Impact of therapeutic education on the choice of renal replacement therapy. Moroccan monocentric experience

Abstract

Therapeutic patient education (TPE) is gaining importance in the management of patients with chronic kidney disease (CKD). The objective of this study is to assess the interest of TPE in the acquisition of knowledge concerning CKD and renal replacement therapy, as well as the orientation of the patients towards a personalized choice of treatment. Patients with a minimum stage 4 CKD were prospectively included between November 2016 and February 2020. We proposed TPE sessions on CKD and its treatment to all patients. We explained the theoretical part through a slideshow about the definition of end-stage renal disease, its symptoms and the various methods of renal replacement therapy. A “basket” of essential material to illustrate a session of hemodialysis (HD) or peritoneal dialysis (PD) was used to achieve the practical part of the study. Data was collected using two questionnaires: the first one, at the start of the session, included the socio-demographic and clinical characteristics of the patients and evaluated their level of basic knowledge, and the second one, at the end of the session, assessed the evolution of knowledge after TPE, leading to a therapeutic choice. The mean age of the 211 included patients was 55.59 years old (SD=15.47). Male to female ratio was 0.73. The level of education was low in 69% of the cases of whom 23.7% were employees. The glomerular filtration rate (GFR) was between 15 and 30mL/min in 56.8% of the cases. Initial nephropathy was known in 60% of patients while the stage of CKD was unknown in 66.4%. Before TPE, patients with a good level of overall knowledge were around 29%, rising to 73% after TPE. A significant correlation was found between the level of education of the patients and their knowledge score before and after TPE. The choice of renal replacement therapy was taken for PD, TR and HD respectively in 36%, 19% and 11.8% of the cases, while 33.2% asked for time to think. Elderly and/or low educated patients most often remained undecided; moreover those who are young and/or educated prefer TR. During the follow-up period, 46% of patients started renal replacement therapy (36.5% started HD, 8.1% PD and 1.4% KT). The choice made by our patients was respected in 42% of the cases: in all the patients who chose HD; in 36% of those who chose PD, and 19% of those who chose kidney transplantation (KT). The final therapeutic modality was strongly linked to the following parameters: age, GFR and level of education. This study highlighted the insufficient level of patients’ information about CKD and its treatment and allowed the patients to express their choice of their replacement therapy, which is a complicated process that must ­integrate the opinion of the nephrologist and the patient’s preference to lead to an ­optimal organization of the therapeutic modality.