Asian Nursing Research 10 (2016) 255e262

Contents lists available at ScienceDirect

Asian Nursing Research

journal homepage: www.asian-nursingresearch.com

Review Article

Self-Management Programs on eGFR, Depression, and Quality of Life

among Patients with Chronic Kidney Disease: A Meta-Analysis
Mei-Chen Lee, RN, PhD, 1 Shu-Fang Vivienne Wu, RN, PhD, 1, * Nan-Chen Hsieh, PhD, 2
Juin-Ming Tsai, PhD 3
1
School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
2
Department of Information Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
3
Department of Long Term Care, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan

a r t i c l e i n f o s u m m a r y

Article history: Purpose: Chronic kidney disease (CKD) is a condition characterized by the gradual loss of kidney function
Received 11 February 2015 over time. Self-management programs have been widely applied to chronic disease education programs,
Received in revised form which are designed to delay deteriorating kidney functions, preclude depression, and improve quality of
6 April 2016
life. This study aims to analyze effectiveness of self-management programs in bettering CKD patients' eGFR,
Accepted 15 April 2016
mitigating depression symptoms and improving quality of life in randomized control or clinical trials.
Methods: Using key terms, a search was conducted in English-language, peer-reviewed journals on CKD
Keywords:
that were published between 2002 and 2014 on databases including CINAHL, Cochrane Library, MED-
depression
kidney diseases
LINE. The measurable variables included CKD patients' eGFR, depression, and quality of life. Random and
meta-analysis xed effects meta analysis were applied with standard error and correlation based measure of effect size.
quality of life Results: Eight studies met the inclusion criteria. A self-management program signicantly impacted CKD
self-management patients' depression and mental quality-of-life dimensions, with an effect size of .29 [95% condence
interval (CI) (0.07, 0.53)] and
.42 [95% CI (
0.75,
0.10)]. However, the intervention of a self-
management program had no signicant effect on patients' eGFR as well as physical quality-of-life di-
mensions, with effect sizes of .06 [95% CI (
0.69, 0.81)] and
.16 [95% CI (
0.81, 0.50)].
Conclusions: Self-management programs of patients with chronic kidney disease can improve the depres-
sion and mental quality of life. Aside from providing more objective evidence-based results, this study
provides a reference for clinical health care personnel who tend to patients with CKD.
Copyright 2016, Korean Society of Nursing Science. Published by Elsevier. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction cardiovascular disease, impacting an individual's psychological and

Chronic kidney disease (CKD) is an important health issue
worldwide. The high prevalence and incidence of CKD and end-
stage renal disease (ESRD) are a serious global problem. Accord-
ing to the 2012 annual report of the United States Renal Data Sys-
tem, 361 out of every million people in Taiwan suffer from CKD, an
incidence rate ranking second highest in the world. Approximately
3,000 incidental ESRD cases occurred in 2012 in a population of 10
million adults; the incidence rate would be 300 per million per year
in the USA [1]. In addition to increasing the odds of death caused by
* Correspondence to: Shu-Fang Vivienne Wu, RN, PhD, School of Nursing,
National Taipei University of Nursing and Health Sciences, 365, Ming Te Road Pei-
tou, 11219 Taipei, Taiwan.
E-mail address: shufang@ntunhs.edu.tw
physical well-being, and affecting patient quality of life, CKD also
poses a heavy burden on the nation's healthcare system [2].
Moreover, patients who had received hemodialysis treatment were
also responsible for self-care to minimize the physical, mental,
social, and spiritual impact of renal failure [3,4].
The National Kidney Foundation redened CKD as a ve-stage
disease, using the estimated glomerular ltration rate (eGFR) as
an index to evaluate abnormal renal function. Stage 1 is dened as
a mildly decreased eGFR ( 90.0 mL/min/1.73m2) with evidence of
kidney damage such as proteinuria and hematuria. Stage 2 is
dened as a mildly decreased eGFR ( 60.0e89.9 mL/min/1.73m2)
with complications such as proteinuria and hematuria. Stage 3 is
dened as a moderately decreased eGFR ( 30.0e59.9 mL/min/
1.73m2). This stage can be subclassied into Stage 3a (
45.0e59.9 mL/min/1.73m2), and Stage 3b (eGFR  30.0e44.9 mL/
min/1.73m2). Stage 4 is dened as an advanced decrease in the

