Telemedicine Chapter 4 : Telemedicine and Chronic Kidney Disease

This chapter is part of Literature reviews carried out for the Heath Service Executive National Telehealth Steering Group April – July 2020

Systematic Reviews

Jeddi, Fateme R et al (2019) [Systematic Review] Features and Effects of Information Technology-Based Interventions to Improve Self-Management in Chronic Kidney Disease Patients: a Systematic Review of the Literature[1]

Slowing down the progression of chronic kidney disease (CKD) and its adverse health outcomes requires the patient’s self-management and attention to treatment recommendations. Information technology (IT)-based interventions are increasingly being used to support self-management in patients with chronic diseases such as CKD. We conducted a systematic review of randomized controlled trials (RCTs) to assess the features and effects of IT-based interventions on self-management outcomes of CKD patients. A comprehensive search was conducted in Medline, Scopus, and the Cochrane Library to identify relevant papers that were published until May 2016. RCT Studies that assessed at least one automated IT tool in patients with CKD stages 1 to 5, and reported at least one self-management outcome were included. Studies were appraised for quality using the Cochrane Risk of Bias assessment tool. Out of 12,215 papers retrieved, eight study met the inclusion criteria. Interventions were delivered via smartphones/personal digital assistants (PDAs) (3 studies), wearable devices (3 studies), computerized systems (1 study), and multiple component (1 study). The studies assessed 15 outcomes, including eight clinical outcomes and seven process of care outcomes. In 12 (80%) of the 15 outcomes, the studies had revealed the effects of the interventions as statistically significant positive. These positive effects were observed in 75% of the clinical outcomes and 86% of the process of care outcomes. The evidence indicates the potential of IT-based interventions (ie smartphones/PDAs, wearable devices, and computerized systems) in self-management outcomes (clinical and process of care outcomes) of CKD patients.

Luo, Li et al (2019) [Systematic Review] Telehealth for the management of blood pressure in patients with chronic kidney disease: A systematic review[2]

Background: Most patients with chronic kidney disease (CKD) fail to achieve blood pressure (BP) management as recommended. Meanwhile, the effects of promising intervention and telehealth on BP control in CKD patients remain unclear. We aimed to evaluate the efficacy of telehealth for BP in CKD non-dialysis patients. Methods: Databases including MEDLINE, EMBASE, CENTRAL, CNKI, Wanfang, VIP and CBM were systematically searched for randomised controlled trials or quasi-randomised controlled trials on telehealth for BP control of CKD3-5 non-dialysis patients. We analysed systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), serum creatinine, and estimated glomerular filtration rate (eGFR) with a fixed-effects model. Results: Three studies, with total 680 subjects, were included in our systematic review and two were included for meta-analysis. Pooled estimates showed decreased SBP (pooled mean difference (MD), -5.10; 95% confidence interval (CI), -11.34, 1.14; p > 0.05, p = 0.11), increased DBP (pooled MD, 0.45; 95% CI, -4.24, 5.13; p > 0.05, p = 0.85), decreased serum creatinine (pooled MD, -0.38; 95% CI, -0.83, 0.07; p > 0.05, p = 0.10) and maintained eGFR (pooled MD, 4.72; 95% CI, -1.85, 11.29; p > 0.05, p = 0.16) in the telehealth group. There was no significant difference from the control group. MAP (MD, 0.6; 95% CI, -6.61, 7.81; p > 0.05, p = 0.87) and BP control rate (p > 0.05, p = 0.8), respectively, shown in two studies also demonstrated no statistical significance in the telehealth group. Conclusions: There was no statistically significant evidence to support the superiority of telehealth for BP management in CKD patients. This suggests further studies with improved study design and optimised intervention are needed in the future.

Shen, Hongxia et al (2019) [Systematic Review] Electronic Health Self-Management Interventions for Patients With Chronic Kidney Disease: Systematic Review of Quantitative and Qualitative Evidence[3]

