Original Investigation
Pathogenesis and Treatment of Kidney Disease and Hypertension
Predialysis Psychoeducational Intervention Extends Survival in CKD: A 20-Year Follow-Up

https://doi.org/10.1053/j.ajkd.2005.08.017Get rights and content

Background: Predialysis psychoeducational interventions increase patient knowledge about chronic kidney disease (CKD) and its treatment and extend time to dialysis therapy without compromising physical well-being in the short run. The present research examines long-term survival after predialysis psychoeducational intervention. In addition, we examined whether survival differed because of early (ie, ≥3 months) versus late referral to nephrology. Methods: We collected follow-up data for patients with CKD who participated in a multicenter randomized controlled trial of predialysis psychoeducational interventions in the mid-1980s. We gathered 20-year survival data from clinical records and databases. Results: Participants included 335 patients with CKD, including 172 patients randomly assigned to receive predialysis psychoeducational interventions (63.0% men; mean age, 50.8 years) and 163 patients assigned to usual care (62.1% men; mean age, 52.7 years). Two hundred forty-six patients (66.8%) died during the course of the study. Mean duration of follow-up was 8.5 ± 7.23 (SD) years. Analyses were by intention to treat. Adjusting for age, general nonrenal health at inception, and time between identification and predialysis psychoeducational intervention or usual care, Cox proportional hazards multiple regression analyses indicated that median survival was 2.25 years longer after patients with CKD received predialysis psychoeducational interventions compared with usual care (chi-square-change [1] = 3.75; P = 0.053; hazard ratio, 1.32; 95% confidence interval, 1.0 to 1.74). Predialysis psychoeducational intervention recipients survived a median of 8.0 months longer than usual-care patients after the initiation of dialysis therapy (chi-square-change [1] = 4.39; P = 0.036; hazard ratio, 1.35; 95% confidence interval, 1.02 to 1.775). No significant survival advantage was evident for early referral to nephrology or the combination of early referral plus predialysis psychoeducational interventions. Conclusion: Predialysis psychoeducational intervention is a safe and useful intervention that contributes valuably to multidisciplinary predialysis care.

Section snippets

Participants

The method relating to the first predialysis psychoeducational intervention cohort has been described previously.20 Briefly, between August 1983 and January 1988, we attempted to identify all individuals at our participating hospitals in Montreal (Royal Victoria Hospital, Montreal General Hospital, Centre Hospitalier Cotes-des-Neiges, and St. Mary’s Hospital) and Calgary, Canada (Foothills Hospital and its satellite centers in Lethbridge, Medicine Hat, and Vulcan, Alberta) with deteriorating

Description of Cohort

We identified 588 prospective participants. This included 400 people (68%) who agreed to enter the cohort and 188 people (32%) who did not enter for a variety of reasons (most commonly because they were very seriously ill, moribund, or died shortly after being identified). Of those who entered the study, 32 patients (8.0% of the enrolled cohort) did not progress beyond the first data-collection point (eg, because of death, transfer, or loss to follow-up). Of the remainder, 172 patients (46.5%)

Discussion

Predialysis psychoeducational interventions increase relevant knowledge and extend time to dialysis therapy. In the present study, we observed a statistically significant survival advantage for predialysis psychoeducational intervention recipients after adjusting for age, general nonrenal health at inception, and time between identification and receipt of predialysis psychoeducational intervention or usual care. Predialysis psychoeducational intervention recipients survived a median of 2.25

Acknowledgment

The authors thank the collaborators, clinical staff, and patients at all participating hospitals, especially the project coordinators Linda Barron and Marjorie MacDonald (Calgary) and Ruth Nabi and Nettie Harris (Montreal); Janet Hargrove for meticulous data management and processing; all other research personnel involved in this work; and the University Health Network (Toronto) Quality of Life Manuscript Review Seminar for valuable feedback on earlier versions of this article.

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    Originally published online as doi:10.1053/j.ajkd.2005.08.017 on October 13, 2005.

    Supported in part by research grant no. 6606-5345-403 from the National Health Research and Development Program (G.M.D., Y.M.B.; co-principal investigators); Ortho-Biotech Inc (Y.M.B., G.M.D.); and Canadian Institutes of Health Research (Senior Investigator Award, G.M.D.).

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