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. 2019 Aug 6;8(8):CD012379.
doi: 10.1002/14651858.CD012379.pub2.

eHealth interventions for people with chronic kidney disease

Jessica K Stevenson  1 , Zoe C Campbell, Angela C Webster, Clara K Chow, Allison Tong, Jonathan C Craig, Katrina L Campbell, Vincent Ws Lee
Affiliations

eHealth interventions for people with chronic kidney disease

Jessica K Stevenson et al. Cochrane Database Syst Rev. .

Abstract

Background: Chronic kidney disease (CKD) is associated with high morbidity and death, which increases as CKD progresses to end-stage kidney disease (ESKD). There has been increasing interest in developing innovative, effective and cost-efficient methods to engage with patient populations and improve health behaviours and outcomes. Worldwide there has been a tremendous increase in the use of technologies, with increasing interest in using eHealth interventions to improve patient access to relevant health information, enhance the quality of healthcare and encourage the adoption of healthy behaviours.

Objectives: This review aims to evaluate the benefits and harms of using eHealth interventions to change health behaviours in people with CKD.

Search methods: We searched the Cochrane Kidney and Transplant Register of Studies up to 14 January 2019 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.

Selection criteria: Randomised controlled trials (RCTs) and quasi-RCTs using an eHealth intervention to promote behaviour change in people with CKD were included. There were no restrictions on outcomes, language or publication type.

Data collection and analysis: Two authors independently assessed trial eligibility, extracted data and assessed the risk of bias. The certainty of the evidence was assessed using GRADE.

Main results: We included 43 studies with 6617 participants that evaluated the impact of an eHealth intervention in people with CKD. Included studies were heterogeneous in terms of eHealth modalities employed, type of intervention, CKD population studied and outcomes assessed. The majority of studies (39 studies) were conducted in an adult population, with 16 studies (37%) conducted in those on dialysis, 11 studies (26%) in the pre-dialysis population, 15 studies (35%) in transplant recipients and 1 studies (2%) in transplant candidates We identified six different eHealth modalities including: Telehealth; mobile or tablet application; text or email messages; electronic monitors; internet/websites; and video or DVD. Three studies used a combination of eHealth interventions. Interventions were categorised into six types: educational; reminder systems; self-monitoring; behavioural counselling; clinical decision-aid; and mixed intervention types. We identified 98 outcomes, which were categorised into nine domains: blood pressure (9 studies); biochemical parameters (6 studies); clinical end-points (16 studies); dietary intake (3 studies); quality of life (9 studies); medication adherence (10 studies); behaviour (7 studies); physical activity (1 study); and cost-effectiveness (7 studies).Only three outcomes could be meta-analysed as there was substantial heterogeneity with respect to study population and eHealth modalities utilised. There was found to be a reduction in interdialytic weight gain of 0.13kg (4 studies, 335 participants: MD -0.13, 95% CI -0.28 to 0.01; I2 = 0%) and a reduction in dietary sodium intake of 197 mg/day (2 studies, 181 participants: MD -197, 95% CI -540.7 to 146.8; I2 = 0%). Both dietary sodium and fluid management outcomes were graded as being of low evidence due to high or unclear risk of bias and indirectness (interdialytic weight gain) and high or unclear risk of bias and imprecision (dietary sodium intake). Three studies reported death (2799 participants, 146 events), with 45 deaths/1000 cases compared to standard care of 61 deaths/1000 cases (RR 0.74, CI 0.53 to 1.03; P = 0.08). We are uncertain whether using eHealth interventions, in addition to usual care, impact on the number of deaths as the certainty of this evidence was graded as low due to high or unclear risk of bias, indirectness and imprecision.

Authors' conclusions: eHealth interventions may improve the management of dietary sodium intake and fluid management. However, overall these data suggest that current evidence for the use of eHealth interventions in the CKD population is of low quality, with uncertain effects due to methodological limitations and heterogeneity of eHealth modalities and intervention types. Our review has highlighted the need for robust, high quality research that reports a core (minimum) data set to enable meaningful evaluation of the literature.