Background: Chronic kidney disease (CKD) poses a major challenge to public health. In CKD patients, adequate disease self-management has been shown to improve both proximal and distal outcomes. Currently, eHealth interventions are increasingly used to optimize patients’ self-management skills. Objective: This study aimed to systematically review the existing evidence regarding the implementation and effectiveness of eHealth self-management interventions for patients with CKD. Methods: Following a search in 8 databases up to November 2017, quantitative and qualitative data on process and effect outcomes were extracted from relevant studies. Quality was appraised using the Crowe Critical Appraisal Tool; narrative synthesis was performed to analyze the data extracted. Results: Of the 3307 articles retrieved, 24, comprising 23 studies, were included in this review; of these, almost half were appraised to be of low to moderate quality. There was considerable heterogeneity in the types of interventions used and the outcomes measured. A total of 10 effect and 9 process outcome indicators were identified. The most frequently reported effect outcome indicators were specific laboratory tests and blood pressure (BP), whereas satisfaction was the most frequently reported process outcome indicator. Positive effects were found for proximal outcomes [eg BP control and medication adherence], and mixed effects were found for more distal outcomes [eg quality of life]. High feasibility, usability, and acceptability of and satisfaction with eHealth self-management interventions were reported. The determinant ability of health care professionals to monitor and, if necessary, anticipate on patient measurements online was mostly cited to influence patients’ adherence to interventions. Conclusions: eHealth self-management interventions have the potential to improve disease management and health outcomes. To broaden the evidence base and facilitate intervention upscaling, more detailed descriptions and thorough analysis of the intervention components used are required. In addition, our review reveals that outcomes closely related to the scope and duration of the intervention implemented are most likely to be impacted. For instance, if a 4-week web-based training to optimize disease management skills is implemented, the outcome perceived control would more likely be affected than kidney function. Although this seems obvious, most studies evaluate only distal outcomes and thereby fail to capture intervention effects that might contribute to long-term health improvement. We advise future researchers to carefully consider their choice of outcomes based on their sensitivity for change. In this way, we ensure that relevant effects are captured and legitimate conclusions are drawn.

Stevenson, Jessica K et al (2019) [Cochrane Systematic Review] eHealth interventions for people with chronic kidney disease[4]

Background: Chronic kidney disease (CKD) is associated with high morbidity and death, which increases as CKD progresses to end-stage kidney disease (ESKD). There has been increasing interest in developing innovative, effective and cost-efficient methods to engage with patient populations and improve health behaviours and outcomes. Worldwide there has been a tremendous increase in the use of technologies, with increasing interest in using eHealth interventions to improve patient access to relevant health information, enhance the quality of healthcare and encourage the adoption of healthy behaviours.

Objectives: This review aims to evaluate the benefits and harms of using eHealth interventions to change health behaviours in people with CKD. Search methods: We searched the Cochrane Kidney and Transplant Register of Studies up to 14 January 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and Selection criteria: Randomised controlled trials (RCTs) and quasi-RCTs using an eHealth intervention to promote behaviour change in people with CKD were included. There were no restrictions on outcomes, language or publication type. Data collection and analysis: Two authors independently assessed trial eligibility, extracted data and assessed the risk of bias. The certainty of the evidence was assessed using GRADE. Main results: We included 43 studies with 6617 participants that evaluated the impact of an eHealth intervention in people with CKD. Included studies were heterogeneous in terms of eHealth modalities employed, type of intervention, CKD population studied and outcomes assessed. The majority of studies were conducted in an adult population, with 16 studies (37%) conducted in those on dialysis, 11 studies (26%) in the pre-dialysis population, 15 studies (35%) in transplant recipients and 1 study (2%) in transplant candidates. We identified six different eHealth modalities including: telehealth; mobile or tablet application; text or email messages; electronic monitors; websites; and video or DVD. Three studies used a combination of eHealth interventions. Interventions were categorised into six types: educational; reminder systems; self-monitoring; behavioural counselling; clinical decision-aid; and mixed intervention types. We identified 98 outcomes, which were categorised into nine domains: blood pressure (9 studies); biochemical parameters (6 studies); clinical end-points (16 studies); dietary intake (3 studies); quality of life (9 studies); medication adherence (10 studies); behaviour (7 studies); physical activity (1 study); and cost-effectiveness (7 studies). Only three outcomes could be meta-analysed as there was substantial heterogeneity with respect to study population and eHealth modalities utilised. There was found to be a reduction in interdialytic weight gain of 0.13kg (4 studies, 335 participants: MD -0.13, 95% CI -0.28 to 0.01; I2 = 0%) and a reduction in dietary sodium intake of 197 mg/day (2 studies, 181 participants: MD -197, 95% CI -540.7 to 146.8; I2 = 0%). Both dietary sodium and fluid management outcomes were graded as being of low evidence due to high or unclear risk of bias and indirectness [interdialytic weight gain] and high or unclear risk of bias and imprecision [dietary sodium intake]. Three studies reported death (2799 participants, 146 events), with 45 deaths/1000 cases compared to standard care of 61 deaths/1000 cases (RR 0.74, CI 0.53 to 1.03; P = 0.08). We are uncertain whether using eHealth interventions, in addition to usual care, impact on the number of deaths as the certainty of this evidence was graded as low due to high or unclear risk of bias, indirectness and imprecision. Authors’ conclusions: eHealth interventions may improve the management of dietary sodium intake and fluid management. However, overall these data suggest that current evidence for the use of eHealth interventions in the CKD population is of low quality, with uncertain effects due to methodological limitations and heterogeneity of eHealth modalities and intervention types. Our review has highlighted the need for robust, high quality research that reports a core minimum data set to enable meaningful evaluation of the literature.