http://dx.doi.org/10.1016/j.anr.2016.04.002
p1976-1317 e2093-7482/Copyright 2016, Korean Society of Nursing Science. Published by Elsevier. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
256 M.-C. Lee et al. / Asian Nursing Research 10 (2016) 255e262
eGER ( 15.0e29.9 mL/min/1.73m2). Stage 5 is dened as renal
failure, with an eGFR less than 15.0 mL/min/1.73m2. Stage 5 refers
to patients suffering from irreversible loss of kidney function,
accumulation of wastes and uid, electrolyte imbalance, acid
alkaline imbalance, with these conditions creating an imperative
for dialysis treatment [2].
Self-management is a broad concept referring to patients' re-
sponsibility and capability of living a healthy lifestyle. Self-
management is also the prerequisite for humans to manage acute
diseases and provide healthcare for patients with chronic disease.
The concept of self-management is built upon an individual's
awareness of the importance of self-care in response to the pro-
gression of a chronic disease. Also, healthcare providers should
share and provide information concerning treatment decisions to
patients [5]. Self-management has been conceptualized as a subset
of self-care behavior. Focused on managing the actual or potential
impact of disease, the concept of self-management of a disease in-
cludes the self-care behaviors of self-monitoring, symptom man-
agement and other related concepts. Self-efcacy is the moderator
or mediator of the concept of self-management [6]. These in-
terventions are the property of a self-management intervention
program. Self-management is an important concept in disease
control, emphasizing health guidance to direct patients to focus on
their own problems. Patients need to identify the problems of most
concern and what they mean to them. This is one of the most
effective health education programs around the world and the most
widely accepted international health education program [7]. Self-
management of patients with CKD is dened as patients' positive
efforts in monitoring their own health and symptoms, making the
best use of available medical resources, living a preferred lifestyle,
and minimizing the likelihood of deteriorating health conditions
[8]. As such, patients with CKD need to be condent and capable of
managing their long-term health condition [9]. Patients with CKD
who have become self-management experts are capable of maxi-
mizing their ability to endure bad health and slow the pace of a
deteriorating health condition. On the other hand, patients who
effectively prevent the onset of medical complications are able to
achieve better physical and mental well-being, a better quality of
life, and live a preferred normal life [10]. A systematic review of
previous research revealed that the content of self-management
programs for patients with ESRD includes (a) a self-efcacy
training program, (b) cognitive behavioral therapy, (c) an empow-
erment program, (d) education intervention, and (e) behavioral
contracting and weekly telephone contact intervention [11].
A systematic review of the effectiveness of a self-management
program on patients with CKD and an examination of research
papers that adopted the randomized controlled trial (RCT) method
revealed that most research results proved the effectiveness of the
intervention with respect to experimental statistics, mental,
behavior, and patient knowledge [12]. According to a study that
examined systematic reviews (including 22 papers), 18 research
papers is identied enhanced patients' disease knowledge,
improved patients' body weights between two dialysis sessions,
and kidney function. The other four papers identied mitigated
patients' depression and stress perception, and improved patients'
self-efcacy and quality of life [13].
Depression is a frequent symptom of mental distress for patients
with CKD. Between 20 and 30 percent of patients with ESRD
experience depression. Symptoms of ESRD that are not effectively
alleviated are likely to increase the likelihood of patient read-
mission to a medical facility or may even lead to death. For that
reason, depression is a frequent variable in detecting patients'
adaptation to their health condition [14].
Patient self-management is a desired goal of healthcare man-
agement. Self-management reduces the risk of complications and
minimizes the use of medical services (including the rate of reho-
spitalization). Self-management reduces medical costs, enhances
patients' ability to adjust, and can increase patient satisfaction.
These effects result in patients' having better control of their
medical symptoms and their recovery while also improving pa-
tients' self-efcacy, sense of control, resilience, quality of life, and
mental and physical wellbeing [15,16]. Previous studies have shown
that the interventions of a self-management program did effec-
tively improve patients' eGFR [17]. However, two studies showed
that the intervention of a self-management program did not
effectively improve patients' eGFR [18,19].
Today, evidence-based nursing is the trend. There is a risk of
publication bias when analyzing a small number of studies. Inter-
vention groups have a sample size of 20 [20], 25 [21] and 23 [19].
Such a relatively small number of unpublished studies with null
results may not change the outcome of the analysis. Three common
variables with CKD, eGFR, depression and quality of life were not
included in the review. Only a few studies have focused on CKD or
ESRD. Only one paper examined patients with stages 1e5 CKD [18].
Work remains to be done focusing on testing the population for
ESRD or CKD stage 3 and stage 4e5. Furthermore, other limitations
of previous reviews may have inuenced the ndings and conclu-
sions reported in existing papers. To date, no meta-analyses have
established the associations of eGFR, depression, and quality of life
with the self-management program.
Conclusions about the association of eGFR, depression, and
quality of life from these three earlier reviews are limited by the
number of studies and the types of disease included. To address
these important issues, we reviewed the recent literature relating
to eGFR, depression, and quality of life across a range of CKD, per-
formed a meta-analysis to evaluate the strength and direction of
this association. As such, this study aims to systematically review
and meta-analyse the effects of a self-management program on
improving CKD patients' kidney function, depression, and the
quality of life from previous evidence-based studies. These
comprehensive research results might inform clinical healthcare
personnel of the empirical benets of a self-management program
on patients with CKD and provide an alternative to a traditional
health education program.
Methods
