Effectiveness of telehealth interventions for palliative care in patients with kidney failure: a systematic review

Abstract

Background

Kidney failure affects a substantial proportion of the global population, and is associated with high morbidity and mortality. These patients require high-quality palliative care to manage symptoms and enhance quality of life. With advances in technology, telehealth offers potentially convenient and scalable means to provide this integral aspect of care. This systematic review assessed the effectiveness of telehealth interventions for providing palliative care in patients with kidney failure.

Methods

A comprehensive search of PubMed (32), Cochrane (1), Google Scholar (938) and HINARI (25) yielded 1039 articles. Following the removal of duplicates, 1013 articles remained. Screening questions were developed in relation to the use of telehealth-based interventions among patients with kidney failure for palliative care. Studies on patients with stages 1–4 of chronic kidney disease, telehealth interventions related to improving renal replacement therapy, interventions focused on optimization of medical complications or drug adherence and caregiver-directed interventions were excluded. Articles were screened by two independent reviewers, with conflicts settled by a third. Risk of bias was assessed using the RoB2 tool for randomized controlled trials (RCTs). Meta-analysis was not performed following heterogeneity assessments. Registration was done in PROSPERO registry with the ID CRD42024582255.

Results

Four RCTs were included in the final review. Two had low risk of bias while the other two had moderate risk. Three of the interventions were nurse-led telehealth interventions that focused on post-discharge follow up with outcomes related to quality of life and symptom control. The other focused on cognitive behavioral therapy (CBT) delivered via telehealth. All post-discharge follow-up telehealth interventions showed significant improvements in symptom control and quality of life. The CBT intervention also demonstrated significant improvement in symptom control.

Conclusions

Telehealth interventions for provision of palliative care in patients with kidney failure seem promising for improvement of symptom control and quality of life.

Introduction

Kidney failure refers to the final stage of chronic kidney disease with an estimated glomerular filtration rate of < 15 ml/kg/m2 or treatment by dialysis [1]. It affects a notable proportion of the global population and imposes a rising global health burden [2]. The burden of kidney failure results from its disease-related symptoms, need for frequent healthcare visits, consequent expenditure of both time and money on healthcare visits and the negative psychosocial ramifications of the above [3]. Patients with kidney failure have a large symptom burden attributable to uremia, which remains underdiagnosed and therefore, under-treated [4]. A systematic review conducted on symptoms experienced by patients with chronic kidney disease (CKD) identified that troubling symptoms such as fatigue (70% severity-22.8), pain (53%, severity-22.5), poor sleep (49%, severity-23.8), sexual dysfunction (48%, severity-56.4) and decreased appetite (42%, severity-19.8) frequently bothered these patients [5]. These symptoms often occur as inter-connected symptom clusters and negatively affect patients’ health-related quality of life (HRQoL), social activities and overall well-being [3].

Alleviating symptoms of kidney failure improves the HrQoL of patients and potentially enables them to live better regardless of life expectancy [6]. The focus on symptom relief is emphasized in the models of ‘supportive care’ and ‘comprehensive conservative care’ highlighted in guidelines published by Kidney Disease Improving Global Outcomes (KDIGO) [7]. Both models aim to improve quality of life in kidney failure through symptom relief, shared decision making, and psychosocial and spiritual support [7]. The term ‘palliative care’ in this review refers to the principles of care highlighted within these models of ‘supportive care’ and ‘comprehensive conservative care’. The effectiveness of pharmacologic therapy for provision of palliative care in this population appears limited and contributes to increased pill-burden [8, 9]. As a result, there is interest in non-pharmacological approaches focusing on symptom clusters in the provision of palliative care in kidney failure [7, 9].

The main challenges for the provision of holistic care to patients with kidney failure, specifically in low- and middle-income countries (LMIC) are inadequacy of skilled healthcare workers, poorly developed primary care systems or infrastructure, and poor access to health care facilities. As a result of these inadequacies, the financial burden of kidney failure is higher in LMIC compared to high income countries [10, 11].Telehealth has emerged as an affordable and feasible method of accessing effective medical care that may be able to circumvent these logistic and financial challenges [12].

The World Health Organization defines telehealth as:

“the delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment, and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities” [12].

A strong telemedicine platform enables renal healthcare teams to serve patients with kidney failure by providing remote patient education, consultations via video conferencing and transmission of medical reports [7]. This enables ease of healthcare access and reduces patients’ travel burden especially those in underserved and rural communities [13]. Telehealth has been shown to reduce financial expenditure on health care visits and consequently results in improved patient satisfaction and reduced stress [9]. Factors such as availability of technology and cultural acceptability may limit the use of telehealth. Hence it is important to objectively assess the real-world efficacy of telehealth modalities in the provision of care [9, 14]. This systematic review aimed to assess the effectiveness of telehealth interventions for the provision of palliative care in patients with kidney failure.

