Introduction
According to the latest estimates, more than 320 million patients are treated with dialysis worldwide According to the most recent estimates, dialysis is used to treat over 320 million people globally. Patients in most developed nations begin dialysis after learning about the various treatment choices (dialysis, transplantation, and conservative therapy). Various international guidelines make recommendations for education and dialysis therapy. These suggestions, which should ideally be evidence-based, aid health care providers in guiding and treating chronic kidney disease (CKD) patients in order to give the best possible care. Good practices are those that have been formed locally and with which health care professionals have extensive experience, but which are not evidence-based and so are not included in (inter)national guidelines.
As a result, certain practices, such as suggestions from (inter)national guidelines, are not widely disseminated and implemented across the country. Good practices, while not evidence-based, can have extra benefits and are thus worth investigating. This article provides a scoping review to identify and summarize the available literature describing good practices for dialysis education, treatment, and electronic health (eHealth).
Methods
Embase, Pubmed, the Cochrane Library, CINAHL databases and Web of Science were searched for relevant articles using all synonyms for the words ‘kidney failure’, ‘dialysis’, and ‘good practice’.
After removal of duplicates, two authors (AES and SV) independently screened titles and abstracts. Articles were eligible for inclusion if they provided a thorough description of the content of a good practice regarding dialysis education, treatment or eHealth for adult patients. Articles of all study types were included, however articles that described a guideline, review or meta-analysis were subsequently excluded after being screened for additional references. Relevant articles were structured according to the categories dialysis education, dialysis treatment or eHealth, and assessed for content and results. Fig 1 provides an overview of the study selection.
Results
Dialysis education
Four of the twelve articles that described good practices for dialysis education, focused on providing objective predialysis education for CKD patients. Fortnum et al. presented the ‘My Kidneys, My Choice’ decision aid, a patient-centered tool to support the education of CKD patients and promote shared decision making. Lacson Jr. et al. initiated a standardized predialysis treatment options education program that consisted of education provided during a single group class session. Patients who followed the standardized education program were significantly more likely to choose PD and had a lower mortality (OR 0.61) during the first 90 days of dialysis treatment. Manns et al. developed a two-phase patient-centered educational intervention, showing manuals and a video for self-care dialysis (i.e. PD, home HD, and self-care)in phase 1 and conducting a small group session in phase 2. The intervention significantly increased the proportion of patients who intended to initiate self-care dialysis (intervention group 82.1% vs. standard care group 50%).
Wu et al. presented a multidisciplinary predialysis education program consisting of quarterly individual nurse-led lectures for CKD patients stage 3 and 4, while this was intensified to monthly lectures for CKD patients stage 5. The qualitative studies of Figueiredo et al. and Firanek et al. focused on PD training. Figueiredo et al. provided a detailed description of a 5-day PD training course. The authors concluded that with this training course PD nurses ensure that the patient can perform PD safely and effectively.
Successful home visit programs were described by Farina et al. and Martino et al. The main similarities between the two programs were: assessment of the home where PD was performed, assessment of the PD procedure performed by the patient, and the patient’s compliance to pharmacological and dialysis therapy. The last three articles focused on an educational program for HD patients and conversations with dialysis patients.
The authors concluded that the program not only reduced morbidity and mortality, but also increased job satisfaction for nurses. The article by Michel et al. also described an approach for talking with dialysis patients about their prognosis based on four aspects: who to tell, when to tell, what to tell, and how to tell. The authors concluded that this approach can help discussing prognosis with dialysis patients, taking into account the patient’s preferences.
Dialysis treatment
The three articles that described good practices for dialysis treatment were all qualitative studies . Abdel-Aal et al. provided a detailed description of the procedure for insertion of a PD catheter by interventional radiologists. Various aspects of pre-procedure preparation, such as bowel preparation and fasting, were discussed followed by a detailed explanation of the PD catheter insertion with explanatory photos. Craswell et al. described practices for insertion, maintenance, and removal of central venous catheters (CVCs) for HD.
The practices for insertion consisted of patient education for insertion, anatomical site selection and decision-making, and training. The practices for maintenance consisted of education, dressing practices, and assessment and monitoring for infection. The practices for removal consisted of the decision for removal and complications of removal. The authors concluded that an interdisciplinary team is very important for patient education and catheter care. Desai et al. reported 155 good practices that could potentially improve outcomes of dialysis centers, such as dialysis dose and anemia management, and overall survival in dialysis patients.