Searching for and selecting relevant literature
This study adopted a systematic review and meta-analysis to
evaluate previous research that addressed the effects of employing
a self-management program intervention on CKD patients' control
of their kidney function. The search for reviewable English-
language CKD studies from peer-reviewed journals published be-
tween January 2002 and June 2014 was carried out on databases
including CINAHL, Cochrane Library, MEDLINE. Considering that
the abnormal kidney function index had been changed from blood
creatinine levels to the eGFR level by the American Society of
Nephrology in 2002 to dene CKD, the keywords we used for the
literature search included chronic kidney disease and self-
management program or self-management promotion program
or self-efcacy training program or empowerment program or
cognitive behavioral group therapy and estimated glomerular
ltration rate and depression and quality of life. Research pa-
pers selected and analyzed in this study had to meet the following
criteria: (a) adopted either the RCT or a quasiexperimental design,
(b) chose CKD patients aged over 20 years old as research partici-
pants, (c) selected self-management program as the intervention,
and (d) used measurable variables including eGFR level, depression,
along with mental and physical components of quality of life.
 M.-C. Lee et al. / Asian Nursing Research 10 (2016) 255e262
Qualied research papers must have used the Beck Depression
Inventory to measure patients' depression condition and used the
Medical Outcome Study, Short Form-36 (MOS SF-36) two distinct
groupings, relating to physical health component scores and
mental health component scores developed by Ware et al [22] to
examine the physical and mental aspects of patients' quality of life.
Also, research papers that met any of the following descriptions
were excluded (a) those that were reviews and systematic reviews
of other research papers for the reason that such research papers
would encompass results of a number of other studies; this indi-
cated that complete relevant information of research samples was
relatively difcult to nd; (b) those that addressed multiple inter-
vention measures, making it difcult to evaluate the effects of a
single measure, and (c) those that did not include a control group in
the experiments. After conducting a keyword search, we perused
the title and abstract of the research papers resulting from the
keyword search criteria we had set for qualied research papers.
Furthermore, we thoroughly read the contents of these research
papers while factoring in what features we preferred not to have in
a research paper to select those papers that met the criteria of this
study.
Quantitative quality
Two kidney disease experts were assigned a critical appraisal
tool published by the Joanna Briggs Institute in 2011 to appraise the
quality of selected research papers for this study. In addition, based
on the quality of evidence, a method was developed to classify all of
these research papers into seven levels, appraise the selected
research papers, reach conclusions of the literature review with
reference to the appraisal standards, and suggest different intensity
levels based on the level of evidence in these papers [23]. The
research paper selection involved two appraisers conducting in-
dependent appraisals rst and cross-checking later, reaching a
consensus through discussions or consultations with a third party
when conicting opinions arose.
Data analysis
The statistical software Comprehensive Meta-Analysis 2.0
(Biostat Corp. Englewood, NJ, USA) was used to analyze the effects
of a self-management program as an intervention measure [24].
Measurable variables included the eGFR, depression, the SF-36
Health Survey for assessing patients' quality of life, and sub-
scales for assessing patients' physical and mental wellbeing. Also,
the arithmetic mean and standard deviation were analyzed. The
standard error in the original research papers was converted into
the standard deviation. Heterogeneity in the research papers was
tested by using the chi-square statistic Q and quantitative incon-
sistency (I2) [25], and p less than .05 indicated heterogeneity.
Signicantly different Q values indicated the heterogeneity in
selected research papers whereas the I2 statistic could represent a
low (25.0%), moderate (50.0%), or high (75.0%) level of heteroge-
neity. In order to include the between-group and within-group
sampling error, a xed effects model was used to perform meta-
analysis on homogeneous research papers whereas a random ef-
fects model was used to perform meta-analysis on heterogeneous
research papers [26]. The effect was set to a 95% condence in-
terval (95% CI). The effect size and the 95% CI were examined using
a forest plot as an index of the strength of an intervention's effects.
Effect sizes of .2, .5, and .8 represented the weak, moderate, and
strong effects of an intervention respectively [27]. Further, the
257
existence of publication bias was examined using a funnel plot for
asymmetry [28].
Results
Figure 1 is the owchart of the process and results of our liter-
ature search. The initial search, conducted on three English data-
base by factoring into components what we wanted in a research
paper. There were 187 papers selected from the database, including
45 papers from CINAHL, 67 papers from Cochrane Library, 75 pa-
pers from MEDLINE. Also, there were 161 papers were conducted to
eliminate duplication, and 26 articles remained from the process of
selection. By reading the abstracts of each research paper, 17 papers
were reviewed for the preliminary assessment and elimination of
unqualied papers by two researchers who reached a consensus on
the quality of selected research papers (represented with JBL level
9). One paper was remained after a scrupulous literature appraisal
by eliminating substandard research papers or incomplete research
data. Finally, there are 8 nalized research papers from Meta-
Analysis. The searching steps were described in Figure 1. Table 1
shows a summary of the eight studies. Our elimination and selec-
tion process indicated that ve of the eight studies could be used to
discuss the effect of self-management programs on patients'
depression; the remaining three research papers could be used to
discuss the effect of the self-management program on patients'
eGFR, each with three papers used to discuss the effects of self-
management programs on patients' physical and mental quality
of life.
The analysis of the effect of self-management programs on pa-
tients' eGFR indicated heterogeneity among the three chosen
research papers (Q 11.37, p .003, I2 82.41%). Using a funnel
plot to check for the existence of publication bias revealed no such