Methods

The systematic search for this study followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the methodology outlined by the Population, Intervention, Comparison, Outcomes (PICO) model [15]. The PICO statement was “Are telehealth interventions used in patients with kidney failure effective for delivery of palliative care?” [15]. According to PICO, ‘Population’ was defined as patients with kidney failure, ‘Intervention’ as telehealth interventions/ interventions delivered via remote communication methods, ‘Comparator’ as patients who received non-telehealth palliative interventions or standard care and ‘Outcome’ as symptom relief or improvement of quality of life.

Five databases were searched using keywords and Medical Subject Heading (MeSH) terms from August to September 2024. The databases that were searched were PubMed, Cochrane library, Google Scholar, HINARI and Clinical Key. The keywords used were “telehealth”, “end stage kidney disease” “kidney failure” and “palliative care”. The MeSH terms used were “telehealth” OR “internet” OR “technology” AND “end stage kidney disease” OR “kidney failure”. The PRISMA flow chart is shown in Fig. 1. Studies conducted during the period from January 2000 to August 2024 were included and studies were not limited to a geographical area. However, only studies which were published in English or translated to English were included.

Fig. 1.

PRISMA flow diagram showing the search strategy

There were four screening criteria: (1) Being a randomized controlled trial, (2) The use of telehealth interventions for provision of palliative care, (3) Inclusion of patients with kidney failure and (4) Description of quantitative outcomes related to effectiveness. Studies with patients in stages 1–4 of chronic kidney disease, studies that assessed telehealth interventions for outcomes other than palliation (i.e. improving drug adherence, minimizing medical complications, improving delivery of renal replacement therapy) and studies which focused on caregiver-directed interventions were excluded. Furthermore, studies that reported secondary data or review articles were excluded.

Two reviewers (MV and MD) independently screened the articles initially with titles and abstracts. Following the initial screening, the selected articles were subjected to full text screening. Conflicts were resolved by a third reviewer (RA). In the event of discrepancies, consensus was reached through discussion. In the end, a total of 4 articles were selected for the review.

Data was extracted to a Microsoft Excel template for analysis. The headings under which data was extracted in addition to PICO were study title, author information, location, study population, study design, year of publication, details of telehealth interventions and details of outcomes of patients. The risk of bias assessment was done by 2 investigators (MV and DG) using the ROB2 tool under the five standard domains of risk of bias [16]. A meta-analysis could not be performed due to clinical, methodological and statistical heterogeneity.

Results

The search identified 1039 articles across five databases. Following deduplication, 1013 articles between 2000 and 2024 remained. Articles were then selected using the inclusion criteria, which eliminated 991 articles, leaving 28 for screening. Following full-text screening, 24 articles were excluded due to inclusion of patients in stages 1–4 of CKD, assessment of interventions related to improving quality of dialysis, assessment of interventions related to improvement of medical outcomes other than palliation such as blood pressure control and lack of availability of a published full article. A total of four randomized controlled trials were included in the systematic review [17–20]. The risk of bias assessment is shown in Fig. 2.

Fig. 2.

Risk of bias assessment

Table 1 shows the details of the four studies that were included in the systematic review

Table 1.

Details of randomized controlled trials assessing efficacy of telehealth intervention for palliative care in patients with kidney failure

Study	Setting	Population	Intervention and comparator	Outcome	Follow up period	Result
Chow SK et al. (2010) [17]	Hong Kong	Patients on peritoneal dialysis (PD) (n = 85)	Intervention: Comprehensive education programme prior to discharge and standardized, 6-week nurse-initiated tele-phone follow-up. Comparator: Routine hospital discharge services.	Kidney Disease Quality of Life Short Form (KDQOL-SF), version 1.3	6 weeks	• Statistically significant within-group effects were seen for symptoms/problems, effects of kidney disease, sleep, pain, emotional wellbeing and social function. • Statistically significant interaction effects were demonstrated for staff encouragement, patient satisfaction, sleep and social function.
Li J et al. (2014) [18]	China	Patients on PD (n = 160)	Intervention: Comprehensive discharge planning protocol prior and a standardized 6-week post-discharge nurse-led telephone support intervention Comparator: Routine discharge care	KDQOL-SF, version 1.3, biochemistry, complication control, readmission and clinic visit rate	12 weeks	• Statistically significant favorable differences were found in the intervention group for symptom/problem, work status, staff encouragement, patient satisfaction, energy/fatigue in KDQOL-SF and 12-week clinic visit rates. • The study group had significant improvement in sleep, staff encouragement, pain and patient satisfaction.
Kargar Jahromi M et al. (2015) [19]	Iran	Patients with kidney failure undergoing haemodialysis (HD) (n = 60)	Intervention: Telephone follow-up 30 days after dialysis shift, in addition to conventional treatment. Duration of session: Approximately 30 min Comparator: Conventional treatment	Depression Anxiety Stress (DASS) scale	30 days	• Significant differences were observed between the two groups terms of depression, anxiety and stress.
Jhamb M et al. (2023) [20]	United States (US)	Patients with kidney failure undergoing HD (n = 160)	Intervention: 12 weekly sessions of cognitive behavioural therapy (CBT) delivered via telehealth in the HD unit or patient home, and/or pharmacotherapy using a stepped approach Comparator: 6 telehealth sessions of health education.	Fatigue Pain Depression	12 months	• Stepped collaborative care intervention led to clinically significant improvements in fatigue and pain at 3 months, which were sustained for 6 months. • Improvements in depression at 3 months were statistically significant but small. • Improvement was not sustained at 12 months

