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sugar, blood lipids, use of tobacco and alcohol, diet,

medication misuse and obesity. Non-modifiable factors

include age, gender, race and genetics (Brown et al. 2003,

de Jong & Brenner 2004). Ageing has been shown to be

associated with a decline in renal function (Brown et al.

2003). Obesity [body mass index (BMI) of more than

30 kg/m2], especially abdominal obesity, is frequently

accompanied by several factors in addition to hypertension

that may accelerate the risk for CKD. Abdominal obesity

refers to subjects with central fat distribution and is a major

risk factor for renal function abnormalities (Pinto-Sietsma

et al. 2003, Kramer et al. 2005). Because the number of

nephrons does not increase after birth, increasing body

weight must result in an increase in the single nephron

glomerular filtration rate (GFR) (Kramer et al. 2005).The

early stage of CKD is often asymptomatic; when symptoms

do arise with progression towards renal failure, it is often

too late to change behaviours to preserve renal function.

Chagnac et al. (2003) showed that therapeutic interventionswere often ineffective at the end stage of CKD. Therefore,

current standards call for early intervention for patients with

progressive CKD.

Many studies have shown that early stage CKD patients

who received predialysis education had lower hospitalisation

rates and shorter lengths of stay when hospitalised than those

who did not receive health education. Researchers have also

indicated that patients with predialysis care experienced less

urgent dialysis (Levin et al. 1997) and better biochemical

parameters at the start of dialysis therapy (Devins et al. 2003,

Goldstein et al. 2004, Tungsanga et al. 2005). Early

intervention to retard renal function deterioration was

recommended when patients serum creatinine (Scr) level

was 1530 mg/dl, or GFR level is from 30 to 59 ml/minutes

(Hebert et al. 2001). Such results indicate that predialysis

education programs could be beneficial for CKD patients. In

contrast, some results of predialysis care have been inconsis-

tent; intensive predialysis management showed little effect on

mortality or kidney function deterioration (Devins et al.

2003, Goldstein et al. 2004, Tungsanga et al. 2005). Also,

investigators have concluded that intensive predialysis man-

agement may not be cost effective (Harris et al. 1998).

In addition to biological outcomes, researchers havestressed that psychosocial indicators should be considered

in follow-up research (Devins et al. 2003). The literature

indicates that quality of life (QOL) is a better measure of

comprehensive responses to the physical, mental and social

dimensions often measured separately by psychosocial instru-

ments. QOL has become an important variable in the

evaluation of therapeutic interventions (Valderrabano et al.

2001). Many studies have recognised that the QOL of

patients with established renal failure is less than that of the

general population (Valderrabano et al. 2001, Suet-Ching

2001, Patel et al. 2002). But few studies have measured the

QOL of patients in the early stage of CKD.

In Taiwan, alternatives to contemporary medicine are

readily available and commonplace. Patients with impaired

renal function often use alternative treatments, especially

traditional Chinese herbs. A phenomenological study indi-

cated that, after being diagnosed with established renal

failure, patients in Taiwan seek further information, includ-

ing getting a second opinion from a traditional Chinese

medicine specialist and explore alternative treatment to

recover renal function (Lin et al. 2005). Many Taiwanese

believe that traditional herbs are natural and thus harmless.

Long periods of information seeking, however, can cause

treatment delays and prevent the patient from receiving

effective treatment in time (Sesso & Yoshihiro 1997, Lin

et al. 2005). In addition, the improper use of herbal

medicine can deteriorate kidney function. Therefore, healtheducation for CKD patients that includes information on the

use of Chinese herbal medicine could be an appropriate

method to prevent or retard the development of renal failure

in Taiwan.

Patients with CKD have been identified as a patient group

in need of specific education (Goldstein et al. 2004, Tung-

sanga et al. 2005). A predialysis educational program may

produce important benefits by increasing illness-related

knowledge and promoting QOL (Harris et al. 1998, Klang

et al. 1999). More research is needed to understand the

effects of an educational intervention on patients with early

stage CKD. Thus, a multidisciplinary predialysis care team

was convened to develop an intervention designed to improve

renal function protection in persons with early stage CKD.

