education for pt
TRANSCRIPT
-
8/6/2019 Education for Pt.
1/9
-
8/6/2019 Education for Pt.
2/9
sugar, blood lipids, use of tobacco and alcohol, diet,
medication misuse and obesity. Non-modifiable factors
include age, gender, race and genetics (Brown et al. 2003,
de Jong & Brenner 2004). Ageing has been shown to be
associated with a decline in renal function (Brown et al.
2003). Obesity [body mass index (BMI) of more than
30 kg/m2], especially abdominal obesity, is frequently
accompanied by several factors in addition to hypertension
that may accelerate the risk for CKD. Abdominal obesity
refers to subjects with central fat distribution and is a major
risk factor for renal function abnormalities (Pinto-Sietsma
et al. 2003, Kramer et al. 2005). Because the number of
nephrons does not increase after birth, increasing body
weight must result in an increase in the single nephron
glomerular filtration rate (GFR) (Kramer et al. 2005).The
early stage of CKD is often asymptomatic; when symptoms
do arise with progression towards renal failure, it is often
too late to change behaviours to preserve renal function.
Chagnac et al. (2003) showed that therapeutic interventionswere often ineffective at the end stage of CKD. Therefore,
current standards call for early intervention for patients with
progressive CKD.
Many studies have shown that early stage CKD patients
who received predialysis education had lower hospitalisation
rates and shorter lengths of stay when hospitalised than those
who did not receive health education. Researchers have also
indicated that patients with predialysis care experienced less
urgent dialysis (Levin et al. 1997) and better biochemical
parameters at the start of dialysis therapy (Devins et al. 2003,
Goldstein et al. 2004, Tungsanga et al. 2005). Early
intervention to retard renal function deterioration was
recommended when patients serum creatinine (Scr) level
was 1530 mg/dl, or GFR level is from 30 to 59 ml/minutes
(Hebert et al. 2001). Such results indicate that predialysis
education programs could be beneficial for CKD patients. In
contrast, some results of predialysis care have been inconsis-
tent; intensive predialysis management showed little effect on
mortality or kidney function deterioration (Devins et al.
2003, Goldstein et al. 2004, Tungsanga et al. 2005). Also,
investigators have concluded that intensive predialysis man-
agement may not be cost effective (Harris et al. 1998).
In addition to biological outcomes, researchers havestressed that psychosocial indicators should be considered
in follow-up research (Devins et al. 2003). The literature
indicates that quality of life (QOL) is a better measure of
comprehensive responses to the physical, mental and social
dimensions often measured separately by psychosocial instru-
ments. QOL has become an important variable in the
evaluation of therapeutic interventions (Valderrabano et al.
2001). Many studies have recognised that the QOL of
patients with established renal failure is less than that of the
general population (Valderrabano et al. 2001, Suet-Ching
2001, Patel et al. 2002). But few studies have measured the
QOL of patients in the early stage of CKD.
In Taiwan, alternatives to contemporary medicine are
readily available and commonplace. Patients with impaired
renal function often use alternative treatments, especially
traditional Chinese herbs. A phenomenological study indi-
cated that, after being diagnosed with established renal
failure, patients in Taiwan seek further information, includ-
ing getting a second opinion from a traditional Chinese
medicine specialist and explore alternative treatment to
recover renal function (Lin et al. 2005). Many Taiwanese
believe that traditional herbs are natural and thus harmless.
Long periods of information seeking, however, can cause
treatment delays and prevent the patient from receiving
effective treatment in time (Sesso & Yoshihiro 1997, Lin
et al. 2005). In addition, the improper use of herbal
medicine can deteriorate kidney function. Therefore, healtheducation for CKD patients that includes information on the
use of Chinese herbal medicine could be an appropriate
method to prevent or retard the development of renal failure
in Taiwan.
