CARE FOR CHRONIC RENAL PATIENTS ROLE OF MULTIDISCIPLINARY APPROACH ÁGNES HARIS MD PHD, ST. MARGIT HOSPITAL, BUDAPEST BUDAPEST NEPHROLOGY SCHOOL, 2017

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1 CARE FOR CHRONIC RENAL PATIENTS ROLE OF MULTIDISCIPLINARY APPROACH ÁGNES HARIS MD PHD, ST. MARGIT HOSPITAL, BUDAPEST BUDAPEST NEPHROLOGY SCHOOL, 2017

2 RENEGOTIATING LIFE WITH CHRONIC KIDNEY DISEASE CONSTANTINI ET AL. NEPHROL NURS J 2008

3 IMPORTANCE OF PATIENT EDUCATION - PATIENT-CENTERED CARE SELF-MANAGEMENT SHARED DECISION-MAKING (COMPROMISED BY LACK OF SUFFICIENT KNOWLEDGE)

4 PATIENTS WITH CRF NEED HIGH LEVEL OF SELF-MANAGEMENT How much do the patients need to know in order to preserve renal function? - disease process - specific medications, prohibited drugs - life-style-management strategies - diet - modality choice, access, wait-listed for Tx - initiation or refusing RRT prognosis, risks and benefits

5 PATIENTS WITH CRF NEED HIGH LEVEL OF SELF-MANAGEMENT The reality: weak perceptions by the patients - majority of patients feel unprepared, illinformed about dialysis initiation - lots of stess and anxiety they have problem with coping Communication barriers and Insufficient/not understandable information given by health care providers to pts

6 PERCEIVED KNOWLEDGE AMONG PATIENTS CARED FOR BY NEPHROLOGISTS ABOUT CHRONIC KIDNEY DISEASE AND END-STAGE RENAL DISEASE THERAPIES FINKELSTEIN ET AL, KINDEY INT 2008 No knowledge of HD 43% No knowledge of CAPD 57% No knowledge of APD 66% No knowledge of transplantation 56% No knowledge of any modality 35% 676 patients from US and Canada, stage 3-5 CKD, attending nephrological clinics for median of 2 years, mean of 5.2 years

7 KNOWLEDGE AND UNDERSTANDING OF THE ADVANTAGES AND DISADVANTAGES OF VARIOUS ESRD THERAPEUTIC MODALITIES Therapy Knowledge of therapy Understand No Yes P-value Any therapy No < Yes HD No < Yes CAPD No < Yes Transplant No < Yes

8 KNOWLEDGE OF VARIOUS ESRD THERAPEUTIC OPTIONS BY COUNTRY United States (%) Canada (%) P-value No knowledge of HD < No knowledge of CAPD < No knowledge of APD No knowledge of transplant No knowledge of any modality

9 PERCEPTIONS AND ATTITUDES TO KIDNEY TX VÁMOS EP ET AL, NDT 2009 HD patients in Budapest, n=459, <70 year old - perceptions of dialysis versus Tx - information on Tx - attitudes to Tx - sociodemographic factors

10 RESULTS OF THE QUESTIONNAIRES VÁMOS EP ET AL, NDT % of patients reported that have not heard about Tx from their doctors, 56% reported that received insufficient information, 35 % believed Tx causes more problems than benefits, 46 % had significant fears about Tx surgery and 45 % had significant fears about immunosuppressive meds.

11 RESULTS OF THE QUESTIONNAIRES VÁMOS EP ET AL, NDT % of the patients wanted to be transplanted (regardless of eligibility), more likely - the younger patients - men (56%) - employed - have higher education - have prior Tx Strongest predictor of positive attitude to Tx: Perception of transplantation is the best modality of RRT

12 Suggestions based on the results Vámos EP et al, NDT 2009

13 PERCEIVED INFORMATIONAL NEEDS OF PATIENTS WITH CKD IV Lewis et al Nephrology Nursing J new patients to the CKD clinic; with high school diplomas, Structured interviews

14 CONSENSUS CONFERENCE ON PATIENT EDUCATION BAGNIS ET AL. NDT 2015 Benefits of patient education - reduced urgent start of dialysis - reduced time spent in hospital - earlier placement of vascular access/ PD cath - greater likelihood of choosing self-modality - extended time to requiring dialysis - better compliance - reduce anxiety and fear - reduced mortality These proven benefits lead to cost savings!