Studies on nurse-led telehealth interventions

Of the four studies chosen for the systematic review, three studies used nurse-led telehealth interventions [17–19]. The study by Chow et al. investigated the effects of a nurse-led telehealth programme on HRQoL in patients undergoing peritoneal dialysis (PD) [17]. Their results showed statistically significant improvements in quality of sleep, patient satisfaction, social functioning and staff encouragement (p < 0.05) with the use of telehealth. A trend towards improvement was seen in terms of physical functioning (p = 0.06). Li et al. conducted a similar study on the effects of post-discharge, nurse-led telephone supportive care on patients with kidney failure undergoing PD in China, but explored additional endpoints compared to the study by Chow et al. [18]. The variables that demonstrated statistically significant improvements in the study group were symptom/problem, work status, staff encouragement, patient satisfaction and energy/fatigue (p < 0.05). A trend towards statistical significance (p = 0.05) between groups and interaction effects were observed for the end point of pain. The additional end points explored were blood chemistry, complication control, and readmission rate. While both groups largely performed similarly in relation to these endpoints, a nonsignificant lower readmission rate and a significant reduction in the 84-day (12-week) clinic visit rates were noted in the telehealth group. The third nurse led telehealth study was a study done by Kargar et al. which explored the effect of nurse-led telephone follow-up (tele-nursing) on depression, anxiety, and stress among hemodialysis patients [19]. The findings showed that tele-nursing significantly reduced levels of depression, anxiety, and stress in the study population (p = < 0.05).

Studies on cognitive behavioral therapy delivered via telehealth

One study focused on the delivery of CBT through telehealth [20]. The study by Jhmab et al. examined the effects of a technology-assisted stepped collaborative care intervention (TĀCcare) which aimed to improve troublesome symptoms in hemodialysis patients [20]. The intervention group received 12 weekly sessions of CBT delivered via telehealth in the hemodialysis unit or home, and/or pharmacotherapy using a stepped approach in collaboration with HD and primary care teams. The attention control group received 6 telehealth sessions of health education. The study found that TĀCcare significantly improved symptoms related to fatigue (p = 0.01) and pain severity (p = 0.02) at 3 months, with good sustenance of results at 6 months (p = 0.03; p = 0 0.02). Improvement in depression at 3 months was statistically significant but not sustained. Adverse events were similar in both groups.

Discussion

This is the first documented systematic review that assesses the current evidence on effectiveness of telehealth interventions for palliative care in patients with kidney failure, to the best knowledge of the authors. It showed that telehealth holds promise for symptom relief and improvement of quality of life in kidney failure. This systematic review included four studies, three of which employed nurse-led telehealth interventions for post-discharge follow up, and one of which employed CBT delivered via telehealth. All the telehealth studies using nurse-led post discharge follow up interventions showed significant improvements in symptoms and quality of life. Symptoms that have shown improvement following the use of telehealth interventions were fatigue, pain, insomnia, depression and anxiety [17–19]. The CBT-focused study assessed outcomes related to depression, pain and fatigue, and showed significant improvement with telehealth [20].