Patients with CKD have been identified as a patient group
in need of specific education (Goldstein et al. 2004, Tung-
sanga et al. 2005). A predialysis educational program may
produce important benefits by increasing illness-related
knowledge and promoting QOL (Harris et al. 1998, Klang
et al. 1999). More research is needed to understand the
effects of an educational intervention on patients with early
stage CKD. Thus, a multidisciplinary predialysis care team
was convened to develop an intervention designed to improve
renal function protection in persons with early stage CKD.
Such an educational intervention has not been previously
developed and evaluated in Taiwan. Therefore, the purpose
of this study was to investigate physical, knowledge and QOL
outcomes of an educational intervention for patients with
CKD.
Methods
This study used a one-group repeated-measures design. Aneducational intervention delivered by a multidisciplinary
predialysis care team and focused on renal function protec-
tion for people with CKD was held with follow-up data
collection. Outcomes physical indicators, QOL and knowl-
edge of renal function protection were measured at
baseline, six and 12 months. Throughout the 12-month
period, participants were able to contact the predialysis care
team with any questions about CKD.
M Yen et al.
2928 2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 17, 29272934
-
8/6/2019 Education for Pt.
3/9
Participants and setting
The study was approved by the institutional review boards of
participating hospitals. After approval by the Health Depart-
ment of Tainan City, a health screening data bank ( n = 2071)
was obtained. The first step was to screen for people with Scr.
between 15 and 3 mg/dl. A total of 640 potentially eligible
persons were identified. Each person was contacted bytelephone and invited to participate in the study. Among
the 640 persons identified in the initial screening process,
reasons for not participating were inconvenience of trans-
portation, not interested in the intervention and having an
alternative treatment plan. Some decided not to participate
without giving any reason. One hundred and fifty four
persons agreed to participate. Each of the 154 persons next
visited a nephrologist at their convenience to determine study
eligibility. Inclusion criteria included: (1) Scr between 15 and
3 mg/dl; (2) diagnosed as CKD by their doctors; (3) aged
18 years or older; and (4) spoke Mandarin or Taiwanese. Of
the 154 who initially agreed to participate, 66 persons
fulfilled the selection criteria. All participants gave written
informed consent prior to data collection.
Educational intervention
The educational intervention consisted of one workshop,
individual consultations every six months and a telephone
number for participant questions. The predialysis care team
for the workshop consisted of a nephrologist, nurse, nutri-
tionist and social worker. The workshop included content on
renal protection, nutrition, exercise and the use of Chineseherbal medicine. An educational handout describing CKD
disease-related information was given to each participant.
The physician focused on the context of renal function,
pharmacological management and the causes of CKD, as well
as the use of Chinese herbal medicine. The nurse provided
information on health promotion for renal function protec-
tion. The nutritionist covered content on diet for people with
decreased renal function, including information on foods to
choose and to avoid. The social worker raised the issue of
support systems for people with CKD. The workshop lasted
for 150 minutes with two short breaks. Desserts recom-
mended by the nutritionist were provided during the breaks
for educational purposes. Lunch boxes were also designed by
the nutritionist and given to the participants at the end of the
workshop. A masters-prepared nurse case manager per-
formed the individual consultations and answered
phone calls from the participants. Individual consultations
and measures of the study indicators at the sixth and
twelfth month were undertaken at the same time. The
multidisciplinary team served as a resource for the case
manager in consultations.
Instruments
Study instruments included physical indicators, World Health
Organisation Quality of Life (WHOQOL) questionnaire,
renal protection knowledge checklist and demographics. The
research assistant called the participants prior to their regular
outpatient clinic check up and reminded them for the follow-
up data collection every six month. Face-to-face interview for
individual questions and measuring study outcomes were
performed at follow-ups.
Physical indicators
The renal function assessment consisted of Scr., blood urea
nitrogen (BUN) and GFR. The GFR was estimated by the
CockcroftGault prediction formula (K/DOQI Work Group,
2002):
GFR 140 age BWkg 085 if female=Scr. 72
Body composition, including body weight, muscle weight,
percentage body fat, body fat, waist to hip ratio (WHR) and
BMI, were measured by INNBODYODY 3.0 Body composition
analyser (INNBODYODY 3.0 Biospace (Upwards Biosystems Ltd,
Taipei, Taiwan); Okamoto et al. 2006). Blood pressure was
taken in a seated position using an automated sphygmo-
manometer.