He, Ting et al (2017) [Systematic Review] Remote home management for chronic kidney disease: A systematic review[5]

Background: Remote home management is a new healthcare model that uses information technology to enhance patients’ self-management of disease in a home setting. This study is designed to identify the effects of remote home management on patients with chronic kidney disease (CKD). Methods: A comprehensive search of PubMed, MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials was performed in January 2015. The reference listings of the included articles in this review were also manually examined. Randomized controlled trials (RCTs) designed to evaluate the effects of remote home management on patients with CKD were included. Results: Eight trials were identified. The results of this study suggest that the quality of life (QOL) enabled by remote home management was higher than typical care in certain dimensions. However, the effects of remote home management on blood pressure (BP) remain inconclusive. The studies that assessed health service utilization demonstrated a significant decrease in hospital readmission, emergency room visits, and number of days in the hospital. Another favorable result of this study is that regardless of their gender, age or nationality, patients tend to comply with remote home management programs and the use of related technologies. Conclusions: The available data indicate that remote home management may be a novel and effective disease management strategy for improving CKD patients’ QOL and influencing their attitudes and behaviors. And, relatively little is known about BP and cost-effectiveness, so future research should focus on these two aspects for the entire population of patients with CKD.

Randomised Controlled Trials

Thilly, Nathalie et al (2017) [Randomised Controlled Trial] Cost-effectiveness of Home Telemonitoring in Chronic Kidney Disease Patients at Different Stages by a Pragmatic Randomized Controlled Trial (eNephro): Rationale and Study Design[6]

Background: Home telemonitoring has developed considerably over recent years in chronic diseases in order to improve communication between healthcare professionals and patients and to promote early detection of deteriorating health status. In the nephrology setting, home telemonitoring has been evaluated in home dialysis patients but data are scarce concerning chronic kidney disease (CKD) patients before and after renal replacement therapy. The eNephro study is designed to assess the cost effectiveness, clinical/biological impact, and patient perception of a home telemonitoring for CKD patients. Our purpose is to present the rationale, design and organisational aspects of this study. Methods: eNephro is a pragmatic randomised controlled trial, comparing home telemonitoring versus usual care in three populations of CKD patients: stage 3B/4 (n = 320); stage 5D CKD on dialysis (n = 260); stage 5 T CKD treated with transplantation (n= 260). Five hospitals and three not-for-profit providers managing self-care dialysis situated in three administrative regions in France are participating. The trial began in December 2015, with a scheduled 12-month inclusion period and 12 months follow-up. Outcomes include clinical and biological data (eg blood pressure, haemoglobin) collected from patient records, perceived health status (eg health related quality of life) collected from self-administered questionnaires, and health expenditure data retrieved from the French health insurance database (SNIIRAM) using a probabilistic matching procedure. Discussion: The hypothesis is that home telemonitoring enables better control of clinical and biological parameters as well as improved perceived health status. This better control should limit emergency consultations and hospitalisations leading to decreased healthcare expenditure, compensating for the financial investment due to the telemedicine system. Trial registration: This study has been registered at under NCT02082093; date of registration: February 14, 2014.

Ishani, Areef et al (2017) [Randomised Controlled Trial] Telehealth by an Interprofessional Team in Patients With CKD: A Randomized Controlled Trial[7]

Background: Telehealth and interprofessional case management are newer strategies of care within chronic disease management. We investigated whether an interprofessional team using telehealth was a feasible care delivery strategy and whether this strategy could affect health outcomes in patients with chronic kidney disease (CKD). Study design: Randomized clinical trial. Setting and Participants: Minneapolis Veterans Affairs Health Care System (VAHCS), St. Cloud VAHCS, and affiliated clinics March 2012 to November 2013 in patients with CKD (estimated glomerular filtration rate < 60mL/min/1.73m2.).

Interventions: Patients were randomly assigned to receive an intervention (n=451) consisting of care by an interprofessional team (nephrologist, nurse practitioner, nurses, clinical pharmacy specialist, psychologist, social worker, and dietician) using a telehealth device (touch screen computer with peripherals) or to usual care (n=150). Outcomes: The primary end point was a composite of death, hospitalization, emergency department visits, or admission to skilled nursing facilities, compared to usual care. Results: Baseline characteristics of the overall study group: mean age, 75.1±8.1 (SD) years; men, 98.5%; white, 97.3%; and mean estimated glomerular filtration rate, 37±9mL/min/1.73m2. Telehealth and interprofessional care were successfully implemented with meaningful engagement with the care system. One year after randomization, 208 (46.2%) patients in the intervention group versus 70 (46.7%) in the usual-care group had the primary composite outcome (HR, 0.98; 95% CI, 0.75-1.29; P=0.9). There was no difference between groups for any component of the primary outcome: all-cause mortality (HR, 1.46; 95% CI, 0.42-5.11), hospitalization (HR, 1.15; 95% CI, 0.80-1.63), emergency department visits (HR, 0.92; 95% CI, 0.68-1.24), or nursing home admission (HR, 3.07; 95% CI, 0.71-13.24). Limitations: Older population, mostly men, potentially underpowered/wide CIs. Conclusions: Telehealth by an interprofessional team is a feasible care delivery strategy in patients with CKD. There was no statistically significant evidence of superiority of this intervention on health outcomes compared to usual care.