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Conflict of interest statement

None known

Figures

1
1
Study flow diagram.
2
2
Bubble plot of reported outcomes by intervention type
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
4
4
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
5
5
Forest plot of comparison: 1 Death, outcome: 1.1 Death.
6
6
Forest plot of comparison: Interdialytic weight gain
7
7
Forest plot of comparison: 5 Dietary sodium, outcome: 5.1 Dietary sodium intake.
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD012379

References

References to studies included in this review

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TAKE‐IT 2014 {published data only}
    1. Bignall O, Pai A, Amaral S, Furth S, Bergman N, Goebel J, et al. Differences in reported barriers to immunosuppression adherence among a cohort of pediatric renal transplant recipients from the United States and Canada [abstract no: D161]. American Journal of Transplantation 2016;16(Suppl 3):751. [EMBASE: 611700425]
    1. Boucquemont J, Foster B. Adherence patterns in adolescent and young adult kidney transplant recipients [abstract no: 229]. American Journal of Transplantation 2016;16(Suppl 3):284. [EMBASE: 611700136]
    1. Boucquemont J, Foster B, TAKE‐IT Investigators. Sex and age differences in medication adherence in adolescent and young adult kidney transplant recipients [abstract no: SA‐PO404]. Journal of the American Society of Nephrology 2016;27(Abstracts):721A. [CENTRAL: CN‐01657535]
    1. Foster B, Pai A, Furth S. The TAKE‐IT intervention improves medication adherence in adolescent kidney transplant recipients [abstract no: 359]. American Journal of Transplantation 2017;17(Suppl 3):332‐3. [EMBASE: 615704529]
    1. Foster B, Zhao H, Pai A, Zelikovsky N, Holly CD, Smith JM, et al. Medication adherence barrier burden predicts subsequent taking adherence in adolescent kidney transplant recipients in the TAKE‐IT trial [abstract no: SA‐PO1027]. Journal of the American Society of Nephrology 2015;26(Abstracts):870A. [CENTRAL: CN‐01657534]
Welch 2013 {published data only}
    1. Welch JL, Astroth KS, Perkins SM, Johnson CS, Connelly K, Siek KA, et al. Using a mobile application to self‐monitor diet and fluid intake among adults receiving hemodialysis. Research in Nursing & Health 2013;36(3):284‐98. [MEDLINE: ] - PMC - PubMed
White 2010 {published data only}
    1. White S. Telemonitoring in the renal program: empowering patients and engaging providers [abstract]. Peritoneal Dialysis International 2011;31(Suppl 1):S29. [EMBASE: 70716162]
    1. White S, Bezaire D, McMurray S. Telemonitoring in the renal program: empowering patients and engaging providers [abstract]. Peritoneal Dialysis International 2010;30(Suppl 1):S14. [CENTRAL: CN‐01658223]
Williams 2017 {published data only}
    1. Williams S, Han M, Ye X, Zhang H, Meyring‐Wosten A, Bonner M, et al. Physical activity and sleep patterns in hemodialysis patients in a suburban environment. Blood Purification 2017;43(1‐3):235‐43. [MEDLINE: ] - PubMed