Quality of life: the World Health Organisation qualityof life questionnaire
Quality of life was evaluated using WHOQOL-BREF-
Taiwan Version (The WHOQOL Taiwan Group, 2000), a
28-item instrument. The WHOQOL-BREF Taiwan Version
encompasses four domains: physical health (seven items),
psychological health (six items), social relationships (four
items), environmental domain (nine items) and two global
items (In general, How would you rate your quality of life?
and In general, How satisfied are you with your health?).
This instrument measured patients QOL during the two -
weeks prior to data collection points with a 5-point Likert
scale: 1 = not satisfied at all, 2 = somewhat satisfied,
3 = moderately satisfied, 4 = very satisfied and 5 = extremely
satisfied. Higher scores indicated a better QOL. The reli-
ability of the overall questionnaire was 090 (The WHOQOL
Taiwan Group 2000). Internal consistency for each of
the four domains ranged from 068077. Content
validity, convergent validity, criteria-related validity and
construct validity were examined. The overall QOL internal
Clinical issues Chronic kidney disease
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 17, 29272934 2929
-
8/6/2019 Education for Pt.
4/9
consistency for this study was 093. Internal consistency for
each of the four domains ranged from 073083.
Renal protection knowledge checklist
A disease-specific knowledge of renal protection checklist
was developed for this study. Two nephrologists and three
nurses with at least five years of clinical experience with CKD
evaluated the content validity prior to the study. The check-
list consisted of 20 items covering three domains: renal
function protection (11 items), knowledge of using Chinese
herbs in related to renal function (five items) and diet with
CKD (four items). Item responses were dichotomous, i.e.
true or false. Each correctly answered item was scored
with five points. Total scores for the checklist ranged from 0
to 100. Higher scores indicated higher knowledge of renal
function protection. The reliability of the questionnaire was
from 043054.
DemographicsDemographic variables included gender, age, language, to-
bacco and alcohol use, state of residence, level of education,
occupation and personal medical history (self-report).
Data analysis
Statistical analyses were conducted using SPSSSPSS (version 14.0)
(SPSS Taiwan Corp., Taipei, Taiwan). All continuous vari-
ables were examined assuming normal distributions.
Descriptive statistics (means, standard deviations and fre-
quencies) were examined for all study variables. Repeated
measures analysis of variance (ANOVA)(ANOVA) was used for variables
collected longitudinally at three points (baseline, six and
12 months) to test the equality of means across times, known
as the within-subjects effects. Using the repeated measures
can reduce the error term, thus increase the power of the
analysis with fewer subjects. Therefore, in this study we
applied repeated measures ANOVAANOVA to determine whether
physical indicators (renal function and body composition),
QOL and knowledge of renal function protection differed
among baseline, six and 12 month time points. There might
be correlation between the measures across time for each
variable because they were from the same people, (Munro
2005:215) also known as compound symmetry. Mauchlys
test of Sphericity was non-significant (p > 005) and thus the
assumption of compound symmetry was met, indicating that
the correlations across the measurements were the same and
the variances were equal across measurements. Statistical
significance was set at p < 005 and all p-values were
reported two sided.
Results
Study sample
Data from 66 participants were analysed in this study. Fifty-
three participants were males and 13 (20%) were females.
The mean age was 674 years (range 3389 SD 1159). The
average years of education were nine (SD 45). Forty-four
participants (67%) were married. More than half of
the participants were Buddhist (n = 36, 55%). Most of the
participants were retired or unemployed (n = 47, 71%).
The average range of income was between 015, 000 NT
dollars (approximately 0470 US dollars) per month. Seven
(11%) participants smoked and only one participant drank
alcohol regularly.
