Milazi Molly, Bonner Ann, Douglas Clint
1School of Nursing, Queensland University of Technology, Brisbane, Australia 2Renal Nursing Professorial Unit, Kidney Health Services, Royal Brisbane and Women's Hospital, Brisbane, Australia 3CEBHA (Centre for Evidence-Based Healthy Ageing): a Joanna Briggs Institute Centre of Excellence.
JBI Database System Rev Implement Rep. 2017 Apr;15(4):971-1010. doi: 10.11124/JBISRIR-2017-003360.
People with end-stage kidney disease (ESKD) develop impaired excretion of phosphate. Hyperphosphatemia develops in ESKD as a result of the kidney's reduced ability to excrete ingested phosphate load and is characterized by high bone turnover and increased musculoskeletal morbidity including bone pain and muscle weakness. Increased serum phosphate levels are also associated with cardiovascular disease and associated mortality. These effects are significant considering that cardiovascular disease is the leading cause of death in ESKD, making phosphate control a crucial treatment goal.
To determine the effectiveness of education or behavioral interventions on adherence to phosphate control in adults with ESKD receiving hemodialysis (HD).
Adults aged over 18 years with ESKD undergoing HD, attending dialysis facilities regardless of frequency and duration of treatment sessions per week. Studies with participants receiving hemodiafiltration were excluded.
TYPES OF INTERVENTION(S)/PHENOMENA OF INTEREST: All types of educational and behavioral interventions aimed at improving adherence to dietary phosphate restriction, phosphate binder medication and HD.
Randomized controlled trials (RCTs), non-RCTs, before and after and cohort studies.
Outcome measures included serum phosphate levels, patient knowledge and adherence to phosphate control methods, chronic kidney disease (CKD) self-management behavior and perceived self-efficacy for CKD related to phosphate control.
A search was conducted in CINAHL, MEDLINE, The Cochrane Library, Embase, Web of Science, PsycINFO and ProQuest Dissertations and Theses Global to find published studies between January 2005 and December 2015.
Risk of bias was assessed by three reviewers prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI).
Data were extracted using the standardized data extraction tool from JBI-MAStARI.
Data were pooled using JBI software. Mean differences (95% confidence interval [CI]) and effect size estimates were calculated for continuous outcomes. Meta-analysis using a random-effects model was performed for serum phosphate levels, and where the findings could not be pooled using meta-analysis, results have been presented in a narrative form. Standard GRADE (Grading of Recommendations Assessment, Development and Evaluation) evidence assessment of outcomes has been reported.
A total of 18 studies were included in the review: seven studies focused on dietary phosphate, four studies focused on medications (phosphate binders) and six studies focused on dietary phosphate and medications. Only one study taught patients about diet, medications and HD to control phosphate. Sixteen studies showed significant improvements in phosphate levels. Meta-analysis of eight RCTs favored educational or behavioral interventions over standard care for serum phosphate control, with a weighted mean reduction of -0.23 mmol/l (95% CI -0.37, -0.08) in treatment groups.
Overall, educational or behavioral interventions increase adherence to phosphate control. Studies in this systematic review revealed improved outcomes on serum phosphate levels, patient knowledge and adherence to phosphate control methods, CKD self-management behavior and perceived self-efficacy for CKD related to phosphate control. However, there is a lack of sufficient data on how some of the studies implemented their interventions, suggesting that further research is required. Successful strategies that improve and optimize long-term adherence to phosphate control still need to be formulated.
终末期肾病（ESKD）患者的磷酸盐排泄功能受损。由于肾脏排泄摄入的磷酸盐负荷的能力下降，ESKD患者会出现高磷血症，其特征是骨转换增加以及肌肉骨骼疾病发病率上升，包括骨痛和肌肉无力。血清磷酸盐水平升高还与心血管疾病及相关死亡率有关。鉴于心血管疾病是ESKD患者的主要死因，这些影响意义重大，这使得控制磷酸盐成为一个关键的治疗目标。
确定教育或行为干预对接受血液透析（HD）的ESKD成年患者坚持磷酸盐控制的有效性。
纳入标准 参与者类型：年龄超过18岁、正在接受HD治疗的ESKD成年患者，无论每周治疗次数和时长，在透析机构接受治疗。排除参与者接受血液滤过的研究。
干预类型/感兴趣的现象：旨在提高对饮食中磷酸盐限制、磷酸盐结合剂药物治疗和HD治疗的依从性的所有类型的教育和行为干预。
随机对照试验（RCT）、非随机对照试验、前后对照研究和队列研究。
结局指标包括血清磷酸盐水平、患者知识以及对磷酸盐控制方法的依从性、慢性肾脏病（CKD）自我管理行为以及与磷酸盐控制相关的CKD自我效能感。
在护理及健康领域数据库（CINAHL）、医学文献数据库（MEDLINE）、考克兰图书馆、荷兰医学文摘数据库（Embase）、科学引文索引数据库（Web of Science）、心理学文摘数据库（PsycINFO）以及博硕士论文数据库（ProQuest Dissertations and Theses Global）中进行检索，以查找2005年1月至2015年12月期间发表的研究。
在纳入综述之前，由三位评审员使用乔安娜·布里格斯循证卫生保健中心统计学评估与评审工具（JBI-MAStARI）的标准化批判性评价工具评估偏倚风险。
使用JBI-MAStARI的标准化数据提取工具提取数据。
使用JBI软件汇总数据。计算连续结局的平均差异（95%置信区间[CI]）和效应量估计值。对血清磷酸盐水平进行随机效应模型的Meta分析，若结果无法通过Meta分析汇总，则以叙述形式呈现。报告了结局的标准GRADE（推荐分级、评估、制定与评价）证据评估。
该综述共纳入18项研究：7项研究聚焦于饮食中的磷酸盐，4项研究聚焦于药物（磷酸盐结合剂），6项研究聚焦于饮食中的磷酸盐和药物。只有1项研究向患者传授饮食、药物和HD以控制磷酸盐。16项研究显示磷酸盐水平有显著改善。对8项RCT的Meta分析表明，在控制血清磷酸盐方面，教育或行为干预优于标准护理，治疗组加权平均降低-0.23 mmol/l（95% CI -0.37，-0.08）。
总体而言，教育或行为干预可提高对磷酸盐控制的依从性。该系统综述中的研究显示，血清磷酸盐水平、患者知识以及对磷酸盐控制方法的依从性、CKD自我管理行为以及与磷酸盐控制相关的CKD自我效能感均有改善。然而，关于一些研究如何实施干预的数据不足，这表明需要进一步研究。仍需制定成功的策略来改善和优化对磷酸盐控制的长期依从性。