References to studies excluded from this review

Abdel‐Kader 2011 {published data only}
    1. Abdel‐Kader K, Fischer GS, Li J, Moore CG, Hess R, Unruh ML. Automated clinical reminders for primary care providers in the care of CKD: a small cluster‐randomized controlled trial. American Journal of Kidney Diseases 2011;58(6):894‐902. [MEDLINE: ] - PMC - PubMed
Chen 2011e {published data only}
    1. Chen SH, Tsai YF, Sun CY, Wu IW, Lee CC, Wu MS. The impact of self‐management support on the progression of chronic kidney disease‐‐a prospective randomized controlled trial. Nephrology Dialysis Transplantation 2011;26(11):3560‐6. [MEDLINE: ] - PubMed
Korus 2017 {published data only}
    1. Korus M, Cruchley E, Gold A, Stinson J, Parekh R, Anthony S. A self‐management website for teenagers who have undergone kidney or liver transplantation: a feasibility randomized controlled pilot trial [abstract no: 401.3]. Pediatric Transplantation 2017;21(Suppl 1):33‐4. [EMBASE: 616208183]
Morales‐Barria 2016 {published data only}
    1. Morales‐Barria J, Morales F, Celis B, Johansson P, Metcalfe C. "Preventing": A new application for smartphones to assess and improve immunosupressant's adherence in renal transplant recipients [abstract no: P.1955]. Transplantation 2016;100(7 Suppl 1):S885. [EMBASE: 613004354]
RaDIANT 2014 {published data only}
    1. Gander JC, Sauls L, Browne T, Plantinga L, McPherson LJ, Gibney EM, et al. Feasibility and sustainability of the RaDIANT community study among Georgia dialysis facillities [abstract no: SA‐PO1006]. Journal of the American Society of Nephrology 2015;26(Abstract Suppl):865A.
    1. Hamoda RE, Gander JC, McPherson LJ, Arriola KJ, Cobb L, Pastan SO, et al. Process evaluation of the RaDIANT community study: a dialysis facility‐level intervention to increase referral for kidney transplantation. BMC Nephrology 2018;19(1):13. [MEDLINE: ] - PMC - PubMed
    1. Patzer RE, Gander J, Sauls L, Amamoo MA, Krisher J, Mulloy LL, et al. The RaDIANT community study protocol: community‐based participatory research for reducing disparities in access to kidney transplantation. BMC Nephrology 2014;15(1):171. [MEDLINE: ] - PMC - PubMed
    1. Patzer RE, Paul S, Plantinga L, Gander J, Sauls L, Krisher J, et al. A randomized trial to reduce disparities in referral for transplant evaluation. Journal of the American Society of Nephrology 2016;28(3):935‐42. [MEDLINE: ] - PMC - PubMed
    1. Patzer RE, Sauls L, Gander JC, Amamoo MA, Plantinga L, Evans DD, et al. A randomized multicomponent intervention to reduce disparities in transplant referral: interim results from the RaDIANT community study [abstract no: SA‐PO1092]. Journal of the American Society of Nephrology 2014;25(Abstract Suppl):B3.
Roberto 2009 {published data only}
    1. Roberto AJ, Krieger JL, Beam MA. Enhancing web‐based kidney disease prevention messages for Hispanics using targeting and tailoring. Journal of Health Communication 2009;14(6):525‐40. [MEDLINE: ] - PubMed
SMILE 2010 {published data only}
    1. Belayev LY, Mor MK, Sevick MA, Shields AM, Rollman BL, Palevsky PM, et al. Longitudinal associations of depressive symptoms and pain with quality of life in patients receiving chronic hemodialysis. Hemodialysis International 2015;19(2):216‐24. [MEDLINE: ] - PMC - PubMed
    1. Green JA, Mor MK, Shields AM, Sevick MA, Arnold RM, Palevsky PM, et al. Associations of health literacy with dialysis adherence and health resource utilization in patients receiving maintenance hemodialysis. American Journal of Kidney Diseases 2013;62(1):73‐80. [MEDLINE: ] - PubMed
    1. Green JA, Mor MK, Shields AM, Sevick MA, Palevsky PM, Fine MJ, et al. Prevalence and demographic and clinical associations of health literacy in patients on maintenance hemodialysis. Clinical Journal of the American Society of Nephrology: CJASN 2011;6(6):1354‐60. [MEDLINE: ] - PMC - PubMed
    1. Green JA, Mor MK, Shields AM, Sevik MA, Palevsky PM, Fine MJ, et al. Renal provider perceptions and practice patterns regarding the management of pain, sexual dysfunction, and depression in hemodialysis patients. Journal of Palliative Medicine 2012;15(2):163‐7. [MEDLINE: ] - PubMed
    1. Mor MK, Sevick MA, Shields AM, Green JA, Palevsky PM, Arnold RM, et al. Sexual function, activity, and satisfaction among women receiving maintenance hemodialysis. Clinical Journal of the American Society of Nephrology: CJASN 2014;9(1):128‐34. [MEDLINE: ] - PMC - PubMed
Warren 2009 {published data only}
    1. Warren G, Heisler M, Perry E, Ferriter M, Piette J, Magee J. Telephone peer mentoring: a new approach to improving access to kidney transplantation [abstract no: 223]. American Journal of Kidney Diseases 2009;53(4):A78. [EMBASE: 70141712]
Wilson 2014 {published data only}
    1. Biswas A, Parikh CR, Feldman HI, Garg AX, Latham S, Lin H, et al. Identification of patients expected to benefit from electronic alerts for acute kidney injury. Clinical Journal of the American Society of Nephrology: CJASN 2018;13(6):842‐9. [MEDLINE: ] - PMC - PubMed
    1. Oh J, Bia JR, Ubaid‐Ullah M, Testani JM, Wilson FP. Provider acceptance of an automated electronic alert for acute kidney injury. Clinical Kidney Journal 2016;9(4):567‐71. [MEDLINE: ] - PMC - PubMed
    1. Ullah MU, Gitelman Y, Borovskiy Y, Aqeel I, Negoianu D, Fuchs BD, et al. Provider acceptance of a short messaging system‐based, electronic alert for acute kidney injury [abstract no: SA‐PO021]. Journal of the American Society of Nephrology 2014;25(Abstract Suppl):637A.
    1. Wilson FP, Reese PP, Shashaty MG, Ellenberg SS, Gitelman Y, Bansal AD, et al. A trial of in‐hospital, electronic alerts for acute kidney injury: design and rationale. Clinical Trials 2014;11(5):521‐9. [MEDLINE: ] - PMC - PubMed
    1. Wilson FP, Shashaty M, Testani J, Aqeel I, Borovskiy Y, Ellenberg SS, et al. Automated, electronic alerts for acute kidney injury: a single‐blind, parallel‐group, randomised controlled trial. Lancet 2015;385(9981):1966‐74. [MEDLINE: ] - PMC - PubMed