Hull, SA et al (2020) [Review] Do Virtual Renal Clinics Improve Access to Kidney Care? A Preliminary Impact Evaluation of a Virtual Clinic in East London[8]

Background: Early identification of people with CKD in primary care, particularly those with risk factors such as diabetes and hypertension, enables proactive management and referral to specialist services for progressive disease. The 2019 NHS Long Term Plan endorses the development of digitally-enabled services to replace the ‘unsustainable’ growth of the traditional out-patient model of care. Shared views of the complete health data available in the primary care electronic health record (EHR) can bridge the divide between primary and secondary care, and offers a practical solution to widen timely access to specialist advice. Methods: We describe an innovative community kidney service based in the renal department at Barts Health NHS Trust and four local clinical commissioning groups (CCGs) in east London. An impact evaluation of the changes in service delivery used quantitative data from the virtual CKD clinic and from the primary care electronic health records (EHR) of 166 participating practices. Survey and interview data from health professionals were used to explore changes to working practices. Results: Prior to the start of the service the general nephrology referral rate was 0.8/1000 GP registered population, this rose to 2.5/1000 registered patients by the second year of the service. The majority (> 80%) did not require a traditional outpatient appointment, but could be managed with written advice for the referring clinician. The wait for specialist advice fell from 64 to 6 days. General practitioners (GPs) had positive views of the service, valuing the rapid response to clinical questions and improved access for patients unable to travel to clinic. They also reported improved confidence in managing CKD, and high levels of patient satisfaction. Nephrologists valued seeing the entire primary care record but reported concerns about the volume of referrals and changes to working practices. Conclusions: Virtual specialist services using shared access to the complete primary care EHR are feasible and can expand capacity to deliver timely advice. To use both specialist and generalist expertise efficiently these services require support from community interventions which engage primary care clinicians in a data driven programme of service improvement.

Yang, Feng-Jung et al (2020) [Quasi-Experimental Study] The Impact of a Social Networking Service-Enhanced Smart Care Model on Stage 5 Chronic Kidney Disease: Quasi-Experimental Study[9] 

Background: Stage 5 chronic kidney disease (CKD) presents a high risk for dialysis initiation and for complications such as uremic encephalopathy, uremic symptoms, gastrointestinal bleeding, and infection. One of the most common barriers to health care for patients with stage 5 CKD is poor continuity of care due to unresolved communication gaps. Objective: Our aim was to establish a powerful care model that includes the use of a social networking service (SNS) to improve care quality for patients with CKD and safely delay dialysis initiation. Methods: We used a retrospective cohort of CKD patients aged 20-85 years who received care between 2007 and 2017 to evaluate the efficacy of incorporating an SNS into the health care system. In 2014, author Feng-Jung Yang, a nephrologist at the National Taiwan University Hospital Yunlin Branch, started to use an SNS app to connect with stage 5 CKD patients and their families. In cases of emergency, patients and families could quickly report any condition to FJY. Using this app, FJY helped facilitate productive interactions between these patients and the health care system. The intention was to safely delay the initiation of dialysis therapy. We divided patients into four groups: group 1 included patients at the study hospital during the 2007-2014 period who had contact only with nephrologists other than FJY; group 2 included patients who visited FJY during the 2007-2014 period before he began using the SNS app; group 3 included patients who visited nephrologists other than FJY during the 2014-2017 period and had no interactions using the SNS; and group 4 included patients who visited F-JY during the 2014-2017 period and interacted with him using the SNS app. Results: We recruited 209 patients with stage 5 CKD who had been enrolled in the study hospital’s CKD program between 2007 and 2017. Each of the four groups initiated dialysis at different times. Before adjusting for baseline estimated glomerular filtration rate (eGFR), the G4 patients had a longer time to dialysis (mean 761.7 days, SD 616.2 days) than the other groups (G1: mean 403.6 days, SD 409.4 days, P=.011 for G4 vs G1; G2: 394.8 days, SD 318.8 days, P=.04; G3: 369.1 days, SD 330.8 days, P=.049). After adjusting for baseline eGFR, G4 had a longer duration for each eGFR drop (mean 84.8 days, SD 65.1 days) than the other groups (G1: mean 43.5 days, SD 45.4 days, P=.005; G2: mean 42.5 days, SD 26.5 days, P=.03; G3: mean 3.8.7 days, SD 33.5 days, P=.002). Conclusions: The use of an SNS app between patients with stage 5 CKD and their physicians can reduce the communication gap between them and create benefits such as prolonging time-to-dialysis initiation. The role of SNSs and associated care models should be further investigated in a larger population.

