EJINME-02964; No of Pages 6 European Journal of Internal Medicine xxx (2015) xxx–xxx

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European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim

Review Article

Multidisciplinary care in patients with chronic kidney disease: A systematic review and meta-analysis Su-Ming Wang a,b, Lien-Cheng Hsiao b,c, I-Wen Ting a,b, Tung-Min Yu b,d, Chih-Chia Liang a,b, Huey-Liang Kuo a,b, Chiz-Tzung Chang a,b, Jiung-Hsiun Liu a,b, Che-Yi Chou a,b,⁎, Chiu-Ching Huang a,b a

Kidney Institute and Division of Nephrology, China Medical University Hospital, Taichung, Taiwan College of Medicine, China Medical University, Taichung, Taiwan Division of Cardiology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan d Division of Nephrology, Department of Medicine, Taichung Veterans General Hospital, Taiwan b c

a r t i c l e

i n f o

Article history: Received 24 April 2015 Received in revised form 1 July 2015 Accepted 2 July 2015 Available online xxxx Keywords: Chronic kidney disease Dialysis Multidisciplinary care Meta-analysis

a b s t r a c t Background: Multidisciplinary care (MDC) was widely used in multiple chronic illnesses but the effectiveness of MDC in patients with chronic kidney disease (CKD) was inconclusive. The aim of this meta-analysis is to estimate the effectiveness of MDC for CKD. Methods: We searched PubMed, Web of Science, Google Scholar, Cochrane Library, and China Journal Full-text Database for relevant articles published in English or Chinese. Studies investigating MDC and non-MDC in patients with CKD were included. Random effect model was used to compare all-cause mortality, dialysis, risk of temporal catheterization, and hospitalization in the two treatment entities. Results: We analyzed 8853 patients of 18 studies in patients with CKD stages 3–5, aged 63 ± 12 years. MDC was associated with lower risk of all-cause mortality with an odds ratio (OR) of 0.52 [95% confidence interval (CI): 0.44–0.88, p = 0.01], mainly in cohort studies. MDC was associated with a lower risk of starting dialysis (p = 0.02) and lower risk of temporal catheterization for dialysis (p b 0.01). MDC was not associated with a higher chance of choosing peritoneal dialysis (p = 0.18) or a lower chance of hospitalization for dialysis (p = 0.13). Conclusions: Limited evidence from randomized controlled trials is currently available to support the benefit of MDC in patients with CKD. MDC is associated with lower all-cause mortality, lower risk of starting dialysis, and lower risk of temporal catheterization for dialysis in cohort studies. MDC is not associated with a higher chance of choosing peritoneal dialysis or a lower chance of hospitalization for dialysis. More studies are needed to determine the optimal professional that should be included in MDC. © 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

1. Introduction Chronic kidney disease (CKD) is a global health issue associated with an increased mortality and substantial health care costs [1]. As care for patients with CKD is complex, a coordinated multidisciplinary care (MDC) may be needed to improve the management and outcomes in patients with CKD [2]. MDC had been widely used in clinical settings such as patients with heart failure [3,4], patients with delirium [5], patients in intensive care [6], and cancer patients [7,8]. MDC had also been used in patients with CKD but the beneficial effects of MDC on CKD patients' clinical outcomes were controversial in the published studies. MDC was associated with lower all-cause mortality [9–11] and lower risk of dialysis [10,12] in some but not all studies [13–15].

MDC is a form of care of patients that consists of professionals from a range of disciplines with different but complementary skills, knowledge, and experience. These professionals work together to deliver comprehensive healthcare aimed at providing the best possible outcome for the physical and psychosocial needs of a patient and their caregivers [16]. As these needs may vary with time and circumstances, the composition of the MDC team vary accordingly. Understanding of the composition of MDC team such as what professionals should be included may help to improve the effectiveness of MDC. In this study, we investigated the effect of MDC on patient's outcomes using metaanalysis based on the published data. We also identified the professionals included in the MDC for CKD in the published studies. 2. Methods

⁎ Corresponding author at: Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, No. 2, Yu-der Road, North District, Taichung 40447, Taiwan. Tel.: +886 4 22052121 3483; fax: +886 4 22058883. E-mail address: [email protected] (C.-Y. Chou).