bias. As shown in the forest plot in Figure 2, a random effects model
for meta-analysis generated an effect size of .06 [95%CI (
0.69,
0.81)], indicating that the intervention of a self-management pro-
gram did not signicantly affect patients' eGFR.
The analysis of the effects of self-management programs on
patients' depression indicated heterogeneity among the ve chosen
research papers (Q 16.30, p .003, I2 75.46%). Using a funnel
plot to check for the existence of publication bias revealed no such
bias. As shown in the forest plot in Figure 3, a random effects model
for meta-analysis generated an effect size of .29 [95% CI (0.07,
0.53)], indicating that the intervention of a self-management pro-
gram signicantly affected patients' depression, although the ef-
fects were on the moderate side.
The analysis of the effect of the self-management program on
patients' performance on the physical quality-of-life dimension
revealed heterogeneity among the three research papers on
patients' physical quality-of-life dimension (Q 8.07, p .018,
I2 75.21%). A funnel plot was used to check for the existence of
publication bias. The result of the funnel plot supported no
publication bias. As shown in the forest plot in Figure 4, a
random effects model for meta-analysis generated an effect size
of
.16 [95%CI (
0.81, 0.50)], indicating that the intervention of a
self-management program did not signicantly affect patients'
performance on the physical quality-of-life dimension.
With regard to patients' mental quality-of-life dimension, the
three research papers were homogenous (Q 0.71, p .703,
I2 < .001%). Further, a funnel plot was used to check for the exis-
tence of publication bias. The result of the funnel plot supported no
publication bias. As shown in the forest plot in Figure 4, a xed
effects model for meta-analysis generated an effect size of
.42
[95%CI (
0.75,
0.10)], indicating that the intervention of a self-
258 M.-C. Lee et al. / Asian Nursing Research 10 (2016) 255e262
Period: January, 2002 to June, 2014
Papers retrieved from the
databases=187
-Papers from CINAHL=45
-Papers from Cochrane Library=67
-Papers from MEDLINE=75
Selected research papers after a process of
elimination (n=26)
Two researchers reaching an consensus on
the quality of the selected research papers
(represented with the JBI level) (n=9)
Note: JBI= Joanna Briggs Institute, there were 10
appraised items in total; the result of how many
appraised items met the standards was placed in
the same column as the evidence quality level.
The finalized research papers for
meta-analysis (n=8)
Figure 1. The owchart of the systematic review and selection of research papers.
management program did signicantly affect the patients' perfor-
mance on the mental quality-of-life dimension, with moderate
effects.
Discussion
The present study was the rst to use a systematic review and
meta-analysis approach to investigate the effect of self-man-
agement programs on kidney function, depression, and quality of
life in patients with chronic kidney disease (CKD).
We begin with the intervention of a self-management program
on improving CKD patients' eGFR. As revealed by the results of a
meta-analysis of three selected studies, the intervention of a self-
management program did not effectively improve patients' eGFR.
The outcomes for which we found none effect size (ES .06) of
patient's with chronic kidney disease self-management programs
can improve patients eGFR. However, the intervention of a self-
management program had no signicant effect on patients' eGFR.
The effect sizes of .06 imply no signicant difference [17]. Two of
three studies found no signicant difference in patient's eGFR be-
tween groups [18,19]. More research evidence is required in order
to conrm the ameliorating effects of intervention methods (group
or individual) on CKD patients' kidney function.
The outcomes for which we found the moderate effect size
(ES .29) of patients with chronic kidney disease self-management
programs can improve patient's depression. However, 4 of 5 studies
found that patient's depression was better in the intervention (self-
management programs) group than in the control (usual care)
group [21,29e31]. One study found no signicant difference in
patient's depression between groups [20]. We found that the above
Eliminating duplicate research papers
(n=161)
Conducting Initial appraisal and
eliminating disqualified research papers
by reading the abstract of each research
paper (n=17)
Eliminating substandard research papers
or research papers with incomplete
research data after scrupulous literature
appraisal (n=1, this studys selection
criteria might be unanalyzable for not
specifying the mean, standard deviation,
or standard error. No answers were
received from the papers author after our
attempts to contact her/him.)
research papers all conducted post intervention tests at least 6
weeks, 3 months, or even 9 months after the intervention of a self-
management program [30]. All research papers found the effects of
the interventions on alleviating patients' depression. Nevertheless,
no specic effects were found in the research [20], nonsignicant
effect was reported when depression was measured in a month. A
piece of advice for papers that adopt the systematic review method
to evaluate the effectiveness of a self-management program on
patients inicted with chronic diseases is that the intervention
should last for at least 4 weeks, the rst post intervention test
should be conducted at least 4 weeks post intervention, and a
follow-up effect should last for at least 3 months [4]. Therefore, we
suggest that a period of at least 4 weeks between an intervention
and the post intervention test as more likely to capture the effects
of an intervention. The nding of this research may serve as
reference for future research.
The outcomes for which we found the moderate effect size
(ES
.42) of patients with chronic kidney disease self-manage-
ment programs did effectively improve patients' mental quality of
life. However, all studies found that patient's mental quality of life
was not better in the intervention (self-management programs)
group than in the control (usual care) group [19,20,31]. This nding
may be due to the differences in sample sizes that were used in
these studies resulting in no signicant intergroup differences in
any single study.
The outcomes for which we found no effect size (ES
.16) of
patients with chronic kidney disease self-management programs
cannot improve patient's physical quality of life. However, 2 of 3
studies found that patient's physical quality of life was better in
the intervention (self-management programs) group than in the
Table 1 Characteristics of Included Study on Self-Management for CKD.