References to ongoing studies

CONNECT 2017 {published data only}
    1. Jeffs L, Jain AK, Man RH, Onabajo N, Desveaux L, Shaw J, et al. Exploring the utility and scalability of a telehomecare intervention for patients with chronic kidney disease undergoing peritoneal dialysis‐a study protocol. BMC Nephrology 2017;18(1):155. [MEDLINE: ] - PMC - PubMed
eNEPHRO 2017 {published data only}
    1. Thilly N, Chanliau J, Frimat L, Combe C, Merville P, Chauveau P, et al. Cost‐effectiveness of home telemonitoring in chronic kidney disease patients at different stages by a pragmatic randomized controlled trial (eNephro): rationale and study design. BMC Nephrology 2017;18(1):126. [MEDLINE: ] - PMC - PubMed
Jung 2017 {published data only}
    1. Jung HY, Seong SJ, Choi JY, Cho JH, Park SH, Kim CD, et al. The efficacy and stability of an information and communication technology‐based centralized monitoring system of adherence to immunosuppressive medication in kidney transplant recipients: study protocol for a randomized controlled trial. Trials [Electronic Resource] 2017;18(1):480. [MEDLINE: ] - PMC - PubMed
KARE 2015 {published data only}
    1. Tuot DS, Velasquez A, McCulloch CE, Banerjee T, Zhu Y, Hsu CY, et al. The Kidney Awareness Registry and Education (KARE) study: protocol of a randomized controlled trial to enhance provider and patient engagement with chronic kidney disease. BMC Nephrology 2015;16:166. [MEDLINE: ] - PMC - PubMed
Kosaka 2017 {published data only}
    1. Kosaka S, Hoshino J, Yamanouchi M, Sekine A. Assessment of efficacy of a CKD support decision making application and home blood pressure measurement system in patients with CKD: study protocol of a randomized, controlled trial [abstract no: PUB188]. Journal of the American Society of Nephrology 2017;28(Abstract Suppl):1013. [CENTRAL: CN‐01657824]
MAGIC 2016 {published data only}
    1. Russell CL, Moore S, Hathaway D, Cheng AL, Chen G, Goggin K. MAGIC Study: aims, design and methods using SystemCHANGETM to improve immunosuppressive medication adherence in adult kidney transplant recipients. BMC Nephrology 2016;17(1):84. [MEDLINE: ] - PMC - PubMed
NCT00394576 {published data only}
    1. Jaffery JB. Assessing novel methods of improving patient education of nutrition. www.clinicaltrials.gov/ct2/show/NCT00394576 (first received 1 November 2006).
NCT02097550 {published data only}
    1. Yank V. Primary care eHealth intervention for improved outcomes in chronic kidney disease (CKD eHealth). www.clinicaltrials.gov/ct2/show/NCT02097550 (first received 27 March 2014).
NCT02610946 {published data only}
    1. Tran H. Do technology Apps improve compliance in adolescent renal transplant recipients?. www.clinicaltrials.gov/ct2/show/NCT02610946 (first received 20 November 2015).
TELEGRAFT 2015 {published data only}
    1. Foucher Y, Meurette A, Daguin P, Bonnaud‐Antignac A, Hardouin JB, Chailan S, et al. A personalized follow‐up of kidney transplant recipients using video conferencing based on a 1‐year scoring system predictive of long term graft failure (TELEGRAFT study): protocol for a randomized controlled trial. BMC Nephrology 2015;16:6. [MEDLINE: ] - PMC - PubMed
Waterman 2015 {published data only}
    1. Waterman AD, McSorley AM, Peipert JD, Goalby CJ, Peace LJ, Lutz PA, et al. Explore Transplant at Home: a randomized control trial of an educational intervention to increase transplant knowledge for black and white socioeconomically disadvantaged dialysis patients. BMC Nephrology 2015;16:150. [MEDLINE: ] - PMC - PubMed
WISHED 2016 {published data only}
    1. Harvey A, Walsh M, Jain AK, Bosch E, Moreau C, Garland J, et al. The WISHED Trial: implementation of an interactive health communication application for patients with chronic kidney disease. Canadian Journal of Kidney Health & Disease 2016;3:29. [MEDLINE: ] - PMC - PubMed

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References to other published versions of this review

Stevenson 2016
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Publication types