Complementary and alternative medicine is popular among chronic renal failure patients – renal teams must increase their competence to advise patients with respect to efficacy and safety
- 1Center for Nephrology and Dialysis, Lindau/Bodensee, Germany
- 2Fifth Department of Medicine, University Hospital Mannheim, Mannheim, Germany
- Correspondence to Rainer Nowack
Center for Nephrology and Dialysis, Dialysezentrum Lindau, Friedrichshafener Str. 82; D-88131 Lindau, Germany;
Implications for practice and research
■ Renal nurses should realise that a substantial subset of their patients use complementary and alternative medicine (CAM) to treat their renal disease.
■ Active inquiry about CAM is warranted, as some products may be harmful for the patient (eg, by causing interactions with medication).
■ To better advise patients, nurses and physicians need to improve their knowledge about efficacy and safety of CAM.
■ For the sake of the patient's safety, research on nurses' communication skills is warranted. Nurses need to be trained to inquire successfully about CAM usage, (eg, by using structured questionnaires).
A substantial subset of patients with chronic renal failure (CRF) has to accept that their disease will progress to end-stage renal disease (ESRD) despite modern evidence-based therapy. Dialysis-dependency is a bitter burden and patients fear the inconveniences more than they welcome it as a tool to survive. CRF patients may therefore not rely on conventional medicine alone to circumvent or postpone ESRD. They may seek treatment elsewhere in a wide range of scientifically unproven health products to be used in place of or in combination with conventional medicine, embraced under the term CAM.1 Knowledge about frequency and pattern of CAM usage by renal patients is currently sparse.
Akyol et al carried out a cross-sectional study on CAM usage in CRF before progression to ESRD. They explored the frequency and type of CAM usage in 206 CRF patients attending three renal centres in Turkey by questionnaire-based interviews.
A total of 2.9% of patients had used CAM prior to the diagnosis of CRF, but thereafter 25% of them turned to CAM, often assuming that this would cure CRF. Although significant, CAM usage is low when compared with dialysis and transplant patients in Germany and Switzerland of whom 50% consume herbal supplements.2 3 Cultural and/or socioeconomic reasons such as income and education on health issues may account for the lower prevalence of CAM consumption among Turkish CRF patients as countries like the USA and Germany have already higher rates of CAM consumption (20%) among their general population.4
It is interesting that Turkish CRF patients appear to rely more on mind-body medicine and manipulative or body-based practices than on herbal supplements. Other studies in renal patients do not include these treatments, but focus only on the intake of herbal supplements. It is therefore unknown to renal teams outside Turkey if their patients favour similar CAM products. Apart from this new information, the study confirmed already known patterns of CAM usage such as poor communication about CAM between patients and renal teams and the increased use of CAM by patients of a higher educational and socioeconomic level.
The study by Akyol et al complements what we already know about CAM in dialysis and transplant patients by extending these findings to CRF patients before progressing to ESRD. Some minor shortcomings such as missing information on the stage of CRF, exact renal diagnosis and concomitant diseases of the study population do not weaken the message that CAM usage is a common behaviour in many renal patients.
The renal team must somehow deal with this. Nurses and physicians should keep an eye on these aspects of a patient's life, often hidden from them. In order to do this successfully, CAM and its users should be addressed respectfully and knowledgeably. Clinicians should understand why patients turn to CAM which may be because of deficits and limits of conventional medicine. This is the most important message from the present study, in which patients declared the curative hopes they place on CAM.
Many CAM therapies have not been studied scientifically and their efficacy and safety is unknown. For safety reasons- the renal team should be notified of any use of CAM. A trustful atmosphere, which allows patients to be honest without fear of disrespectful comments, can facilitate this.
Harmful consequences of unnoticed use of herbal drugs have occurred in transplant patients. Herbal products beyond the infamous St. John's Wort may affect the metabolism of concomitant drugs, but such interactions have rarely been reported. They may be overlooked, because the intake of herbal products often goes unnoticed by the renal team. Pilot studies have shown that detailed inquiry about herbal drugs can lead to the detection of herb/drug interactions, for example, of those caused by herbal teas.5 However, an overall pessimistic view about herbal supplements is currently not justified as serious complications besides those linked to St. John's Wort and herbal teas have not been reported.
The popularity of CAM among renal patients challenges the renal team who should react by increasing their competence to better advise patients. Nurses could play an eminent role as they are often closer to the patients than physicians. CAM products need to be explored by clinical research in order to understand their potential benefits and risks.