Clemens, K et al (2019) [Scoping Review]  Nonconventional diabetes-related care strategies for patients with chronic kidney disease: A scoping review of the literature[10]

Background: Patients with diabetes and chronic kidney disease (CKD) are at high risk of diabetes-related complications. Diabetes care can support these individuals, but outpatient clinic appointments can be difficult to attend, given their already high burden of multimorbidity. Methods: We systematically searched the medical and grey literature for studies that evaluated the effect of nonconventional diabetes care strategies on diabetes-related outcomes in adults with stages 2-5 CKD or using dialysis. We included both randomized-controlled trials and observational studies. Study selection and data extraction were completed by two independent reviewers. Diabetes-related outcomes included glycemic, blood pressure, and lipid control, along with microvascular complications, macrovascular complications, and death.

Results: After screening 2,177 relevant citations, we identified 34 studies which met inclusion. The majority were observational studies. Studies were frequently small, single-centered, and excluded patients with more advanced CKD. Nonconventional diabetes care strategies included community-based care, unique self-management and education programs, nurse-led care clinics, dialysis-based diabetes programs, telemedicine, and interdisciplinary care clinics. Programs were most often developed by study investigators. Although there were limitations to several of the included studies, programs were described to have modest effects on physiologic outcomes, and in some cases, diabetes-related complications and death. Conclusions: Nonconventional diabetes-related care might be helpful to patients with CKD. Prior to developing and implementing programs, however, it will be important to study them more rigorously, understand their acceptability to patients, and evaluate their costs and feasibility in a real-world setting.

Doyle, N et al. (2019) [Intervention Study] The “Mikidney” smartphone app pilot study: Empowering patients with Chronic Kidney Disease[11]

Background: Successful management of chronic kidney disease (CKD) depends on patients’ self-management efforts. Mobile health applications can empower patients with CKD to manage their own condition. We developed, with patient involvement, the MiKidney smartphone application. Aim: Evaluate the MiKidney app as an aid to empowering patients with CKD to become more engaged in the management of their condition. Design: Pilot single group pre- and post-test intervention study. Setting: Renal clinic of an urban University Hospital in Ireland. Patients: Aged over 18 years with CKD and able to use a smartphone. Sample size based on expression of interest and availability of free smartphones (n = 23); three patients withdrew prior to T3 data collection (n = 20). Measurements: Data were collected at T1 (baseline), T2 (week 6) and when exiting the study (T3, 12 weeks) on physical activity, body measurements and blood parameters. Information on app usage and patient satisfaction collected at T2 and T3. Results: There was significant improvement in the six-minute walking test (p = 0.02), total cholesterol (p = 0.023) and LDL cholesterol (p = 0.005) serum levels and a significant decrease in waist circumstance (p = 0.00) and body fat (p = 0.01) measurements. Eighteen participants found the MiKidney app easy to navigate. Conclusion: The MiKidney study highlights the viability and usability of the MiKidney app. It has the potential to empower and motivate patients to understand and self-manage their condition by providing them with the necessary information on renal diet and symptom management. Additionally, tools such as exercise tracker and reminder alerts are available on a readily accessible user-friendly platform. Conflict of interest: article added to this literature review by request of one of the authors.

Park, Sook H et al (2019) [Review] Recent Advances of Biosensors for Hypertension and Nephrology[12]

Purpose of review: Hypertension (HTN) and chronic kidney disease (CKD) are significant problems. With recent advances in technologies, biosensors have shown a great potential to provide better home monitoring in hypertension (HTN), medication compliance, diagnostic device for kidney disease, CKD/end-stage renal disease (ESRD) care, and post kidney transplant management. Recent findings: Multiple devices/biosensors have been developed related to HTN, kidney function including real-time glomerular filtration rate, CKD/end-stage renal disease, and transplant care. In recent advances in wearable biosensors, point of care monitoring system could provide more integrated care to the patients via telenephrology. Summary: This review focuses on the recent advances in biosensors which may be useful for HTN and nephrology. We will discuss future potential clinical implication of these biosensors.