Study/ Study design/country Subjects/age/sample size/ Intervention Treatment (T) & follow up (F) Outcome (Mean SD) Level of evidence based
author dropout n (%) (Quality of the papers)a

Chen et al [17] RCT/Taiwan CKD stage 3e5/ Self-management support: providing health T: 12 mo eGFR (I: 29.11 20.61; (7/10)
68.2 12.1; I: 27, information, reinforcing patients' motivation F: 12 mo C: 15.72 10.67),
C: 27/10 (16.0%) to learn, encouraging self-care and p .04
continuing existing treatments (once per
month), telephone follow-ups (once per
week) and a support group (twice a month,
5e10 people).
Choi & Lee Quasiexperimental CKD/ Self-management educational program: T: 4 wk eGFR (I: 38.22 14.96; (5/10)
[18] design/South Korea 56.13 13.01; I: 31, teaching knowledge and skills in relation to F: 4 wk, 8 wk C: 43.86 11.73),
C: 30/Not reported kidney function and self-health care p .822
(8 groups in total, each of which consisted of
3e5 people; 20 minutes per session for a
duration of 4 weeks).
Campbell RCT/Australia CKD stage 4e5/ Individualized nutritional counseling: T: 1 mo eGFR (I: 21.90 6.30; (7/10)
et al [19] 69.75 12.15; I: 23, providing individualized nutritional F: 12 wk C: 23.40 7.90),
C: 24/13 (22.0%) counseling (once every 2 weeks), telephone p .53