Such an educational intervention has not been previously

developed and evaluated in Taiwan. Therefore, the purpose

of this study was to investigate physical, knowledge and QOL

outcomes of an educational intervention for patients with

CKD.

Methods

This study used a one-group repeated-measures design. Aneducational intervention delivered by a multidisciplinary

predialysis care team and focused on renal function protec-

tion for people with CKD was held with follow-up data

collection. Outcomes physical indicators, QOL and knowl-

edge of renal function protection were measured at

baseline, six and 12 months. Throughout the 12-month

period, participants were able to contact the predialysis care

team with any questions about CKD.

M Yen et al.

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Participants and setting

The study was approved by the institutional review boards of

participating hospitals. After approval by the Health Depart-

ment of Tainan City, a health screening data bank ( n = 2071)

was obtained. The first step was to screen for people with Scr.

between 15 and 3 mg/dl. A total of 640 potentially eligible

persons were identified. Each person was contacted bytelephone and invited to participate in the study. Among

the 640 persons identified in the initial screening process,

reasons for not participating were inconvenience of trans-

portation, not interested in the intervention and having an

alternative treatment plan. Some decided not to participate

without giving any reason. One hundred and fifty four

persons agreed to participate. Each of the 154 persons next

visited a nephrologist at their convenience to determine study

eligibility. Inclusion criteria included: (1) Scr between 15 and

3 mg/dl; (2) diagnosed as CKD by their doctors; (3) aged

18 years or older; and (4) spoke Mandarin or Taiwanese. Of

the 154 who initially agreed to participate, 66 persons

fulfilled the selection criteria. All participants gave written

informed consent prior to data collection.

Educational intervention

The educational intervention consisted of one workshop,

individual consultations every six months and a telephone

number for participant questions. The predialysis care team

for the workshop consisted of a nephrologist, nurse, nutri-

tionist and social worker. The workshop included content on

renal protection, nutrition, exercise and the use of Chineseherbal medicine. An educational handout describing CKD

disease-related information was given to each participant.

The physician focused on the context of renal function,

pharmacological management and the causes of CKD, as well

as the use of Chinese herbal medicine. The nurse provided

information on health promotion for renal function protec-

tion. The nutritionist covered content on diet for people with

decreased renal function, including information on foods to

choose and to avoid. The social worker raised the issue of

support systems for people with CKD. The workshop lasted

for 150 minutes with two short breaks. Desserts recom-

mended by the nutritionist were provided during the breaks

for educational purposes. Lunch boxes were also designed by

the nutritionist and given to the participants at the end of the

workshop. A masters-prepared nurse case manager per-

formed the individual consultations and answered

phone calls from the participants. Individual consultations

and measures of the study indicators at the sixth and

twelfth month were undertaken at the same time. The

multidisciplinary team served as a resource for the case

manager in consultations.

Instruments

Study instruments included physical indicators, World Health

Organisation Quality of Life (WHOQOL) questionnaire,

renal protection knowledge checklist and demographics. The

research assistant called the participants prior to their regular

outpatient clinic check up and reminded them for the follow-

up data collection every six month. Face-to-face interview for

individual questions and measuring study outcomes were

performed at follow-ups.

Physical indicators

The renal function assessment consisted of Scr., blood urea

nitrogen (BUN) and GFR. The GFR was estimated by the

CockcroftGault prediction formula (K/DOQI Work Group,

2002):

GFR 140 age BWkg 085 if female=Scr. 72

Body composition, including body weight, muscle weight,

percentage body fat, body fat, waist to hip ratio (WHR) and

BMI, were measured by INNBODYODY 3.0 Body composition

analyser (INNBODYODY 3.0 Biospace (Upwards Biosystems Ltd,

Taipei, Taiwan); Okamoto et al. 2006). Blood pressure was

taken in a seated position using an automated sphygmo-

manometer.