Physical indicators
Table 1 summarises the physical indicator outcomes. The
major criterion for selection of participants in this study
Table 1 Physical indicators at three time
points (n = 66)Variable
Baseline
mean (SD)
Sixth month
Mean (SD)
Twelfth month
Mean (SD) F Post hoc
GFR 421 (106) 411 (111) 412 (117) 287
Scr 21 (05) 22 (07) 21 (07) 150
BUN 286 (03) 308 (104) 295 (130) 104
SBP 1415 (16
0) 141
0 (15
7) 141
9 (15
9) 2
87
DBP 842 (83) 849 (74) 847 (76) 272
Body weight 682 (87) 678 (86) 684 (81) 278
Muscle weight 466 (59) 465 (60) 460 (57) 285
Body fat 225 (46) 223 (46) 228 (44) 287
WHR 103 (02) 101 (01) 100 (01) 603* 12*
BMI 254 (33) 251 (34) 250 (33) 437* 12*
*p < 005. GFR, glomerular filtration rate; Scr, serum creatinine; BUN, blood urea nitrogen;
SBP, systolic blood pressure; DBP, diastolic blood pressure; WHR, waisthip ratio; BMI, body
mass index.
M Yen et al.
2930 2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 17, 29272934
-
8/6/2019 Education for Pt.
5/9
was Stage 3 of CKD, GFR range from 30 to 59 ml/
minutes/173m2. Data from the baseline, sixth and twelfth
month follow-ups showed that the indicators of renal
function (Scr., BUN and GFR) were not significantly
different over time (F = 104287; p > 005). Body com-
position (body weight, muscle weight, body fat percentage
and total body fat) was also not significantly different at
the three time points. However, both WHR and BMI were
significantly different at the three time points (F = 603 and
F = 437; p < 005). Other physical indicators, including
systolic blood pressure and diastolic blood pressure, were
not significantly different within the 12-month follow-up
period.
Knowledge checklist
The 20-item knowledge checklist contained three domains:
renal function protection, knowledge of using Chinese herbs
related to renal function and diet with CKD. The overallknowledge scores, covering all three domains, increased at
the sixth month and decreased at the twelfth month
(p < 005; Table 2). Similarly, scores from two domains,
knowledge of using Chinese herbs and diet with CKD,
increased at six months and decreased 12 months
(p < 005). However, the renal function protection domain
showed no significant change over time.
Quality of life
The brief version of the WHOQOL contains four domains
with 26 items. Thirty eight participants completed the QOL
questionnaire in this study (the remainder left 20% or more
items blank and thus could not be included in analysis). The
mean age of those who did not complete the QOL question-
naires was younger than the 38 participants who did
(p < 005). Other demographic variables (gender, education
level, religion and marital and job status) were similar for
these two groups (p > 005). Table 3 depicts the QOL
results. There were no significant differences at baseline, sixth
and twelfth month follow-ups in the physical, psychological,
social relationship and environmental domains. Two single
items were asked to evaluate global QOL and health status:
How would you rate your quality of life? and How satisfied
are you with your health? The scores for satisfaction with
personal health increased significantly (F = 964; p < 005).
However, the global QOL item score increased at the sixthmonth and decreased at the twelfth month (F = 995;
p < 005).
Discussion
These results show that renal function was stable in this
sample over the 12 months of the study. The physical
Table 2 Renal function protection
knowledge at three time points (n = 66)Variable
Baseline
mean (SD)
Sixth month
Mean (SD)
Twelfth month
Mean (SD) F Post hoc
Overall protection renal
function knowledge
856 (60) 920 (50) 842 (60) 1039* 12*
23*
Subscales
Renal function protection 468 (57) 485 (62) 484 (51) 24
Use of Chinese herbs 224 (38) 227 (35) 193 (51) 139* 12*
23*
Diet with CKD 178 (34) 189 (27) 175 (34) 348* 12*
23*
*p < 005. CKD, chronic kidney disease.