M.-C. Lee et al. / Asian Nursing Research 10 (2016) 255e262

counseling, and self-management principles. SF-36: PCS
(I: 35.90 10.20;
C: 29.90 7.90),
p .107
SF-36: MCS
(I: 47.70 11.70;
C: 40.00 12.60),
p .069
Lii et al [20] RCT/Taiwan ESRD (HD)/ Group psychosocial intervention: T: 2 mo BDI (I: 12.85 6.64; (9/10)
Not report; I: 20, encompassing the cognitive-behavioral F: 1 mo C: 21.39 15.10),
C: 28/12 (20.0%) theory and the self-efcacy theory, which can p .001
enhance patients' knowledge, familiarize SF-36: PCS
patients with relevant skills, enable (I: 42.87 5.93;
smoothly-performed treatments, and enable C: 40.46 9.75),
individuals have the ability of p .008
self-management. A group class was used SF-36: MCS
and there were 8 class sessions in total (I: 43.49 7.49;
(1 session per week and 2 hours for each C: 40.10 12.13),
session). p .19
Tsay & RCT/Taiwan ESRD (HD)/ Empowerment program (3 times per week): T: 1 mo BDI (I: 13.36 10.55; (9/10)
Hung [21] 51.18 9.75; I: 25, assisting patients to develop skills and F: 6 wk C: 10.40 10.34),
C: 25/Not reported self-awareness, reinforcing patients' p .03
self-efciency, enabling patients to
practice self-care, and self-management.
Chen et al RCT/Taiwan ESRD (HD)/ CBT program including sleep hygiene education T: 6 wk BDI (I: 13.80 11.30; (6/10)
[29] 58.00 11.00; I: 37, (once per week and 30 minutes each time for F: 6 wk C: 16.10 14.00),
C: 35/8 (10.0%) 6 weeks in total). Videos were used to p .022
supplement the CBT program in the period
when patients received HD. Group
discussions and education ensued after
the HD.
Duarte RCT/Brazil ESRD (HD)/ CBT program once per week, 0.5e1 hour, T: 12 wk BDI (I: 10.80 8.80; (7/10)
et al [30] 53.20 14.30; I: 41, 12 week. Additionally, once per month, F: 3 mo, 9 mo C: 17.60 11.20),
C: 44/16 (18.0%) meetings for the purpose of reinforced effects p .002
were provided at the maintenance stage to
help patients maintain abilities that they
had acquired.
(continued on next page)

259
 260 M.-C. Lee et al. / Asian Nursing Research 10 (2016) 255e262

published by the Joanna Briggs Institute: there were 10 appraised items in total; the result of how many appraised items met the standards was placed here. For example, (7/10) meant that 7 of the 10 appraised items met the
The level of evidence based on a seven-level evidence categorization model developed by Melnyk and Fineout-Overholt [23]; type of literature: RCT; the appraisal of the quality of study was based on an critical appraisal tool
Note. BDI Beck Depression Inventory; C control group; CBT cognitive behavioral therapy; CKD chronic kidney disease; eGFR estimated glomerular ltration rate; ESRD end-stage renal disease; HD hemodialysis;
control (usual care) group [20,31]. One study found no signicant
Level of evidence based
(Quality of the papers)a

difference in patient's physical quality of life between groups [19].

We recommend continuing bigger sample of meta-analysis in the
(7/10)

future.

Study limitations

The research papers analyzed in this study addressed the effects

of self-management programs. RCTs and quasi-experimental de-
Outcome (Mean SD)

BDI (I: 13.28 6.03;

C: 21.56 15.37),

C: 40.68 11.94),

signs were adopted, while a blind design was not feasible and a
C: 40.29 9.90),
(I: 43.89 5.79;

(I: 43.98 7.23;

double blind design was especially difcult. Otherwise, a double

SF-36: MCS
SF-36: PCS

blind design would have precluded selection bias, performance

p .001

bias, and detection bias. Some of the studies did not clearly explain
p .01

p .69

that the Joanna Briggs Institute quality assessment scores were

lower. Studies that did not specify the rates of participant loss or the
reasons for participant dismissal among different research groups
I intervention group; MCS mental components scale; PCS physical components scale; RCT randomized controlled trials; SF-36 Short Form-36 quality of life.

were likely susceptible to attrition bias. In this study, systematic

Treatment (T) & follow up (F)

review has small number of studies (n 8) included for the meta-

analysis. As such, only three studies on the outcome of quality of life
were analyzed. One study no answer was received from these pa-
pers' authors after our attempts to contact her/him.
F: 3 mo
T: 8 wk

As revealed in our study, the effects of a self-management

program intervention on CKD patients' eGFR remain inconclusive.
Such intervention may have some degree of effectiveness on
emotional and psychosocial well-being but not on kidney function.
In actuality, many factors can affect the control of renal function.
Whether self-management is the cause of the real impact remains
meeting once per week, 2 hours per meeting
diseases in an appropriate manner. The goal
patients nd out causes of stress and adjust

group meeting: 8e10 people in each group,

for a total of 8 meetings, one follow-up per

to be determined by future research. This study acquired three

required skills, and develop corresponding
strategies with a reinforced structure. The
Adaptation training program: the cognitive-

eligible papers for analyzing eGFR and quality of life. Future

behavioral theory was adopted to help

their negative thoughts about chronic

self-awareness, become familiar with

research is expected to substantiate this intellectual research re-

gard to self-management programs for patients with CKD. Sys-
was to enhance ESRD patients'

tematic literature analysis could be performed only on the

Intervention

documentation contained in the three studies to examine a self-

management program. Given the greatly varied self-management
program content, future research is expected to clarify what denes
a self-management program and how to collect more empirical
studies for meta-analysis.
month).