There are three important observations from this review. The first is that there exists a dearth of high-quality evidence related to the utility of telehealth for palliative care in kidney failure. There are only a few randomized controlled trials on the topic with small sample sizes and short periods of follow-up to assess the sustenance of presumed benefits. We also noted significant clinical and methodological heterogeneity in these studies. The second observation is that all available studies have been conducted in patients who were receiving some form of renal replacement therapy (RRT), with no studies conducted on patients receiving “comprehensive conservative care”. It remains to be seen whether there is a place for telehealth for provision of palliative care to patients on a purely conservative modality of care, without the benefits of RRT. It seems reasonable to speculate that the benefits of telehealth in the conservative care population might be greater, as RRT itself may make contributions to relief of symptoms such as insomnia, fatigue and loss of appetite. The third observation is that not all modalities of telehealth have been utilized for palliative care in kidney failure at present. The modalities that were utilized in the trials included in this review were telephone-based follow-up, health education, and telehealth- guided CBT. There remains unexplored potential for telehealth modalities such as remote monitoring using wearable technology to relieve anxiety and reduce healthcare visits, and provision of education on difficult topics such as advanced care planning using smart phone applications and interactive video conferencing.

One limitation of this review is its restriction to RCTs, which may have excluded valuable data from observational studies, qualitative research, and feasibility studies, particularly in low- and middle-income settings. However, the trials that were included in the review are instrumental in showing that there is promise for the use of telehealth modalities for provision of palliative care in kidney failure. Patients on both HD and PD have shown improvements in their quality of life with telephone-based consultations, and several of these interventions have been delivered by nursing officers [17–19]. The importance of testing telenursing in this manner is that it provides evidence for interventions which are easily translated to real-world practice. Use of telenursing has greater real-world applications in comparison to trials that used trained or highly specialized palliative or mental-health professionals. The three trials on telenursing provide evidence for active utilization of nursing officers for delivery of renal palliative care, a strategy which may be cost-effective in LMIC settings. Furthermore, several of the interventions utilized in these trials were simple strategies with no great reliance of resources, without requiring additional time either on the part of the patient or the care-provider. This is encouraging when designing such interventions for future trials, or even when choosing to apply the current evidence in real-world practice. It is also inspiring to note that there has been satisfactory uptake of telehealth by the study participants in almost all studies, and that a reasonable degree of engagement has been shown for most interventions. This could be interpreted as high acceptability of telehealth interventions in different parts of the world, although it is possible that sampling bias could have played a role.

With the evidence emerging from this review, there is potential for enhancing real-world applications of telehealth for the provision of palliative care in patients with kidney failure. Apart from the reduction of symptoms and improvement of quality of life as shown in this review, there is additional potential for health economic benefits. In previous studies, the use of telehealth has objectively demonstrated a reduction of cost and time spent on healthcare, a reduction of hospitalization, increase of healthcare access and facilitation of multidisciplinary care [9].

The authors would like to emphasize here that there is still untapped potential for telehealth in providing renal palliative care. There is presently scarce information on the use of telehealth for palliative care in ESKD for patients on “comprehensive conservative care” and those in LMIC in South Asia and Africa. There is a need for trials conducted with greater follow-up periods and trials that utilize less commonly used telehealth modalities. Telehealth may be an effective modality for provision of information related to advanced care planning, followed by a multidisciplinary discussion using a synchronized virtual platform. Facilitation of advanced care planning in this manner from the comfort of the patient’s own home in the presence of one’s loved ones may result in better shared decision-making compared to having this stressful conversation at a busy clinic setting. These measures have the potential for allowing increased consideration for genuine patient wishes when making palliative decisions.

When designing future trials or considering the use of telehealth in one’s practice, clinicians must be mindful of the limitations of telehealth such as poor acceptability, lack of strong internet access, patient inexperience with handling technology, technical failures and the variability of health literacy levels [9]. The execution of more carefully designed telehealth-based trials will enable practitioners to identify and overcome these problems, to utilize telehealth for effective provision of palliative care to this group of underserved patients.

Conclusions

Telehealth interventions in the form of telenursing and CBT may improve symptoms and quality of life in patients with kidney failure. Further research on telehealth-based renal supportive care is needed to explore the untapped potential in underused telehealth modalities.

Abbreviations

CBT

Cognitive behavioral therapy

CKD

Chronic kidney disease

HD

Haemodialysis

HRQoL

Health related quality of life

KDIGO

Kidney Disease Improving Global Outcomes

KDQoL

SF-Kidney disease quality of life-short form

LMIC

Low and middle income countries

MeSH

Medical subject headings

PD

Peritoneal dialysis

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

RCT

Randomized controlled trial

RRT

Renal replacement therapy

TĀCcare

Technology-assisted stepped collaborative care intervention

Author contributions

MV-Screening articles, risk of bias assessment and writing the main manuscript. MD- Screening articles and writing the main manuscript. RA- Screening articles and writing the main manuscript. DG- Risk of bias assessment and writing the main manuscript. BM-Supervision and editing of the manuscript.

Funding

None.

Data availability

Data is provided within the manuscript or supplementary information files.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.