Siddique, Abu Bakker et al (2019) [Scoping Review] Mobile Apps for the Care Management of Chronic Kidney and End-Stage Renal Diseases: Systematic Search in App Stores and Evaluation[13]

Background: Numerous free and low-cost mobile apps for the care management of kidney disease have become available in recent years. Although these appear to be promising tools, they have not been evaluated comparatively based on standard mobile app metrics; and thus, limited evidence is available regarding their efficacy. This study systematically cataloged and assessed mobile apps designed to assist medication compliance and nutrition tracking that are useful to the chronic kidney disease (CKD) and the end-stage renal disease (ESRD) patients who are on dialysis. Objective: The objective of this study was to comprehensively evaluate mobile apps used for medication compliance and nutrition tracking for possible use by CKD and ESRD patients. Methods: A systematic review framework was applied to the search, screening, and assessment of apps identified and downloaded from the iOS and Android app stores. We selected apps using 13 relevant search terms, narrowed down based on a set of inclusion and exclusion criteria, and then used the Mobile App Rating Scale (MARS), a widely adopted app evaluation tool to assess the effectiveness of apps. The internal consistency and interrater reliability were tested using Cronbach alpha and interclass correlation coefficients (ICCs), respectively. Results: The MARS total score had excellent internal consistency (Cronbach alpha=.90) and a moderate level of interrater reliability (2-way mixed ICC 0.65). Overall, 11 out of the 12 reviewed apps met the minimum acceptable score of 3.0 in MARS rating. The 3 apps with the highest combined scores were My Kidneys, My Health Handbook (MARS=4.68); My Food Coach (MARS=4.48); and National Kidney Foundation Malaysia (MARS=4.20). The study identified general weaknesses in the existing apps: the apps fell short of accommodating advanced interactive features such as providing motivational feedback and promoting family member and caregiver participations in the app utilization. Conclusions: The MARS rating system performed well in the app evaluation. The 3 highest ranked apps scored consistently high across the 5 dimensions specified in MARS. These apps were developed in collaboration with reputable organizations and field experts, demonstrating the importance of expert guidance in developing medical apps.

Thomas, Nicola et al (2019) [Qualitative Analysis] Using Chronic Kidney Disease Trigger Tools for Safety and Learning: A Qualitative Evaluation in East London Primary Care[14]

Background: An innovative programme to improve identification and management of chronic kidney disease (CKD) in primary care was implemented across three clinical commissioning groups (CCGs) in 2016. This included a falling estimated glomerular filtration rate (eGFR) trigger tool built from data in the electronic health record (EHR). This tool notifies GP practices of falling eGFR values. By alerting clinicians to patients with possible CKD progression the tool invites clinical review, a referral option, and written reflection on management. Aim: To identify practitioner perceptions of trigger tool use from interviews, and compare these with reflections on clinical management recorded within the tools. Design and setting: A qualitative analysis set in 136 practices across East London during 2016-2018. Method: Eight semi-structured interviews with GPs and practice staff were recorded, and thematic analysis was undertaken using framework analysis. The reflective comments recorded in the trigger tools of 1921 cases were categorised by age group, referral status, and by the drop in eGFR (>15 or >25 ml/min).

Results: Three themes emerged from the interviews: getting started; patient safety; and trigger tools for learning. Well-organised practices found the tool was readily embedded into workflow and expressed greater motivation for using it. The tool was seen to support patient safety, and was used for learning about CKD management, both individually and as a practice. Reflective comments from 1921 trigger tools were reviewed. These supported the theme of patient safety. The free-text data, stratified by age, challenged the expectation that younger cases, at higher risk of progressive CKD, would have higher referral rates. Conclusion: Building electronic trigger tools from the EHR can identify patients with a falling eGFR, prompting review of the eGFR trajectory and management plan. Interview and reflective data illustrated that practice use of the tool supports the patient safety agenda and encourages learning about CKD management.

Bonner, Ann et al (2018) [Cross-Sectional Study] Evaluating the prevalence and opportunity for technology use in chronic kidney disease patients: a cross-sectional study[15]

Background: Chronic kidney disease (CKD) is increasing worldwide and early education to improve adherence to self-management is a key strategy to slow CKD progression. The use of the Internet and mobile phone technologies (mHealth) to support patients is considered an effective tool in many other chronic disease populations. While a number of mHealth platforms for CKD exist, few studies have investigated if and how this population use technology to engage in self-management. Methods: Using a cross-sectional design across five health districts in Queensland (Australia), a 38-item self-report survey was distributed to adults with CKD attending outpatient clinics or dialysis units to measure current use and type of engagement with mHealth, perceived barriers to use, and opportunities to support CKD self-management. Odds ratio (OR) were calculated to identify associations between demographic characteristic and mHealth use. Results: Of the 708 participants surveyed, the majority had computer access (89.2%) and owned a mobile phone (83.5%). The most likely users of the Internet were those aged ≤ 60 years (OR: 7.35, 95% confidence interval: 4.25-12.75, p < 0.001), employed (OR: 7.67, 95% CI: 2.58-22.78, p < 0.001), from non-indigenous background (OR: 6.98, 95% CI: 3.50-13.93, p < 0.001), or having completed higher levels of education (OR: 3.69, CI: 2.38-5.73, p < 0.001). Those using a mobile phone for complex communication were also younger (OR: 6.01, 95% CI: 3.55-10.19, p < 0.001), more educated (OR: 1.99, 95% CI: 1.29-3.18, p < 0.01), or from non-indigenous background (OR: 3.22, 95% CI: 1.58-6.55, p < 0.001). Overall, less than 25% were aware of websites to obtain information about renal healthcare. The mHealth technologies most preferred for communication with their renal healthcare teams were by telephone (56.5%), Internet (50%), email (48.3%) and text messages (46%).