Table 3 Quality of life at three time
points (n = 38)Variable
Baseline
mean (SD)
Sixth month
Mean (SD)
Twelfth month
Mean (SD) F Post hoc
Global QOL (single item) 31 (06) 32 (08) 26 (08) 964* 23*
Global health status
(single item)
27 (08) 32 (09) 33 (10) 995* 12*
Physical domain 138 (18) 139 (19) 138 (20) 007
Psychological domain 125 (16) 128 (17) 129 (13) 111
Social-related domain 134 (19) 136 (15) 137 (22) 042
Environment domain 146 (22) 151 (15) 145 (22) 186
*p < 005; Thirty-eight participants completed the QOL questionnaire. QOL, quality of life.
Clinical issues Chronic kidney disease
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 17, 29272934 2931
-
8/6/2019 Education for Pt.
6/9
indicators (Scr, BUN and GFR) were not significantly
changed across time (p = 005). Two outcome physical
indicators in this study, the WHR and BMI significantly
decreased over the 12-month follow-up period. Knowledge
scores (using Chinese herbs and diet with CKD) increased at
6 months and decreased at 12 months. There was no
significant difference among scores for four domains of
QOL. However, the two global items, overall QOL and
general health, showed change over time (p < 005). Overall
QOL was increased at six months and decreased at
12 months, while general health (as measured by the satis-
faction with personal health item) increased over time.
Changes in renal function
The level of GFR is widely accepted as the best indicator of
overall kidney function and the definition and staging of
CKD depends on the assessment of GFR (Levey et al. 1999,
K/DOQI Work Group 2002). GFR levels were not signifi-cantly changed during baseline, six and 12 month follow-ups
in this study. The results were consistent with the findings
from a randomised, controlled trial predialysis education
study (Klang et al. 1999, Devins et al. 2003). Another
longitudinal study in Thailand reported similar findings: GFR
seemed to be stable over a four-year follow-up after imple-
menting a multidisciplinary educational intervention
(Tungsanga et al. 2005). Retarding or preventing deteriora-
tion of renal function as measured by GFR levels is a key task
of early stage CKD educational intervention.
The GFR level was stable among participants in this study,
even though the mean age, 674-year old, was older than
reported in other studies (Levin et al. 1997, Devins et al.
2003), indicating that the educational intervention may have
been successful in retarding deterioration of renal function in
spite of age, a major risk factor for declining renal function
(Brown et al. 2003).
Changes in body composition
Obesity is believed to be associated with renal damage (Iseki
et al. 2004). A body of research demonstrates that central fat
distribution may be more salient to the problem of renaldamage than general obesity. One study revealed that GFR
decreases linearly with the increase of the WHR ratio after
adjusting for confounding factors (Pinto-Sietsma et al. 2003).
In Okinawa, Japan, a study on a group of over 100,000
individuals identified that obesity was a major risk factor for
the development of CKD and the degree of obesity also
predicted the progression to end-stage renal disease (ESRD)
(Iseki et al. 2004). Similarly, a cohort study with follow-ups
over 14 years found that higher BMI was a risk for
hypertension and diabetes, both of which increased the risk
of ESRD (Gelber et al. 2005).
Two outcome indicators in this study, WHR and BMI,
significantly decreased over the 12-month follow-up period.
This finding may help explain why the renal function
indicator, GFR, remained stable. Because the nephron num-
ber does not increase as adults gain weight, increased body
weight and body size merely enhance single-nephron loading,
which may lead to a loss of GFR over time (Kramer et al.
2005). Furthermore, this outcome provides supporting evi-
dence for early educational intervention in CKD to retard
renal function deterioration. In other words, an educational
intervention should include a focus on reducing central body
fat distribution and BMI to stabilise renal function. Although
BMI showed a statistically significant decrease at the sixth
and twelfth month, the average of BMI was still greater than
25 at the end of the follow-up period.
Changes in renal function protection knowledge
A fundamental consideration for delaying the progress of
CKD is patient education at the early stage (Devins et al.
2005). Overall knowledge scores increased slightly at the
sixth month and decreased at the twelfth month in this study.
This indicates that to maintain patients knowledge of renal
function protection, use of Chinese herbs and diet, work-
shops may need to be conducted at least every six months.