15 CONSENSUS CONFERENCE ON PATIENT EDUCATION BAGNIS ET AL. NDT 2015 Educational team - Minimum: nephrologist and CKD nurse - Optimal: Multidisciplinary team - nephrologist - CKD nurse - dietician - social worker - mental health professional - physical therapist - expert patient

16 CONSENSUS CONFERENCE ON PATIENT EDUCATION BAGNIS ET AL. NDT 2015 Suggested teaching materials - One-to-one meetings with staff - Written booklets, - appropriate to disease stage - level of education and - cultural/relegious background - Multimedia presentation - Tours of dialysis facilities - Online materials with carefully selected websites - Non-mandatory meetings or videos with expert patients - Group education sessions

17 MULTIDISCIPLINARY CARE OF PREDIALYSIS PATIENTS CURTIS BM ET AL, NDT 2005

18 SURVIVAL AFTER STARTING CHRONIC DIALYSIS THERAPY Curtis B M et al. Nephrol. Dial. Transplant. 2005;20:

19 PREDICTORS OF SURVIVAL: AGE AND TYPE OF EDUCATION Curtis B M et al. Nephrol. Dial. Transplant. 2005;20:

20 EFFECTS OF A NATIONWIDE PREDIALYSIS EDUCATIONAL PROGRAM ON MODALITY CHOICE, VASCULAR ACCESS, AND PATIENT OUTCOMES LACSON, ET AL. AJKD 2011 Peritoneal dialysis All TOPs Patients Matched TOPs Cohort a Unadjusted 8.45 ( ) 7.51 ( ) Case-mix adjusted 5.51 ( ) 8.37 ( ) Case-mix + lab.adjusted 5.13 ( ) 7.73 ( ) Noncatheter access Unadjusted 2.14 ( ) 1.82 ( ) Case-mix adjusted 2.17 ( ) 1.83 ( ) Case-mix + lab.adjusted 2.06 ( ) 1.73 ( )

21 Figure 2 90 DAYS PATIENT OUTCOMES LACSON, ET AL. AJKD 2011 American Journal of Kidney Diseases , DOI: ( /j.ajkd ) Copyright 2011 National Kidney Foundation, Inc. Terms and Conditions

22 Figure 3 HAZARD RATIOS OF DEATH LACSON, ET AL. AJKD 2011 American Journal of Kidney Diseases , DOI: ( /j.ajkd ) Copyright 2011 National Kidney Foundation, Inc. Terms and Conditions

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24 ALL-CAUSE MORTALITY OF CKD PATIENTS ON MULTIDISCIPLINARY CARE (MDC) AND ON NON-MDC

25 RISK OF RENAL REPLACEMENT THERAPY IN CKD PATIENTS ON MULTIDISCIPLINARY CARE (MDC) AND ON NON-MDC Renal replacement therapy includes HD, PD and kidney Tx

26 INCIDENCE OF TEMPORAL CATHETERIZATION FOR DIALYSIS IN CKD PATIENTS ON MDC AND NON-MDC

27 RISK OF HOSPITALIZATION FOR DIALYSIS IN CKD PATIENTS ON MULTIDISCIPLINARY CARE (MDC) AND NON-MDC

28 MULTIDISCIPLINARY PATIENT EDUCATION WITH THEIR FAMILY MEMBERS - OUR OWN EXPERIENCES EDUCATION AND LIFE STYLE CAMPS FOR PATIENTS AND THEIR RELATIVES IN DIÓSJENŐ ORGANIZER AND LEADER: DR KÁLMÁN POLNER

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30 EDUCATION AND LIFE STYLE CAMPS FOR PATIENTS AND THEIR RELATIVES IN DIÓSJENŐ Voluntary registration The only requirement : bring one of the relatives! All the expenses have been covered by our St Margit Hospital Kindey Foundation Education for one week duration, groups for predialysis and CAPD patients : 14 groups, 151 patients and 154 relatives participated

31 MULTIDISCIPLINARY TEAM NEPHROLOGISTS, EDUCATIONAL NURSE, DIETICIAN, SOCIAL WORKER, PSYCHOLOGIST, REHABILITATION SPECIALIST, TAI-CHI- AND PHYSIOTHERAPEUTIST, CASE PRESENTATIONS BY PATIENTS

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33 EDUCATIONAL TOPICS Basic function of the kidneys Fluid and electrolyte balance Normal and abnormal laboratory results Importance of diet Importance of drug treatments Modality selection Kidney transplantation (living or cadaver donor Tx) Major comorbidities Assistance for social problems, rehabilitation, psychosocial issues Legal rights of the patients Alleviation handicap

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36 MAIN RESULTS OF THE MULTIDISCIPLINARY EDUCATION Improving clinical and laboratory results - normalized phosphate levels - decreasing urinary protein excretion - slower GFR decline - better BP control - modality choice: 56% PD - significantly improved Tx activity

37 EXPERIENCES OF THE EDUCATORS Patients were very enthusiastic By involving the relatives: more effective learning process, enhanced personal activity Patients accepted their diseases more easily, families fight together Self-directed, family assisted cooperation in diet and medication-adherence Importance of psychoeducation, self knowledge, psychological balance For the educators: not only teaching but learning experience

38 THANK YOU FOR YOUR ATTENTION!