Conclusion and recommendations

In conclusion, the present study adds to the evidence and show

that a self-management program signicantly impacts CKD pa-
Subjects/age/sample size/

tients' depression and mental components of quality of life. How-

50.72 14.10; I: 30,

ever, the intervention of a self-management program has no

dropout n (%)

C: 27/9 (14.0%)

signicant effects on patient's eGFR as well as physical dimensions

of quality of life. As this study's results indicate, the intervention of
ESRD (HD)/

a self-management program is moderate in effect size for depres-

sion and mental component of quality of life. A self-management
program, which is an innovative health instruction method alter-
native to traditional health education, is designed for patients with
chronic disease, such as CKD, to effectively alleviate patients'
depressed mood and mental component of quality of life.
Study design/country

The study's results not only provide more objective-based ev-

idence for renal healthcare personnel, who in turn could educate
RCT/Taiwan

patients on the importance of self-management for CKD, but also

provide a reference for the delivery of relevant healthcare. As
such, we advise that future research enthusiastically propose the
use of a self-management program on patients with CKD. Lastly,
Table 1 (continued )

given that a smaller research sample size may compromise the

Tsay et al [31]

accuracy of an estimated population parameter [32], future re-

searchers are advised to conduct research with a larger sample
standards.
author

size to enhance the meticulousness of the research design and

Study/

further verify the effects of a self-management program on pa-

a

tients with CKD.

 M.-C. Lee et al. / Asian Nursing Research 10 (2016) 255e262 261

Figure 2. The effects of a self-management program on improving patients' eGFR.

Figure 3. The effects of a self-management program on mitigating patients' depression.

Figure 4. The effects of a self-management program on improving patients' physical and mental quality of life.

