Key messages
• For people with both chronic kidney disease (a long-term condition where the kidneys do not work effectively) and diabetes (a lifelong condition that causes a person's blood sugar level to become too high), education programmes (planned activities designed to improve a person's ability to manage their condition) may improve their knowledge of diabetes, their ability to manage their condition, and self-management behavioural changes.
• However, the small number of people enrolled in these studies and the wide range of outcomes reported means our findings must be interpreted cautiously. Larger, well-designed studies with common outcomes and longer follow-ups are needed.
Why is improving diabetes care important for people with kidney disease?
Chronic kidney disease (a long-term condition where the kidneys do not work effectively) and diabetes (a lifelong condition that causes a person's blood sugar level to become too high) are chronic conditions that bring on many challenges for people, particularly when they have to manage both at the same time. Diabetes can accelerate the development of kidney disease and is the leading cause of kidney failure (a condition where the kidneys no longer function well enough to keep a person alive). While sticking to complex treatment plans can be challenging, successful self-management in the early stages of kidney disease can improve outcomes later in life and delay the need for dialysis or a kidney transplant.
What are education programmes?
Education programmes are any set of planned activities designed to improve a person's ability to manage their condition and delay the progression of their kidney disease. These activities can aim to improve a person's knowledge of their disease, self-care activities, and their ability to self-monitor the disease, thus encouraging and motivating them to create healthy lifestyle changes, improve their treatment compliance, and improve quality of life.
What did we want to find out?
We wanted to find out whether an education programme designed for people with both kidney disease and diabetes helps them understand their condition and recognise the importance of strategies aimed at slowing its progression and preventing long-term complications.
What did we do?
We searched for randomised studies (studies in which participants are assigned randomly to two or more treatment groups) that compared education programmes to usual care for people with both kidney disease and diabetes. We compared and summarised the results and rated our confidence in the evidence based on factors such as study methods and sizes.
What did we find?
We included eight studies involving 840 people 18 years or older with both kidney disease and diabetes. Four studies were undertaken in multiple centres, and four studies were performed in single centres. The duration of follow-up ranged from 12 weeks to four years. Most of the education programmes were designed to increase a person's knowledge of their condition and improve self-management behaviours. One study focused on reducing stress using mindfulness (a person's ability to be aware of where they are and what they are doing), and it was adapted to include practices for complex thoughts and feelings related to diabetes, and one study used a co-ordinated medical care approach with multiple practitioners involved in a person's care.
Overall, education programmes probably lower blood glucose levels and may lower total cholesterol and blood pressure, but may make little or no difference to kidney function, abnormally low or high blood sugar, and cardiovascular disease (disorders of the heart and blood vessels).
For people with diabetes on dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), an education programme may improve their knowledge of diabetes, self-management behaviour for checking their feet, using lotion, wearing appropriate shoes and socks, and coping with stress.
For people with moderately increased protein in the urine, there may be an improvement in their general knowledge of diabetes, their confidence in monitoring their blood sugar levels at home, their beliefs in their personal control, as well as behavioural changes to their diet. There may be no behavioural changes to exercise, foot care, or quitting smoking.
What are the limitations of the evidence?
We have low confidence in education programmes improving the understanding of diabetes in people with kidney disease. This is because the number of studies reporting outcomes of interest was low, and the education programmes varied, so we were unable to properly analyse the results.
How up-to-date is the evidence?
The evidence is current to July 2024.
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.
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.
To evaluate the benefits and harms of education programmes for people with CKD and diabetes.
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.
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.
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.
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.