title: Multidisciplinary management of diabetic kidney disease: a systematic review and meta-analysis.
abstract: The increasing prevalence of diabetes poses significant challenges to healthcare systems around the world. Diabetes is the leading cause of end-stage renal disease. Diabetic kidney disease (DKD) is becoming a global health concern because it is a progressive disease associated with major health complications and increased health costs. The treatment goals for DKD are to slow the progression of the renal disease and prevent cardiovascular events. Accordingly, patients are expected to adhere to prescribed treatments and manage a wide range of daily self-care activities. Multidisciplinary management of chronic diseases, like diabetes and kidney disease, has been suggested as a means to improve patients' adherence to treatment and enhance health-related outcomes. This systematic review of multidisciplinary management of DKD is an important step in evaluating if such a management approach is effective in delaying disease progression.
  
  
  
  The goal of this systematic review was to identify the best available evidence regarding multidisciplinary management of DKD and to determine if a multidisciplinary management of DKD can improve patient outcomes. Specifically the review question was: What is the impact of multidisciplinary management of DKD on patient outcomes?
  
  
  
  The current review considered adults aged 18 years and older who had been diagnosed with type 1 or type 2 diabetes and chronic kidney disease.
  
  
  
  The current review examined studies that compared multidisciplinary interventions with usual standard care in ambulatory settings for patients with DKD.
  
  
  
  The current review considered studies with the following primary outcomes: kidney function, incidence of kidney failure, generic or specific health-related quality of life, patient self-care abilities, adherence to treatment recommendations or goals; and the following secondary clinical outcomes: mortality rates secondary to DKD, glycemic control, blood pressure (BP) control, lipid profile, incidence of cardiovascular disease/events, patient knowledge on diabetes or DKD, patient empowerment or self-efficacy, generic or specific patient satisfaction with care and patient healthcare utilization.
  
  
  
  The current review will consider randomized and quasi-experimental trials but included only randomized controlled trials (RCTs).
  
  
  
  A three-step search strategy was utilized starting with a search of MEDLINE and CINAHL for the identification of keywords, followed by a search using keywords and index terms across MEDLINE, CINAHL and Embase databases and clinical trials registry platforms, and finally a search of the reference list of all identified papers. Studies published from the time of the respective database inception to November 2014 in English, German and French were considered.
  
  
  
  Two independent reviewers assessed the methodological validity of the papers prior to inclusion in the review using the standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI).
  
  
  
  Data were extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI.
  
  
  
  Quantitative data were pooled using the RevMan 5 software for kidney function using estimated Glomerular Filtration Rate (eGFR), glycated hemoglobin, BP and total cholesterol (TC). Results were considered significant for P < 0.05.
  
  
  
  Three RCTs were included in this review. Meta-analysis showed that multidisciplinary management was associated with a statistically significant improvement of glycated hemoglobin as compared with standard usual care (Relative Risk [RR] -0.49, at 95% confidence interval [CI] -0.83, -0.16, P < 0.01). The meta-analysis for eGFR showed a tendency to favor standard care; however, this finding cannot be conclusive because the CI was too wide (RR -3.30, at 95% CI -6.55, -0.05, P = 0.05). Meta-analysis results for BP and TC failed to show a difference between the multidisciplinary management of DKD and the usual standard care. Only one study measured patient-oriented primary and secondary outcomes and showed an improvement in health-related quality of life, patient self-care abilities, patient level of knowledge on diabetes and exercise self-efficacy.
  
  
  
  Multidisciplinary management of DKD has the potential for improving glycemic control and thus preventing complications. Its effect on other clinical and patient-oriented outcomes, especially on delaying the progression of the disease through preserving and preventing the decline in kidney function, has yet to be determined. There is not enough evidence to recommend multidisciplinary management for preserving kidney function. Further studies are needed.
authors.affiliation: 1Bureau d'Echange des Savoirs pour des praTiques exemplaires de soins (BEST), The University of Health Sciences (HESAV), Lausanne, University of Applied Sciences of Western Switzerland: an Affiliate Center of the Joanna Briggs Institute 2University of Lausanne-Faculty of Biology and Medicine, Institut Universitaire de Formation et de Recherche en Soins IUFRS, Lausanne, Vaud, Switzerland 3Service of Endocrinology, Diabetes and Metabolism, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Vaud, Switzerland 4Service of Nephrology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Vaud, Switzerland 5Inselspital, University Hospital Berne, Directorate of Nursing and Allied Health Professions, Department of Nursing Development, Switzerland.
authors.forename: Nancy
authors.initials: N
authors.lastname: Helou
authors.forename: Andrew
authors.initials: A
authors.lastname: Dwyer
authors.forename: Maya
authors.initials: M
authors.lastname: Shaha
authors.forename: Anne
authors.initials: A
authors.lastname: Zanchi
mesh_terms: D003924:Diabetes Mellitus, Type 2; D003928:Diabetic Nephropathies / Q000628:therapy*; D006801:Humans; D007676:Kidney Failure, Chronic; D011788:Quality of Life; D012648:Self Care