An important issue with this Taiwanese sample was the use
of Chinese herbs. The intervention developed and delivered in
this study included content on the use of Chinese herbs,
which has seldom been the focus of interventions for people
with early stage CKD. It has been shown that many CKD
patients in Taiwan use Chinese herbs in the belief that herbs
will preserve kidney function (Lin et al. 2005). Two retro-
spective studies revealed that patients with ESRD had
previously used one or more forms of complementary therapy
before they received haemodialysis treatment in Taiwan.
Complementary therapies used, included traditional Chinese
herbs, which were not always reported to health care
providers (Chiou 1999, Lin et al. 2005). In Taiwan, many
people believe Herbs cannot harm, only cure. Herbs arepanacea. Natural things are better than synthetic ones
Chinese herb medicines do not give side effects (Dahi 2001,
Isnard et al. 2005). However, the effects of herbal medicine
are controversial; their use may harm the kidney itself.
Study participants expressed that all Chinese herbs were
safe, warm, nourishing. Thus, people may not use them
carefully with physicians prescriptions. Our findings
highlight that although herb medicine may have many
M Yen et al.
2932 2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 17, 29272934
-
8/6/2019 Education for Pt.
7/9
advantages, health professionals have to be very careful in
evaluating the patients reliance and use of it. The misuse of
herbs may lead to a decreased of GFR or even directly to a
nephrotoxic state (Dahi 2001). In Taiwanese culture, many
people use Chinese herbs for restorative preparations and to
build up physical strength (Teng et al. 1995). Furthermore,
because Chinese herbs are perceived as natural foods for daily
use, patients with CKD may not recognise Chinese herbs as
medicines and thus not report their use during a medication
history. The use of Chinese herbs and culturally appropriate
lifestyle interventions need attention in future research.
Changes in quality of life
Health status may influence ones perception of QOL (Suet-
Ching 2001). In this study, participants in the early stage of
CKD may not yet experience or be aware of CKD symptoms.
Perceived overall health in our study was high compared with
haemodialysis patients (Sesso & Yoshihiro 1997). Althoughwe found that overall satisfaction with health status reported
by CKD patients did improve over time, we suspect that the
improvement might not reflect the true improvement of
health status but rather could be an intervention effect.
Research indicates that when GFR is below 30 ml/minutes/
173m2, symptoms associated with uraemia, such as lack of
energy or fatigue, may appear (Patel et al. 2002). These
symptoms may affect peoples QOL (Sesso & Yoshihiro
1997). The average GFR for the studied participants was
41 ml/minutes/173m2. QOL measured overall and through
four subdimensions, was significantly higher in this study
than other ones where patients kidney function was lower
(Jang et al. 2004, Perlman et al. 2005, Yang et al. 2005).
However, the scores for overall QOL in this study decreased
at the twelfth month follow-up although GFR levels
remained stable. It is possible that post intervention lifestyle
adjustments, such as changes in diet, may have affected
perceptions of QOL.
Limitations
This study must be interpreted with limitations in mind.
Generalisability of the study findings may be restricted due tothe small sample size and selection bias. It is possible that
participants might have better health and higher motivation
to learn health promotion activities than those who did not
participate. The one-group design also limits drawing
conclusions about the effects of the educational intervention.
However, current recommendations emphasise early
intervention. This study used a one-group design with
repeated measurements over 12 months; for ethical reasons,
we wanted all participants to receive an educational
intervention.
Conclusion
Early predialysis educational interventions are recommended
to slow the progression of CKD. Although the participants in
this study were older than those in previous studies average
renal function remained stable during the one-year follow-up
period, indicating that the educational intervention may have
had some success in retarding deterioration of renal function.