Quality of life: the World Health Organisation qualityof life questionnaire

Quality of life was evaluated using WHOQOL-BREF-

Taiwan Version (The WHOQOL Taiwan Group, 2000), a

28-item instrument. The WHOQOL-BREF Taiwan Version

encompasses four domains: physical health (seven items),

psychological health (six items), social relationships (four

items), environmental domain (nine items) and two global

items (In general, How would you rate your quality of life?

and In general, How satisfied are you with your health?).

This instrument measured patients QOL during the two -

weeks prior to data collection points with a 5-point Likert

scale: 1 = not satisfied at all, 2 = somewhat satisfied,

3 = moderately satisfied, 4 = very satisfied and 5 = extremely

satisfied. Higher scores indicated a better QOL. The reli-

ability of the overall questionnaire was 090 (The WHOQOL

Taiwan Group 2000). Internal consistency for each of

the four domains ranged from 068077. Content

validity, convergent validity, criteria-related validity and

construct validity were examined. The overall QOL internal

Clinical issues Chronic kidney disease

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 17, 29272934 2929


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consistency for this study was 093. Internal consistency for

each of the four domains ranged from 073083.

Renal protection knowledge checklist

A disease-specific knowledge of renal protection checklist

was developed for this study. Two nephrologists and three

nurses with at least five years of clinical experience with CKD

evaluated the content validity prior to the study. The check-

list consisted of 20 items covering three domains: renal

function protection (11 items), knowledge of using Chinese

herbs in related to renal function (five items) and diet with

CKD (four items). Item responses were dichotomous, i.e.

true or false. Each correctly answered item was scored

with five points. Total scores for the checklist ranged from 0

to 100. Higher scores indicated higher knowledge of renal

function protection. The reliability of the questionnaire was

from 043054.

DemographicsDemographic variables included gender, age, language, to-

bacco and alcohol use, state of residence, level of education,

occupation and personal medical history (self-report).

Data analysis

Statistical analyses were conducted using SPSSSPSS (version 14.0)

(SPSS Taiwan Corp., Taipei, Taiwan). All continuous vari-

ables were examined assuming normal distributions.

Descriptive statistics (means, standard deviations and fre-

quencies) were examined for all study variables. Repeated

measures analysis of variance (ANOVA)(ANOVA) was used for variables

collected longitudinally at three points (baseline, six and

12 months) to test the equality of means across times, known

as the within-subjects effects. Using the repeated measures

can reduce the error term, thus increase the power of the

analysis with fewer subjects. Therefore, in this study we

applied repeated measures ANOVAANOVA to determine whether

physical indicators (renal function and body composition),

QOL and knowledge of renal function protection differed

among baseline, six and 12 month time points. There might

be correlation between the measures across time for each

variable because they were from the same people, (Munro

2005:215) also known as compound symmetry. Mauchlys

test of Sphericity was non-significant (p > 005) and thus the

assumption of compound symmetry was met, indicating that

the correlations across the measurements were the same and

the variances were equal across measurements. Statistical

significance was set at p < 005 and all p-values were

reported two sided.

Results

Study sample

Data from 66 participants were analysed in this study. Fifty-

three participants were males and 13 (20%) were females.

The mean age was 674 years (range 3389 SD 1159). The

average years of education were nine (SD 45). Forty-four

participants (67%) were married. More than half of

the participants were Buddhist (n = 36, 55%). Most of the

participants were retired or unemployed (n = 47, 71%).

The average range of income was between 015, 000 NT

dollars (approximately 0470 US dollars) per month. Seven

(11%) participants smoked and only one participant drank

alcohol regularly.