Through a survey among 342 respondents, a top 30 of good practices that had the most impact on overall outcomes in dialysis was compiled. The majority of the top 30 good practices focused on conducting a successful multidisciplinary team meeting, performing audits, training nurses, reviewing the performance of health care professionals, and enhancing communication and teamwork.
eHealth
Four articles described good practices for eHealth, one of which focused on HD and three on PD. The qualitative article on PD by Kaldoudi et al. described the components of an eHealth system by which data could be collected such as PD method, prescription, body weight and hearth rate. While Kaldoudi et al. and Viglino et al. focused more on the technical aspects of eHealth systems for PD patients, Li et al. conducted a randomized controlled trial to investigate the effect of post-discharge telephone support for PD patients.
Affer discharge from the hospital, the nurse called the patients from the intervention group every week during a period of 6 weeks to assess their status and to give advice. This approach led to a significant improvement of several health-related quality of life domains and a reduction in the number of hospital visits. Finally, Sicofie et al. reported two eHealth models for in-center HD patients: virtual patients rounds and telecase reviews with a multidisciplinary team.
During the virtual patient rounds, a remote nephrologist and nurse had contact with a patient and his/her nurse at the dialysis center. During the telecase review, a remote nephrologist and nurse had contact with the general practitioners and nurses at the dialysis center via videoconference, without the patient being present. Both models led to a significant reduction in the number of medication changes per month during a follow-up of 2 years.
Conclusion
Our scoping review identifies 19 articles describing good practices and their results for dialysis education, dialysis treatment, and eHealth. These good practices could be valuable in addition to guidelines for increasing shared-decision making in predialysis education, using patients’ contribution in the implementation of their dialysis treatment, and advanced care planning.
References
1. 1.Bikbov B, Purcell CA, Levey AS, Smith M, Abdoli A, Abebe M, et al. Global, regional, and national burden of chronic kidney disease, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. The Lancet. 2020;395(10225):709–33.
2. Fadem SZ, Walker DR, Abbot G, Friedman AL, Goldman R, Sexton S, et al. Satisfaction with renal replacement therapy and education: the American Association of Kidney Patients survey. Clin J Am Soc Nephrol. 2011;6(3):605–12. pmid:21330485
3. Morton RL, Howard K, Webster AC, Snelling P. Patient INformation about Options for Treatment (PINOT): a prospective national study of information given to incident CKD Stage 5 patients. Nephrol Dial Transplant. 2011;26(4):1266–74. pmid:20819955
4. Van Biesen W, van der Veer SN, Murphey M, Loblova O, Davies S. Patients’ perceptions of information and education for renal replacement therapy: an independent survey by the European Kidney Patients’ Federation on information and support on renal replacement therapy. PLoS One. 2014;9(7):e103914. pmid:25079071
5. Covic A, Bammens B, Lobbedez T, Segall L, Heimburger O, van Biesen W, et al. Educating end-stage renal disease patients on dialysis modality selection: clinical advice from the European Renal Best Practice (ERBP) Advisory Board. Nephrol Dial Transplant. 2010;25(6):1757–9. pmid:20392704
6. Taersall J, Dekker F, Heimburger O, Jager KJ, Lameire N, Lindley E, et al. When to start dialysis: updated guidance following publication of the Initiating Dialysis Early and Late (IDEAL) study. Nephrol Dial Transplant. 2011;26(7):2082–6. pmid:21551086
7. Kidney Disease Improving Global Outcomes (KDIGO). KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2013;3(1).
8. Inker LA, Astor BC, Fox CH, Isakova T, Lash JP, Peralta CA, et al. KDOQI US commentary on the 2012 KDIGO clinical practice guideline for the evaluation and management of CKD. Am J Kidney Dis. 2014;63(5):713–35. pmid:24647050
9. Nederlandse Internisten Vereniging, Nederlandse Federatie voor Nefrologie. Evidence-based guideline ‘Zorg bij eindstadium nierfalen’ 2020. Available at: https://www.nefro.nl/richtlijnen.
10. Nederlandse Internisten Vereniging, Nederlandse Federatie voor Nefrologie. Guideline ’Nierfunctievervangende behandeling, wel of niet?’ 2016. Available at: https://richtlijnendatabase.nl/richtlijn/nierfunctievervangende_behandeling/nierfunctievervangende_behandeling_-_startpagina.html
11. Briggs V, Davies S, Wilkie M. International Variations in Peritoneal Dialysis Utilization and Implications for Practice. Am J Kidney Dis. 2019;74(1):101–10. pmid:30799030
