Abstract
Background: Adherence to complex regimens for people with chronic kidney disease (CKD) and diabetes is often poor. Interventions to enhance adherence require intensive education and behavioural counselling. However, whether the existing evidence is scientifically rigorous and can support recommendations for routine use of educational programmes in people with CKD and diabetes is still unknown. This is an update of a review first published in 2011.
Objectives: To evaluate the benefits and harms of education programmes for people with CKD and diabetes.
Search methods: We searched the Cochrane Kidney and Transplant Register of Studies up to 19 July 2024 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 Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov.
Selection criteria: We included randomised controlled trials (RCTs) and quasi‐RCTs investigating the benefits and harms of educational programmes (information and behavioural instructions and advice given by a healthcare provider, who could be a nurse, pharmacist, educator, health professional, medical practitioner, or healthcare provider, through verbal, written, audio‐recording, or computer‐aided modalities) for people 18 years and older with CKD and diabetes.
Data collection and analysis: Two authors independently screened the literature, determined study eligibility, assessed quality, and extracted and entered data. We expressed dichotomous outcomes as risk ratios (RR) with 95% confidence intervals (CI) and continuous data as mean difference (MD) with 95% CI. Data were pooled using the random‐effects model. The certainty of the evidence was assessed using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach.
Main results: Eight studies (13 reports, 840 randomised participants) were included. The overall risk of bias was low for objective outcomes and attrition bias, unclear for selection bias, reporting bias and other biases, and high for subjective outcomes.
Education programmes compared to routine care alone probably decrease glycated haemoglobin (HbA1c) (4 studies, 467 participants: MD ‐0.42%, 95% CI ‐0.53 to ‐0.31; moderate certainty evidence; 13.5 months follow‐up) and may decrease total cholesterol (179 participants: MD ‐0.35 mmol/L, 95% CI ‐0.63 to ‐00.07; low certainty evidence) and low‐density lipoprotein (LDL) cholesterol (179 participants: MD ‐0.40 mmol/L, 95% CI ‐0.65 to ‐0.14; low certainty evidence) at 18 months of follow‐up.
One study (83 participants) reported education programmes for people receiving dialysis who have diabetes may improve the diabetes knowledge of diagnosis, monitoring, hypoglycaemia, hyperglycaemia, medication with insulin, oral medication, personal health habits, diet, exercise, chronic complications, and living with diabetes and coping with stress (all low certainty evidence). There may be an improvement in the general knowledge of diabetes at the end of the intervention and at the end of the three‐month follow‐up (one study, 97 participants; low certainty evidence) in people with diabetes and moderately increased albuminuria (A2).
In participants with diabetes and moderately increased albuminuria (A2) (one study, 97 participants), education programmes may improve a participant’s beliefs in treatment effectiveness and total self‐efficacy at the end of five weeks compared to routine care (low certainty evidence). Self‐efficacy for in‐home blood glucose monitoring and beliefs in personal control may increase at the end of the three‐month follow‐up (low certainty evidence). There were no differences in other self‐efficacy measures.
One study (100 participants) reported an education programme may increase change in behaviour for general diet, specific diet and home blood glucose monitoring at the end of treatment (low certainty evidence); however, at the end of three months of follow‐up, there may be no difference in any behaviour change outcomes (all low certainty evidence). There were uncertain effects on death, serious hypoglycaemia, and kidney failure due to very low certainty evidence. No data was available for changes in kidney function (creatinine clearance, serum creatinine, doubling of serum creatinine or proteinuria).
For an education programme plus multidisciplinary, co‐ordinated care compared to routine care, there may be little or no difference in HbA1c, kidney failure, estimated glomerular filtration rate (eGFR), systolic or diastolic blood pressure, hypoglycaemia, hyperglycaemia, and LDL and high‐density lipoprotein (HDL) cholesterol (all low certainty evidence in participants with type‐2 diabetes mellitus and documented advanced diabetic nephropathy). There were no data for death, patient‐orientated measures, change in kidney function (other than eGFR and albuminuria), cardiovascular disease morbidity, quality of life, or adverse events.
Authors' conclusions: Education programmes may improve knowledge of some areas related to diabetes care and some self‐management practices. Education programmes probably decrease HbA1c in people with CKD and diabetes, but the effect on other clinical outcomes is unclear. This review only included eight studies with small sample sizes. Therefore, more randomised studies are needed to examine the efficacy of education programmes on important clinical outcomes in people with CKD and diabetes.