake target in L-MIP group. Meanwhile, the percentage of patients who smoked and used alcohol also dropped dramatically in this group compared with that in the S-MIP group (smoking, 3.1% vs. 12.8%, p < 0.05; drinking, 0.5% vs. 4.2%, p < 0.001).

Survival of Kidney Function

The proportion of patients receiving longer time education (L-MIP) was higher among patients with more severe decrease of renal function: 45.5% (76/167), 61.3% (46/75), 66.7% (40/60) in CKD stage 3, CKD stage 4, and CKD stage 5, respectively (p < 0.05). In the multivariate regression analysis, the amount of CKD multi-education was independently associated with the length of time until a decline of renal function by 25% was noted, after adjusting for age, gender, Charlson comorbidity index, and other traditional risk factors such as smoking, hypertension, and renal function (GFR), as shown in Table 5. The decline in the rate of renal function was significantly faster in the low education group compared with the high education group (p = 0.0334), as shown in Figure 1.

Figure 1. Survival of kidney function in long-time education group (L-MIP) and short-time education group (S-MIP).

DISCUSSION

The principal finding in this study was that the multi-dimensional education program was found to have a positive effect on preventing or delaying the deterioration of kidney function in pre-dialysis patients. Our results indicate that multi-dimensional intervention combining components of knowledge, skill, and encouragement may help patients to achieve better control of their blood pressure and better adherence to the recommended low-protein diet, and suggest that these improvements may have contributed to the observed improvement of clinical outcome. The observation that the percentage of patients receiving more education was less among CKD stage 3 patients compared with CKD stages 4 and 5 may suggest that patients with earlier stages of CKD have less motivation. It may reflect that patients think that as the progression of disease in early stages still was slow, they did not need to pay much attention to the self-management. Therefore, improved strategies in patient education need to be developed to motivate patients in the early stages of CKD.

A high-protein intake can contribute to a decline of kidney function, and appropriate protein restriction can reduce the progression of CKD in renal disease patients⁸: when GFR is 13–24 mL/min/1.73 m², for every 0.2 g/kg/day reduction of protein in diet, the rate of kidney function reduction was reported to drop by 29%. The protein intake in CKD stages 3, 4, and 5 is recommended by K/DOQI² to be less than 0.6 g/kg/day, but in clinical practice, we found that although many patients had this knowledge, few of them knew how to make a menu that would allow them to achieve a protein intake target of 0.6 g/kg/day.

This study demonstrated that multi-education program can improve the control of protein intake in pre-dialysis patients. In the multi-dimensional education program, a dietician gave lectures about the importance of protein control, and specific skills such as how to control protein intake and how to calculate protein intake. The dietician also provided menu suggestions to the patients. Group discussions and sharing the experience of “expert patients” were also used as previous studies found that information is more effectively transferred to and accepted by patients through group communication⁹ than by oral education given by medical staff.¹⁰ Group education can help patients to control their protein intake and can help them to achieve other important lifestyle changes that are beneficial for disease therapy.

Blood pressure is a well-established independent factor for the progression of CKD. Intake of <3 g salt daily was recommended by K/DOQI for CKD patients,² but most patients lacked the skills of avoiding eating too much salt. Our education program gave the CKD patients specific skills and knowledge, which helped them to reduce salt intake with little influence on their daily life, and this may have had a favorable effect on the blood pressure control. Although we have inadequate information about the actual sodium intake and fluid status of our patients, the statistically significant decrease in SBP and DBP in the L-MIP group may indicate that an important improvement in salt and volume control was achieved in this group. In a previous study in PD patients on the effect of this multi-dimensional education program, we could show that the dietary salt and fluid intake decreased, resulting in a better control of SBP.¹¹

Since CKD is a chronic disease which accompanies patients during their whole life, CKD patients experience an increased mental pressure, and in countries like China this may be further aggravated by the economic burden of the disease. It is known that mental disorders are more frequent in CKD patients than in the general population. Karen and Meer reported that among ESRD patients who received RRT, the patients who had better mental status had better clinical outcome.¹² As part of this study, we organized a patient association, and with the help of this association, many community activities were held regularly. This patient association can help the patient to develop a feeling of pride of belonging to a group. Patients were encouraged to explore their emotional responses, explore alternative ways of coping with stress, and repeatedly practice stress management skills during the group activities. The collaboration and communication between patients and medical staff help the patients to take an active part in the therapy, and to improve the self-care and self-management abilities. Similar to other chronic diseases, the behavioral changes of CKD patient include five steps: unconsciousness, consciousness, preparation, activity, and preservation; every stage may happen repeatedly in the whole change period.¹³ Encouragement given by medical staff and family members to patients is critically important when the patients feel it is too hard to make the necessary lifestyle changes. The medical staff in this program gave continuous support to individual patients, helping them to maintain appropriate lifestyle changes and preventing them from going back to a preceding behavioral stage. The group community work encourages patients to go back to social work (social participation) or to former job position and this may significantly improve their quality of life.^14–16

One limitation of this study was that we were not able to quantitatively study the specific impact of patient’s self-care ability and self-management because of the retrospective nature of the study; a new prospective study including more detailed data about sodium intake and urinary sodium should be done in the next step. Further studies that include detailed questionnaires about behavior and more detailed dietary information, or more structured instructional tools are highly warranted.

In conclusion, the multi-dimensional education program was found to have a positive effect on the rate of progression of renal function in pre-dialysis patients. As the implementation of this framework can lead to possible prevention or delay in the progression of kidney disease, possibly because of better control of blood pressure and protein intake, the medical staff should pay more attention to the education of pre-dialysis patients, especially in the early stages of CKD. According to our experience, the education of CKD patients should be composed of a program providing not only basic knowledge but also coping skills and indispensable mental encouragement. A wider use of a multi-dimensional education program such as the one applied in this study could have major implications in developing countries without sufficient medical resources as in China.

ACKNOWLEDGMENTS

This study was partly supported by a grant (36-1) from Cheung Kong Scholar Program, Ministry of Education, People’s Republic of China, and by China Scholarship Council (2009601096) and a grant from Beijing Municipal Science and Technology Foundation (09050704310905). The authors thank all the staff in the Division of Nephrology, Peking University Third Hospital. Bengt Lindholm is employed by Baxter Healthcare Corporation. Baxter Novum is the result of a grant to the Karolinska Institute from Baxter Healthcare Corporation.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.