2.1. Search strategy The overview of this meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-

http://dx.doi.org/10.1016/j.ejim.2015.07.002 0953-6205/© 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

Please cite this article as: Wang S-M, et al, Multidisciplinary care in patients with chronic kidney disease: A systematic review and meta-analysis, Eur J Intern Med (2015), http://dx.doi.org/10.1016/j.ejim.2015.07.002

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S.-M. Wang et al. / European Journal of Internal Medicine xxx (2015) xxx–xxx

analysis (PRISMA) statement [17]. Two investigators (IW and HL) searched all relevant articles from Jan 1980 to Dec 2014 using PubMed, Web of Science, Google Scholar, the Cochrane Library, and China Journal Full-text Database. We used the following search key words: “multidisciplinary care”, “interdisciplinary care”, “pre-dialysis program or care”, and “chronic kidney disease”, “end-stage renal disease”, and “chronic renal failure”. The languages chosen were English and Chinese. We also manually searched the references of selected articles to identify additional potentially relevant studies. 2.2. Selection criteria The articles included in the meta-analysis were as follows: (1) Articles published in peer-reviewed, English- or Chinese-language journals between January 1980 and Dec 2014. (2) Studies reported MDC and non-MDC in adult patients with CKD without dialysis. (3) Studies reported patient number of mortality, starting renal replacement therapy (hemodialysis, peritoneal dialysis, and kidney transplant), hospitalization for dialysis, and temporal catheterization for dialysis. (4) Studies reported professions involved in the MDC. 2.3. Data extraction and quality assessment

Identification

Two investigators (SM and CC) independently reviewed the full manuscripts of the studies included and extracted the data in a standardized data-collection form. The data extracted included first author's name; year of publication; study design; region; sample size; patients' mean age; number of participants in each group; number of participants died, number of participants commenced hemodialysis, peritoneal dialysis, or kidney transplant, number of participants hospitalized for

Records identified through database searching (n = 754)

dialysis, number of patients on temporal catheterization for dialysis, and professionals included in the MDC. Any discrepancy was resolved by discussion or a third author (JH). 2.4. Statistical analysis All meta-analyses were performed using the Comprehensive MetaAnalysis (version 2, Biostat, Englewood, NJ, USA). We calculated odds ratios (ORs) and corresponding 95% confidence intervals (Cis) for each outcome and studies separately and checked the findings against published data for accuracy. We calculated numbers of outcome events using the event rates and sample size. Outcomes were then pooled and compared with a random-effects model. We analyzed the appropriateness of pooling of data across studies using the Cochran Q statistic and I2 test for heterogeneity. The random effect model was used to minimize the potential heterogeneity between studies. 3. Role of the funding source There was no funding source for this study. All authors had full access to all the data in the study and had the final responsibility for the decision to submit for publication. 4. Results 4.1. Literature search Our initial literature search yielded 754 citations and 63 potential citations from the references link (Fig. 1). After the removal of 456 duplicates, 361 citations were screened at the level of title or abstract.

Additional records identified through manual search (n = 63)

Eligibility

Screening

Records after duplicates removed (n = 456)

Records screened (n = 361)

Full-text articles assessed for eligibility (n = 44)

Records excluded: not MDC, not CKD patients, no control patients, etc (n = 317)

Full-text articles excluded, no outcomes available (n = 22), no components of MDC(n=3), same population (n=1)

Included

Studies included in qualitative synthesis (n = 18)

Studies included in quantitative synthesis (metaanalysis) (n = 18)

Fig. 1. Flow chart of meta-analysis.

Please cite this article as: Wang S-M, et al, Multidisciplinary care in patients with chronic kidney disease: A systematic review and meta-analysis, Eur J Intern Med (2015), http://dx.doi.org/10.1016/j.ejim.2015.07.002

S.-M. Wang et al. / European Journal of Internal Medicine xxx (2015) xxx–xxx

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was included in 10 studies, a pharmacist in 6 studies, and a social worker in 9 studies.

Table 1 Characteristics of included studies. Study

Design

Year

Location

Population

N

Age

MDC

Chen [12] Barrett [13] Hemmelgarn [19] Curtis [11] Chen [22] Chen [36] Cho [21] Fenton [26] Rognant [25] Wei [20] Wu [10] Yu [27] Goldstein [29] Peeters [14] Harris [23] Devins [15] Yeoh [24] Levin [28]

Cohort RCT Cohort Cohort Cohort Cohort Cohort Cohort Cohort Cohort Cohort RCT Cohort RCT Cohort RCT Cohort Cohort

3 1.7 3.5 3.4 3 5 2.5 4 1 1 1 2.8 2.3 5.7 5 1 4 3.5

Taiwan Canada Canada Canada, Italy Taiwan Taiwan Korea UK France Taiwan Taiwan Taiwan Canada Netherland US Canada US Canada

CKD 3B-5 CKD 3-4 CKD 3-5 CKD 5 CKD 3-5 CKD 3-5 CKD 3B-5 CKD 4-5 CKD 4-5 CKD 4-5 CKD 3-5 CKD 3-5 CKD 3-5 CKD 2-5 CKD 3-5 CKD 3B-5 CKD 5 CKD 5

1382 474 374 288 1056 822 198 365 160 140 573 445 87 788 437 297 103 76

63 67 76 62 65 63 58 63 66 60 63 64 58 60 69 59 58 –

1,2 – 1,3 1,2,3 1,2,3 1,2,3 1,2,3 3 – 1 1 1 1,2,3 – 3 3 – –

RCT: randomized controlled trial. Professionals in MDC include nephrologist, specific nurses for chronic kidney disease, and 1 dietitian, 2 pharmacists, 3 social workers.