The intervention may also improve knowledge related to
renal function protection and perceptions of general physical
health. This study reports that overall knowledge scores
(renal function protection, Chinese herbs and diet) showed
significant differences between the baseline, sixth and twelfth
month follow-up. Knowledge of use of Chinese herbs and
diet domains increased at the sixth month then decreased at
the twelfth month, while the renal function protectiondomain showed no change over time. This study provides
evidence that Taiwanese CKD patients routinely use Chinese
herbs and may not report their use to health care providers or
understand possible adverse effects on renal function. Edu-
cation for early-stage CKD patients should incorporate more
traditional, culturally specific diet information and emphasise
content on traditional Chinese herbs for patients likely to use
alternative therapies. Finally, overall QOL scores in this
study decreased at the twelfth month follow-up, despite
stable renal function.
Acknowledgements
This study was funded by National Science Council, Taiwan
(NSC92-2314-B-006-097). We would like to thank the
patients with CKD who participated in this study and Blair
G. Darney for editorial assistance.
Contributions
Study design: MY, J-JH; data collection and analysis: MY,
J-JH, H-LT and manuscript preparation: MY, J-JH, H-LT.
References
Brown WW, Peters RM, Ohmit SE, Keane WF, Collins A, Chen SC,
King K, Klag MJ,Molony DA & Flack JM (2003) Early detection of
kidney disease in community settings: the kidney early evaluation
program (KEEP). American Journal of Kidney Diseases 42, 2235.
Chagnac A, Weinstein T, Herman M, Hirsh J, Gafter U & Ori Y
(2003) The effects of weight loss on renal function in patients with
Clinical issues Chronic kidney disease
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 17, 29272934 2933
-
8/6/2019 Education for Pt.
8/9
severe obesity. Journal of the American Society of Nephrology 14,
14801486.
Chiou CP (1999) Ancillary use of complementary therapies by ESRD
patients receiving hemodialysis in Taiwan. The Journal of Nursing
Research 7, 398406.
Dahi NV (2001) Herbs and supplements in dialysis patients: panacea
or poison. Seminars in dialysis 14, 186192.
Devins GM, Mendelssohn DC, Barre PE & Binik YM (2003) Pre-
dialysis psychoeducational intervention and coping styles influenceto dialysis in chronic kidney disease intervention and coping styles
influence to dialysis in chronic kidney disease. American Journal of
Kidney Diseases 42, 693703.
Devins GM, Mendelssohn DC, Barre PE, Taub K & Binik YM (2005)
Predialysis psychoeducational extends survival in CKD: a 20-year
follow-up. American Journal of Kidney Diseases 46, 10881098.
Gelber RP, Kurth T, Kausz AT, Manson JE, Buring JE, Levey AS &
Gaziano JM (2005) Association between body mass index and
CKD in apparently healthy men. American Journal of Kidney
Diseases 46, 871880.
Goldstein M, Yassa T, Dacouris N & McFarlane P (2004)
Multidisciplinary predialysis care and morbidity and mortality of
patients on dialysis. American Journal of Kidney Diseases 44,
706714.
Harris LE, Luft FC, Rudy DW, Kesterson JG & Tierney WM (1998)
Effects of multidisciplinary case management in patients with
chronic renal insufficiency. American Journal of Medicine 105,
464471.
Hebert LA, Wilmer WA, Falkenhain ME, Ladson-Wofford SE,
Nahman NS Jr & Rovin BH (2001) Renoprotection: one or many
therapies? Kidney International 59, 12111226.
Iseki K, Ikemiya Y, Kinjo K, Inoue T, Iseki C & Takishita S (2004)
Body mass index and the risk of development of end-stage renal
disease in a screened cohort. Kidney International65, 18701876.
Isnard BC, Deray G, Baumelou A, Le Quintrec M & Vanherweghem
JL (2005) Herbs and the kidney. American Journal of Kidney
Diseases 44, 111. Jang Y, Hsieh CL & Wang YH (2004) A validity study of the
WHOQOL-BREF assessment in persons with traumatic spinal
cord injury. Archives of Physical Medicine and Rehabilitation 85,
18901895.
de Jong PE & Brenner BM (2004) From secondary to primary pre-
vention of progressive renal disease: the case for screening for
albuminuria. Kidney International 66, 21092118.