Conicts of Interest
The authors declare no potential conicts of interest with respect
to the research, authorship, and/or publication of this paper.
Acknowledgements
This work received grant support from Taiwan Ministry of Sci-
ence and Technology (MOST 104-2314-B-227-006-MY3).
References
1. United States Renal Data System. 2012 Atlas of end-stage renal disease
[Internet]. Washington Heights, NY: USRDS Coordinating Center; 2012 [cited
2015 May 21]. Available from: http://www.usrds.org/2014/view/v2_01.aspx
2. Eknoyan G. Chronic kidney disease denition and classication: no need for a rush
to judgment. Kidney Int. 2009;75:1015e8. http://dx.doi.org/10.1038/ki.2009.53
3. Barlow JH, Wright CC, Sheasby JE, Turner AP, Hainsworth JE. Self-management
approaches for people with chronic conditions: a review. Patient Educ Couns.
2002;48:177e87.
4. Kuo CC, Wang HH. Applying self-management intervention studies to patients
with chronic illness: a systematic review. J Nurs Health Res. 2012;8(1):52e62.
Chinese http://tao.wordpedia.com/show_pdf.ashx?sesswapzys453jwueo45y-
b0nyfvl&le_nameJO00000826_8-1_50-60&le_typer
5. Richard CJ. Self-care management in adults undergoing hemodialysis. Nephrol
Nurs J. 2006;33(4):387e94.
6. Richard AA, Shea K. Delineation of self-care and associated concepts. J Nurs
Scholarsh. 2011;43(3):255e64.
http://dx.doi.org/10.1111/j.1547-5069.2011.01404.x
7. Lorig K, Hurwicz M, Sobel D, Hobbs M, Ritter PA. A national dissemination of an
evidence-based self-management program: a process evaluation study. Patient
Educ Couns. 2005;59:69e79. http://dx.doi.org/10.1016/j.pec.2004.10.002
8. Curtin R, Mapes D. Health care management strategies of long term dialysis
survivors. Nephrol Nurs J. 2001;28(4):385e94.
9. Lau-Walker M, Thompson DR. Self-management in long-term health condi-
tions: a complex concept poorly understood and applied? Patient Educ Couns.
2009;75(2):290e2. http://dx.doi.org/10.1016/j.pec.2009.02.001
262 M.-C. Lee et al. / Asian Nursing Research 10 (2016) 255e262
10. Novak M, Costantini L, Schneider S, Beanlands H. Approaches to self-
management in chronic illness. Semin Dial. 2013;26(2):188e94.
http://dx.doi.org/10.1111/sdi.12080
11. Reid C, Hall J, Boys J, Lewis S, Chang A. Self-management of haemodialysis for end
stage renal disease: a systematic review. JBI Libr Syst Rev. 2011;9(3):69e103.
12. Mason J, Khunti K, Stone M, Farooqi A, Carr S. Educational interventions in
kidney disease care: a systematic review of randomized trials. Am J Kidney Dis.
2008;51(6):933e51. http://dx.doi.org/10.1053/j.ajkd.2008.01.024
13. Idier L, Untas A, Koleck M, Chauveau P, Rascle N. Assessment and effects of
therapeutic patient education for patients in hemodialysis: a systematic re-
view. Int J Nurs Stud. 2011;48(12):1570e86.
http://dx.doi.org/10.1016/j.ijnurstu.2011.08.006
14. Hoth KF, Christensen AJ, Ehlers SL, Raichle KA, Lawton WA. Longitudinal ex-
amination of social support, agreeableness and depressive symptoms in
chronic kidney disease. J Behav Med. 2007;30(1):69e76.
http://dx.doi.org/10.1007/s10865-006-9083-2
15. Sidani S. Nursing outcomes: the state of the science. 2nd ed. Sudbury (MA):
Jones and Bartlett; 2011.
16. Song M. Diabetes mellitus and the importance of self-care. J Cardiovasc Nurs.
2010;25(2):93e8. http://dx.doi.org/10.1097/JCN.0b013e3181c5a364
17. Chen SH, Tsai YF, Sun CY, Wu IW, Lee CC, Wu MS. The impact of self-
management support on the progression of chronic kidney disease: a pro-
spective randomized controlled trial. Nephrol Dial Transplant. 2011a;26(11):
3560e6. http://dx.doi.org/10.1093/ndt/gfr047
18. Choi ES, Lee J. Effects of a face-to-face self-management program on knowl-
edge, self-care practice and kidney function in patients with chronic kidney
disease before the renal replacement therapy. J Korean Acad Nurs. 2012;42(7):
1070e8. http://dx.doi.org/10.4040/jkan.2012.42.1070
19. Campbell KL, Ash S, Bauer JD. The impact of nutrition intervention on quality of
life in pre-dialysis chronic kidney disease patients. Clin Nutr. 2008;27(4):
537e44. http://dx.doi.org/10.1016/j.clnu.2008.05.002
20. Lii YC, Tsay SL, Wang TJ. Group intervention to improve quality of life in he-
modialysis patients. J Clin Nurs. 2007;16(11C):268e75.
http://dx.doi.org/10.1111/j.1365-2702.2007.01963.x
21. Tsay SL, Hung LO. Empowerment of patients with end-stage renal disease: a
randomized controlled trial. Int J Nurs Stud. 2004;41(1):59e65.
22. Ware JE, Kosinski M, Keller SD. SF-36 physical and mental health summary
scales: a user's manual. 1st ed. Boston (MA): The Health Institute, New England
Medical Center; 1994.
23. Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing and
healthcare: a guide to best practice. 3rd ed. Philadelphia (PA): Wolters Kluwer;
2015.
24. Borenstein M, Hedges LV, Higgins JPT, Rothstein HR. Introduction to meta-
analysis. Chichester (UK): John Wiley & Sons; 2009.
25. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in
meta-analyses. Br Med J. 2003;327(6):557e60.
http://dx.doi.org/10.1136/bmj.327.7414.557
26. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control. Clin Trials.
1986;7(3):177e88.
27. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale
(MI): Erlbaum; 1988.
28. Egger M, Davey SG, Schneider M, Minder C. Bias in meta-analysis detected by a
simple, graphical test. Br Med J. 1997;315(13):629e34.
29. Chen HY, Cheng IC, Pan YJ, Chiu YL, Hsu SP, Pai MF, et al. Cognitive-behavioral
therapy for sleep disturbance decreases inammatory cytokines and oxidative
stress in hemodialysis patients. Kidney Int. 2011b;80(4):415e22.
http://dx.doi.org/10.1038/ki.2011.151
30. Duarte PS, Miyazaki MC, Blay SL, Sesso R. Cognitive-behavioral group therapy is
an effective treatment for major depression in hemodialysis patients. Kidney
Int. 2009;76(4):414e21. http://dx.doi.org/10.1038/ki.2009.156
31. Tsay SL, Lee YC, Lee YC. Effects of an adaptation training program for patients
with end-stage renal disease. J Adv Nurs. 2005;50(1):39e46.
http://dx.doi.org/10.1111/j.1365-2648.2004.03347.x
32. Sanchez-Meca J, Marin-Martinez F. Weighting by inverse variance or by sample
size in meta-analysis: a simulation study. Educ Psychol Meas. 1998;58(2):
211e20. http://dx.doi.org/10.1177/0013164498058002005