Behavioral and educational strategies can improve phosphate control in hemodialysis (HD) patients, according to a new review and meta-analysis.

Of 18 studies looking at the effect of behavioral and education interventions on adherence to phosphate control, 7 looked at dietary phosphate, 4 focused on phosphate binders, and 6 examined dietary phosphate and medications. Only a single study involving teaching patients about a combined strategy of diet, medication, and HD. The 2760 total patients had initial serum phosphate levels above 5.5 mg/dL, were currently prescribed phosphate binders, or received weekly HD of any frequency or duration.

Sixteen of the 18 studies reported significant reductions in phosphate levels, based on moderate-level evidence, Molly Milazi, RN, PhD, Ann Bonner, RN, PhD, and Clint Douglas, RN, PhD, of the School of Nursing at Queensland University of Technology in Brisbane, Australia, reported in JBI Database of Systematic Reviews and Implementation Reports (2017;15:971-1010). When investigators pooled data from 8 randomized controlled trials for meta-analysis, they found a weighted mean reduction of 0.23 mmol/L in serum phosphate in groups receiving educational or behavioral interventions vs standard care.

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“Phosphate control is complex and requires a person with end-stage kidney disease to adhere to a combination of dietary, medication, and dialysis treatments,” Dr Bonner told Renal & Urology News. “Overall, educational or behavioral interventions increase adherence to phosphate control. Studies in this systematic review revealed improved outcomes on serum phosphate levels, patient knowledge and adherence to phosphate control methods, CKD self-management behavior, and perceived self-efficacy for CKD related to phosphate control.”

The interventions varied across studies, with some including psychological or behavioral components such as cognitive and/or behavioral therapy. Many involved individual patient counseling, but current research also favors small groups. The team noted that intensive education can reinforce concepts and behaviors over time and improve patient adherence, based on other evidence.

Future research needs to clarify the best design and methods of implementation that would lead to treatment adherence. “Successful strategies that improve and optimize long-term adherence to phosphate control still need to be formulated,” Dr Bonner said. “A bundle of patient-centered education and/or behavioral support strategies could improve understanding and adherence with dietary phosphate, phosphate binding medications, and dialysis treatment regimen.”

Before any intervention could be incorporated into practice, the investigators recommended randomized control trials of standardized programs that target all 3 methods of phosphate control.

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1. Milazi M, Bonner A, Douglas C. Effectiveness of educational or behavioral interventions on adherence to phosphate control in adults receiving hemodialysis: a systematic review. JBI Database System Rev Implement Rep 2017; 15(4):971–1010.