Conclusion: In the CKD cohort, younger patients are more likely than older patients to use mHealth intensively and interactively although all patients’ technology literacy ought to be thoroughly assessed by renal teams before implementing in practice. Further research testing mHealth interventions to improve self-management in a range of patient cohorts is warranted. Ethics approval and consent to participate: Prior to undertaking the study, ethical approval was obtained for each study site via the Metro South Human Research Ethics Committee (HREC/15/QPAH/19), and also from the Queensland University of Technology (1500000370). Participants were advised that the questionnaire was anonymous and that completing the questionnaire would indicate consent.   

Lunney, Meaghan et al (2018) [Review] Impact of Telehealth Interventions on Processes and Quality of Care for Patients With ESRD[16]

Caring for patients with end-stage renal disease (ESRD) requiring dialysis is intensive and expensive. Telehealth may improve the access and efficiency of ESRD care. For this perspective, we systematically reviewed studies that examined the effectiveness of telehealth versus or in addition to usual care for ESRD management. 10 studies were identified, including 7 randomized trials and 3 cohort studies. Study populations, modes of delivery including telephone, telemetry, or videoconferencing, and the outcomes evaluated varied substantially between studies. Two studies examined telehealth interventions versus standard ESRD care and demonstrated mixed results on processes of care, no differences in laboratory surrogate markers of ESRD care, and reduced or similar rates of hospitalization. Eight studies evaluated the addition of telehealth to usual care and demonstrated no significant improvements in processes of care or surrogate laboratory measures, variable impacts on hospitalization rates, and mixed impacts on some domains of quality of life, including improvement in mental health. Although potential benefits of telehealth in ESRD care have been reported, optimal designs for delivery and elements of care that may be improved through telehealth remain uncertain.

Salani, M et al (2018) [Review] Innovations in Wearable and Implantable Artificial Kidneys[17]

More than 2 million people worldwide receive treatment for end-stage renal disease (ESRD). Current modalities of renal replacement therapy include in-center hemodialysis, peritoneal dialysis, home hemodialysis, and kidney transplantation. Patient survival has gradually increased during the past 2 decades and efforts continue to improve mortality and quality of life for patients with ESRD. Developments in sorbent technology, nanotechnology, and cell culture techniques provide promise for new innovations in ESRD management. New modalities currently in testing include wearable (WAKs) and implantable artificial kidneys (IAKs). The automated WAK (AWAK) and WAK are devices that have undergone small trials in humans. Additional study is needed before regulatory approval, coverage decisions, and widespread clinical implementation. The IAK is a biohybrid combining artificial filters and living cells currently in preclinical testing. These portable devices reduce the need for large quantities of water and continuous electrical supply. This could lower some barriers to home dialysis, making self-care renal replacement therapy more accessible and desirable. If widely successful, these devices could reduce the need to build and staff dialysis facilities, thus lowering health care costs associated with dialysis. The potential advantages and shortcomings of the AWAK, WAK, and IAK are described here.

Rosner, Mitchell H et al (2017) [Review] Perspectives From the Kidney Health Initiative on Advancing Technologies to Facilitate Remote Monitoring of Patient Self-Care in RRT[18]

Telehealth and remote monitoring of a patient’s health status has become more commonplace in the last decade and has been applied to conditions such as heart failure, diabetes mellitus, hypertension, and chronic obstructive pulmonary disease. Conversely, uptake of these technologies to help engender and support home RRTs has lagged. Although studies have looked at the role of telehealth in RRT, they are small and single-centered, and both outcome and cost-effectiveness data are needed to inform future decision making. Furthermore, alignment of payer and government regulations with telehealth procedures is needed along with a better understanding of the viewpoints of the various stakeholders in this process: patients, caregivers, clinicians, payers, dialysis organizations, and government regulators. Despite these barriers, telehealth has great potential to increase the acceptance of home dialysis, and improve outcomes and patient satisfaction while potentially decreasing costs. The Kidney Health Initiative convened a multidisciplinary workgroup to examine the current state of telehealth use in home RRTs as well as outline potential benefits and drawbacks, impediments to implementation, and key unanswered questions.