Physical indicators

Table 1 summarises the physical indicator outcomes. The

major criterion for selection of participants in this study

Table 1 Physical indicators at three time

points (n = 66)Variable

Baseline

mean (SD)

Sixth month

Mean (SD)

Twelfth month

Mean (SD) F Post hoc

GFR 421 (106) 411 (111) 412 (117) 287

Scr 21 (05) 22 (07) 21 (07) 150

BUN 286 (03) 308 (104) 295 (130) 104

SBP 1415 (16

0) 141

0 (15

7) 141

9 (15

9) 2

87

DBP 842 (83) 849 (74) 847 (76) 272

Body weight 682 (87) 678 (86) 684 (81) 278

Muscle weight 466 (59) 465 (60) 460 (57) 285

Body fat 225 (46) 223 (46) 228 (44) 287

WHR 103 (02) 101 (01) 100 (01) 603* 12*

BMI 254 (33) 251 (34) 250 (33) 437* 12*

*p < 005. GFR, glomerular filtration rate; Scr, serum creatinine; BUN, blood urea nitrogen;

SBP, systolic blood pressure; DBP, diastolic blood pressure; WHR, waisthip ratio; BMI, body

mass index.

M Yen et al.



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was Stage 3 of CKD, GFR range from 30 to 59 ml/

minutes/173m2. Data from the baseline, sixth and twelfth

month follow-ups showed that the indicators of renal

function (Scr., BUN and GFR) were not significantly

different over time (F = 104287; p > 005). Body com-

position (body weight, muscle weight, body fat percentage

and total body fat) was also not significantly different at

the three time points. However, both WHR and BMI were

significantly different at the three time points (F = 603 and

F = 437; p < 005). Other physical indicators, including

systolic blood pressure and diastolic blood pressure, were

not significantly different within the 12-month follow-up

period.

Knowledge checklist

The 20-item knowledge checklist contained three domains:

renal function protection, knowledge of using Chinese herbs

related to renal function and diet with CKD. The overallknowledge scores, covering all three domains, increased at

the sixth month and decreased at the twelfth month

(p < 005; Table 2). Similarly, scores from two domains,

knowledge of using Chinese herbs and diet with CKD,

increased at six months and decreased 12 months

(p < 005). However, the renal function protection domain

showed no significant change over time.

Quality of life

The brief version of the WHOQOL contains four domains

with 26 items. Thirty eight participants completed the QOL

questionnaire in this study (the remainder left 20% or more

items blank and thus could not be included in analysis). The

mean age of those who did not complete the QOL question-

naires was younger than the 38 participants who did

(p < 005). Other demographic variables (gender, education

level, religion and marital and job status) were similar for

these two groups (p > 005). Table 3 depicts the QOL

results. There were no significant differences at baseline, sixth

and twelfth month follow-ups in the physical, psychological,

social relationship and environmental domains. Two single

items were asked to evaluate global QOL and health status:

How would you rate your quality of life? and How satisfied

are you with your health? The scores for satisfaction with

personal health increased significantly (F = 964; p < 005).

However, the global QOL item score increased at the sixthmonth and decreased at the twelfth month (F = 995;

p < 005).

Discussion

These results show that renal function was stable in this

sample over the 12 months of the study. The physical

Table 2 Renal function protection

knowledge at three time points (n = 66)Variable

Baseline

mean (SD)

Sixth month

Mean (SD)

Twelfth month


Overall protection renal

function knowledge

856 (60) 920 (50) 842 (60) 1039* 12*

23*

Subscales

Renal function protection 468 (57) 485 (62) 484 (51) 24

Use of Chinese herbs 224 (38) 227 (35) 193 (51) 139* 12*

23*

Diet with CKD 178 (34) 189 (27) 175 (34) 348* 12*

23*

*p < 005. CKD, chronic kidney disease.

Table 3 Quality of life at three time

points (n = 38)Variable

Baseline

mean (SD)

Sixth month

Mean (SD)

Twelfth month


Global QOL (single item) 31 (06) 32 (08) 26 (08) 964* 23*

Global health status

(single item)

27 (08) 32 (09) 33 (10) 995* 12*

Physical domain 138 (18) 139 (19) 138 (20) 007

Psychological domain 125 (16) 128 (17) 129 (13) 111

Social-related domain 134 (19) 136 (15) 137 (22) 042

Environment domain 146 (22) 151 (15) 145 (22) 186

*p < 005; Thirty-eight participants completed the QOL questionnaire. QOL, quality of life.