MDC was not used in 112 studies and 108 studies were not conducted in CKD patients. There were 97 studies with no control patients group. All of the above-mentioned studies were excluded. Full-text of 44 articles was obtained for the analysis and 25 articles were excluded because the number of patients who died or commenced dialysis were not reported (n = 21, including 8 studies in Chinese), the composition of MDC team was not shown (n = 3), and a study from the same group of patients (n = 1) [14,18]. The final analysis conducted was based on 8853 patients of 18 studies with a mean age of 63 ± 12 years old [9–15,18–29]. 4.2. Study characteristics Out of the 18 studies, 4 studies were randomized controlled trials (RCTs) and 14 studies were observational cohort studies (Table 1). Three studies were conducted in patients with CKD stage 3B-5, 7 studies in patients with CKD stages 3–5, 3 studies in patients with CKD stages 4–5, and 3 studies in patients with CKD 5. The median of the duration of follow-up was 3 years (1 to 5.7 years). Six studies were conducted in Taiwan and 6 studies were conducted in Canada. All MDC team in the 18 studies included a nurse for CKD and a nephrologist. A dietician

Studies Barrett 2011 Hemmelgarn 2007 Curtis 2005 Chen 2012 Chen PM 2014 Cho 2012 Rognant 2013 Wu 2009 Goldstein 2004 Peeters 2014 Harris 1998 Devins 2003 Combined

OR

95 % CI

4.3. MDC and outcomes In the 13 studies that reported the number of patients who died, CKD patients who received MDC was associated with lower all-cause mortality than those who did not. The OR of overall morality was 0.62 (95% CI: 0.44–0.88, p = 0.01) in patients who received MDC (Fig. 2). A random effects model was selected because of the heterogeneity between studies (Q = 34.37, I2 = 67.99, p b 0.001). This beneficial effect of MDC was also observed in four of the 13 studies. The lower mortality in MDC patients was mainly observed in cohort studies but not in four RCTs (Fig. 3). MDC was associated with lower risk for starting renal replacement therapy (Fig. 4). The OR of MDC was 0.59 (95% CI: 0.38–0.92, p = 0.02) and three of six studies showed the benefit of MDC in decreasing risk of renal replacement therapy. MDC was not associated with a higher chance of peritoneal dialysis (Fig. 5) although a higher chance of peritoneal dialysis was observed in four of nine studies. MDC was associated with lower risk of temporal catheterization for dialysis (Fig. 6) with an OR of 0.40 (95% CI: 0.26–0.63, p b 0.01). The lower chance of temporal catheterization was also observed in five of 11 studies. The number of patients who were hospitalized for dialysis was reported in four studies and MDC was not associated with lower chance of hospitalization for dialysis (Fig. 7). 5. Discussion This is the first meta-analysis regarding the effectiveness of MDC in patients with CKD. As MDC treatment should provide care that fits the needs of CKD patients and caregivers of these CKD patients, the professionals in the MDC team may be different in different circumstances. For example, an adequate pain control in patients with neurological pain may reduce the use of non-steroidal anti-inflammatory drugs and decrease further damage of the kidneys. Nephrologists, dietitians, and nurses were included in most of the studies, while pharmacists or social workers were included in some studies of MDC. As malnutrition [30,31] and dietary phosphate associated bone mineral bone disorder [32] are critical for the outcomes of patients with CKD, it may not be surprising that dietitians were expected to be included in MDC. Polypharmacy is common in patients with CKD and is associated with increased complications [33]. Although this issue is important, studies regarding pharmacists' interventions of polypharmacy in CKD patients were sparse [34]. As the cost of CKD treatment was high, social workers can

p

MDC

non-MDC

0.12

7 / 238

2 / 236

1.05

0.09

61 / 187

77 / 187

0.51 1.01

Multidisciplinary care in patients with chronic kidney disease: A systematic review and meta-analysis.

Multidisciplinary care (MDC) was widely used in multiple chronic illnesses but the effectiveness of MDC in patients with chronic kidney disease (CKD) ...
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