Solomon, Richard et al (2017) [Review] Real-time Measurement of Glomerular Filtration Rate[19]

Purpose: Measurement of glomerular filtration rate is an essential tool for determining the health or dysfunction of the kidney. The glomerular filtration rate is a dynamic function that can change almost instantaneously in response to stressors. Despite its central role in nephrology, there are no techniques available to the clinician for monitoring glomerular filtration rate in real time. Recent advances in technology to measure fluorescent compounds through the skin are providing a new approach for real-time monitoring of glomerular filtration rate. This review frames these technologies within how such measurements might be used in clinical medicine. Recent Findings: Fluorescent molecules that act as ideal filtration markers are now available. Using transdermal sensors, the plasma disappearance rate of these exogenous markers can be measured rather than their steady state concentration. This eliminates the delay inherent in using an endogenous marker of filtration and permits continuous monitoring of GFR. Summary: These new technologies provide enhanced opportunities for diagnosis of kidney dysfunction and therapeutic monitoring. Accurate assessment of measured GFR will eliminate the erroneous diagnosis of chronic kidney disease (CKD) from many patients. Assessment of renal reserve will provide a new risk factor for progression of CKD. Real-time monitoring of GFR in critically ill patients will allow for earlier diagnosis of acute kidney injury and a dynamic metric to guide therapeutics. These are but a few of the many opportunities that this new technology will provide in both the clinical and research arenas.

Tuot, Delphine S et al (2017) [Review] Telehealth Applications to Enhance CKD Knowledge and Awareness Among Patients and Providers[20]

CKD affects 13% of the US adult population, causes excess mortality, and is associated with significant sociodemographic disparities. Optimal CKD management slows progression of disease and reduces cardiovascular-related outcomes. Resources for patients and primary care providers, major stakeholders in preventive CKD care, are critically needed to enhance understanding of the disease and to optimize CKD health, particularly because of the asymptomatic nature of kidney disease. Telehealth is defined as the use of electronic communication and telecommunications technology to support long-distance clinical health care, patient and professional health-related education, and public health and health administration. It provides new opportunities to enhance awareness and understanding among these important stakeholders. This review will examine the role of telehealth within existing educational theories, identify telehealth applications that can enhance CKD knowledge and behavior change among patients and primary care providers, and examine the advantages and disadvantages of telehealth vs usual modalities for education.

Weiner, Shoshana et al (2017) [Review] Telemedicine to Promote Patient Safety: Use of Phone-Based Interactive Voice-Response System to Reduce Adverse Safety Events in Pre-dialysis CKD[21]

CKD patients have several features conferring on them a high risk of adverse safety events, which are defined as incidents with unintended harm related to processes of care or medications. These characteristics include impaired kidney function, polypharmacy, and frequent health system encounters. The consequences of such events in CKD can include new or prolonged hospitalization, accelerated kidney function loss, acute kidney injury, ESRD, and death. Health information technology administered via telemedicine presents opportunities for CKD patients to remotely communicate safety-related findings to providers for the purpose of improving their care. However, many CKD patients have limitations that hinder their use of telemedicine and access to the broad capabilities of health information technology. In this review, we summarize previous assessments of the pre-dialysis CKD populations’ proficiency in using telemedicine modalities and describe the use of interactive voice-response system to gauge the safety phenotype of the CKD patient. We discuss the potential for expanded interactive voice-response system use in CKD to address the safety threats inherent to this population.

Ong, Stephanie W et al (2016) [Proof-of-Principle Study] Integrating a Smartphone-Based Self-Management System into Usual Care of Advanced CKD[22]

Background and Objectives: Patient self-management has been shown to improve health outcomes. We developed a smartphone-based system to boost self-care by patients with CKD and integrated its use into usual CKD care. We determined its acceptability and examined changes in several clinical parameters. Design, Setting, Participants, and Measurements: We recruited patients with stage 4 or 5 CKD attending outpatient renal clinics who responded to a general information newsletter about this 6-month proof-of-principle study. The smartphone application targeted four behavioral elements: monitoring BP, medication management, symptom assessment, and tracking laboratory results. Prebuilt customizable algorithms provided real-time personalized patient feedback and alerts to providers when predefined treatment thresholds were crossed or critical changes occurred. Those who died or started RRT within the first 2 months were replaced. Only participants followed for 6 months after recruitment were included in assessing changes in clinical measures. Results: In total, 47 patients (26 men; mean age =59 years old; 33% were ≥65 years old) were enrolled; 60% had never used a smartphone. User adherence was high [>80% performed ≥80% of recommended assessments] and sustained. The mean reductions in home BP readings between baseline and exit were statistically significant (systolic BP, -3.4 mmHg; 95% confidence interval, -5.0 to -1.8 and diastolic BP, -2.1 mmHg; 95% confidence interval, -2.9 to -1.2); 27% with normal clinic BP readings had newly identified masked hypertension. One hundred twenty-seven medication discrepancies were identified; 59% were medication errors that required an intervention to prevent harm. In exit interviews, patients indicated feeling more confident and in control of their condition; clinicians perceived patients to be better informed and more engaged. Conclusions: Integrating a smartphone-based self-management system into usual care of patients with advanced CKD proved feasible and acceptable, and it appeared to be clinically useful. The results provide strong rationale for a randomized, controlled trial.

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