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indicators (Scr, BUN and GFR) were not significantly

changed across time (p = 005). Two outcome physical

indicators in this study, the WHR and BMI significantly

decreased over the 12-month follow-up period. Knowledge

scores (using Chinese herbs and diet with CKD) increased at

6 months and decreased at 12 months. There was no

significant difference among scores for four domains of

QOL. However, the two global items, overall QOL and

general health, showed change over time (p < 005). Overall

QOL was increased at six months and decreased at

12 months, while general health (as measured by the satis-

faction with personal health item) increased over time.

Changes in renal function

The level of GFR is widely accepted as the best indicator of

overall kidney function and the definition and staging of

CKD depends on the assessment of GFR (Levey et al. 1999,

K/DOQI Work Group 2002). GFR levels were not signifi-cantly changed during baseline, six and 12 month follow-ups

in this study. The results were consistent with the findings

from a randomised, controlled trial predialysis education

study (Klang et al. 1999, Devins et al. 2003). Another

longitudinal study in Thailand reported similar findings: GFR

seemed to be stable over a four-year follow-up after imple-

menting a multidisciplinary educational intervention

(Tungsanga et al. 2005). Retarding or preventing deteriora-

tion of renal function as measured by GFR levels is a key task

of early stage CKD educational intervention.

The GFR level was stable among participants in this study,

even though the mean age, 674-year old, was older than

reported in other studies (Levin et al. 1997, Devins et al.

2003), indicating that the educational intervention may have

been successful in retarding deterioration of renal function in

spite of age, a major risk factor for declining renal function

(Brown et al. 2003).

Changes in body composition

Obesity is believed to be associated with renal damage (Iseki

et al. 2004). A body of research demonstrates that central fat

distribution may be more salient to the problem of renaldamage than general obesity. One study revealed that GFR

decreases linearly with the increase of the WHR ratio after

adjusting for confounding factors (Pinto-Sietsma et al. 2003).

In Okinawa, Japan, a study on a group of over 100,000

individuals identified that obesity was a major risk factor for

the development of CKD and the degree of obesity also

predicted the progression to end-stage renal disease (ESRD)

(Iseki et al. 2004). Similarly, a cohort study with follow-ups

over 14 years found that higher BMI was a risk for

hypertension and diabetes, both of which increased the risk

of ESRD (Gelber et al. 2005).

Two outcome indicators in this study, WHR and BMI,

significantly decreased over the 12-month follow-up period.

This finding may help explain why the renal function

indicator, GFR, remained stable. Because the nephron num-

ber does not increase as adults gain weight, increased body

weight and body size merely enhance single-nephron loading,

which may lead to a loss of GFR over time (Kramer et al.

2005). Furthermore, this outcome provides supporting evi-

dence for early educational intervention in CKD to retard

renal function deterioration. In other words, an educational

intervention should include a focus on reducing central body

fat distribution and BMI to stabilise renal function. Although

BMI showed a statistically significant decrease at the sixth

and twelfth month, the average of BMI was still greater than

25 at the end of the follow-up period.

Changes in renal function protection knowledge

A fundamental consideration for delaying the progress of

CKD is patient education at the early stage (Devins et al.

2005). Overall knowledge scores increased slightly at the

sixth month and decreased at the twelfth month in this study.

This indicates that to maintain patients knowledge of renal

function protection, use of Chinese herbs and diet, work-

shops may need to be conducted at least every six months.

An important issue with this Taiwanese sample was the use

of Chinese herbs. The intervention developed and delivered in

this study included content on the use of Chinese herbs,

which has seldom been the focus of interventions for people

with early stage CKD. It has been shown that many CKD

patients in Taiwan use Chinese herbs in the belief that herbs

will preserve kidney function (Lin et al. 2005). Two retro-

spective studies revealed that patients with ESRD had

previously used one or more forms of complementary therapy

before they received haemodialysis treatment in Taiwan.

Complementary therapies used, included traditional Chinese

herbs, which were not always reported to health care

providers (Chiou 1999, Lin et al. 2005). In Taiwan, many

people believe Herbs cannot harm, only cure. Herbs arepanacea. Natural things are better than synthetic ones

Chinese herb medicines do not give side effects (Dahi 2001,

Isnard et al. 2005). However, the effects of herbal medicine

are controversial; their use may harm the kidney itself.