K/DOQI Work Group (2002) KDOQI clinical practice guidelines for
chronic kidney disease: evaluation, classification and stratification
kidney disease outcome quality initiative. American Journal of
Kidney Diseases 39, S37S169.
Klang B, Bjorvell H & Clyne N (1999) Predialysis education helps
patients choose dialysis modality and increases disease-specific
knowledge. Journal of Advanced Nursing 29, 869876.
Kramer H, Luke A, Bidani A, Cao G, Cooper R & McGee D (2005)
Obesity and prevalent and incident CKD: the hypertension detec-
tion and follow-up program. American Journal of Kidney Diseases
46, 587594.
Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N & Roth D (1999)
A more accurate method to estimate glomerular filtration rate from
serum creatinine. Annals of Internal Medicine 130, 461470.
Levin A, Lewis M, Mortiboy P, Faber S, Hare I, Porter EC &
Mendelssohn DC (1997) Multidisciplinary predialysis programs:
quantification and limitations of their impact on patient outcomes
in two Canadian settings. American Journal of Kidney Diseases 29,
533540.
Lin CC, Lee BO & Hicks FD (2005) The phenomenology of decidingabout hemodialysis among Taiwanese. Western Journal of Nursing
27, 915929.
Munro BH (2005) Repeated measures analysis of variance. In:
Statistical Methods for Health Care Research (Munro BH ed.),
Lippincott, Philadelphia, PA, pp. 213238.
Okamoto M, Fukui M, Kursus A, Shou I, Maeda K, Hamada C &
Tomino Y (2006) Usefulness of a body composition analyzer, In-
body 2.0, in chronic hemodialysis patients. Kaohsiung Journal of
Medical Sciences 22, 207210.
Patel SS, Shah VS, Peterson RA & Kimmel PL (2002) Psychosocial
variables, quality and religious beliefs in ESRD patients treated
with hemodialysis. American Journal of Kidney Diseases 40, 1013
1022.
Perlman RL, Finkelstein FO, Liu L, Roys E, Kiser M, Eisele G,
Burrows-Hudson S, Messana JM, Levin N, Rajagopalan S, Port
FK, Wolfe RA & Saran R (2005) Quality of life in chronic kidney
disease (CKD): a cross-sectional analysis in the renal research
institute-CKD study. American Journal of Kidney Diseases 45,
658666.
Pinto-Sietsma SJ, Navis G, Janssen WM, de Zeeuw D, Gans RO & de
Jong PE (2003) A central body fat distribution is related to renal
function impairment even in lean subjects. American Journal of
Kidney Diseases 41, 733741.
Sesso R & Yoshihiro MM (1997) Time of diagnosis of chronic renal
failure and assessment of quality of life in hemodialysis patients.
Nephrology Dialysis Transplantation 12, 21112116.
Suet-Ching WL (2001) The quality of life for Hong Kong dialysispatients. Journal of Advanced Nursing 35, 218272.
Teng JH, Wang TL, Lin WC, Chen MT & Chen ZH (1995) Inves-
tigation on four heavy metal constituents of commercial restorative
Chinese medicine. Journal of Food and Drug Analysis 3, 193202.
The WHOQOL Taiwan Group (2000) Introduction to the develop-
ment of the WHOQOL-Taiwan version. Chinese Journal of Public
Health 19, 315324.
Tungsanga K, Ratanakul C, Pooltavee W, Mahatanan N, Na
Ayuthaya AI & Rodpai S (2005) Experience with prevention
programs in Thailand. Kidney International 67, S68S69.
Valderrabano F, Jofre R & Lopez-Gomez JM (2001) Quality of life
in end-stage renal disease patients. American Journal of Kidney
Diseases 38, 443464.
Yang SC, Kuo PW, Wang JD, Lin MI & Su S (2005) Quality of life
and its determinants of hemodialysis patients in Taiwan measured
with WHOQOL-BREF (TW). American Journal of Kidney
Diseases 46, 635641.
M Yen et al.
2934 2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 17, 29272934
-
8/6/2019 Education for Pt.
9/9