Study participants expressed that all Chinese herbs were

safe, warm, nourishing. Thus, people may not use them

carefully with physicians prescriptions. Our findings

highlight that although herb medicine may have many

M Yen et al.



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advantages, health professionals have to be very careful in

evaluating the patients reliance and use of it. The misuse of

herbs may lead to a decreased of GFR or even directly to a

nephrotoxic state (Dahi 2001). In Taiwanese culture, many

people use Chinese herbs for restorative preparations and to

build up physical strength (Teng et al. 1995). Furthermore,

because Chinese herbs are perceived as natural foods for daily

use, patients with CKD may not recognise Chinese herbs as

medicines and thus not report their use during a medication

history. The use of Chinese herbs and culturally appropriate

lifestyle interventions need attention in future research.

Changes in quality of life

Health status may influence ones perception of QOL (Suet-

Ching 2001). In this study, participants in the early stage of

CKD may not yet experience or be aware of CKD symptoms.

Perceived overall health in our study was high compared with

haemodialysis patients (Sesso & Yoshihiro 1997). Althoughwe found that overall satisfaction with health status reported

by CKD patients did improve over time, we suspect that the

improvement might not reflect the true improvement of

health status but rather could be an intervention effect.

Research indicates that when GFR is below 30 ml/minutes/

173m2, symptoms associated with uraemia, such as lack of

energy or fatigue, may appear (Patel et al. 2002). These

symptoms may affect peoples QOL (Sesso & Yoshihiro

1997). The average GFR for the studied participants was

41 ml/minutes/173m2. QOL measured overall and through

four subdimensions, was significantly higher in this study

than other ones where patients kidney function was lower

(Jang et al. 2004, Perlman et al. 2005, Yang et al. 2005).

However, the scores for overall QOL in this study decreased

at the twelfth month follow-up although GFR levels

remained stable. It is possible that post intervention lifestyle

adjustments, such as changes in diet, may have affected

perceptions of QOL.

Limitations

This study must be interpreted with limitations in mind.

Generalisability of the study findings may be restricted due tothe small sample size and selection bias. It is possible that

participants might have better health and higher motivation

to learn health promotion activities than those who did not

participate. The one-group design also limits drawing

conclusions about the effects of the educational intervention.

However, current recommendations emphasise early

intervention. This study used a one-group design with

repeated measurements over 12 months; for ethical reasons,

we wanted all participants to receive an educational

intervention.

Conclusion

Early predialysis educational interventions are recommended

to slow the progression of CKD. Although the participants in

this study were older than those in previous studies average

renal function remained stable during the one-year follow-up

period, indicating that the educational intervention may have

had some success in retarding deterioration of renal function.

The intervention may also improve knowledge related to

renal function protection and perceptions of general physical

health. This study reports that overall knowledge scores

(renal function protection, Chinese herbs and diet) showed

significant differences between the baseline, sixth and twelfth

month follow-up. Knowledge of use of Chinese herbs and

diet domains increased at the sixth month then decreased at

the twelfth month, while the renal function protectiondomain showed no change over time. This study provides

evidence that Taiwanese CKD patients routinely use Chinese

herbs and may not report their use to health care providers or

understand possible adverse effects on renal function. Edu-

cation for early-stage CKD patients should incorporate more

traditional, culturally specific diet information and emphasise

content on traditional Chinese herbs for patients likely to use

alternative therapies. Finally, overall QOL scores in this

study decreased at the twelfth month follow-up, despite

stable renal function.

Acknowledgements

This study was funded by National Science Council, Taiwan

(NSC92-2314-B-006-097). We would like to thank the

patients with CKD who participated in this study and Blair

G. Darney for editorial assistance.

Contributions

Study design: MY, J-JH; data collection and analysis: MY,

J-JH, H-LT and manuscript preparation: MY, J-JH, H-LT.

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