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Multidisciplinary Strategies in the

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Archives of Medical Research 44 (2013) 611e615

REVIEW ARTICLE
Multidisciplinary Strategies in the Management of Early Chronic
Kidney Disease
Hector R. Martnez-Ramrez, Laura Cortes-Sanabria, Enrique Rojas-Campos,
Aurora Hernandez-Herrera, and Alfonso M. Cueto-Manzano
Medical Research Unit in Kidney Disease, Specialty Hospital, CMNO, IMSS, Guadalajara, Jalisco, Mexico
Received for publication August 22, 2013; accepted October 22, 2013 (ARCMED-D-13-00464).

Chronic kidney disease (CKD) is a worldwide epidemic especially in developing coun-

tries, with clear deficiencies in identification and treatment. Better care of CKD requires
more than only economic resources, utilization of health research in policy-making and
health systems changes that produce better outcomes.
A multidisciplinary approach may facilitate and improve management of patients from
early CKD in the primary health-care setting. This approach is a strategy for improving
comprehensive care, initiating and maintaining healthy behaviors, promoting teamwork,
eliminating barriers to achieve goals and improving the processes of care. A multidisci-
plinary intervention may include educational processes guided by health professional, use
of self-help groups and the development of a CKD management plan. The complex and
fragmented care management of patients with CKD, associated with poor outcome, en-
hances the importance of implementing a multidisciplinary approach in the management
of this disease from the early stages. Multidisciplinary strategies should focus on the
needs of patients (to increase their empowerment) and should be adapted to the resources
and health systems prevailing in each country; its systematic implementation can help to
improve patient care and slow the progression of CKD. 2013 IMSS. Published by
Elsevier Inc.
Key Words: Multidisciplinary strategies, Early chronic kidney disease, Primary health care.

Introduction The Mexican CKD scenario is extraordinarily complex:

Problem Description
Chronic kidney disease (CKD) is a worldwide epidemic,
especially in disadvantaged populations, with marked defi-
ciencies in its identification and treatment (1e3). Moreover,
due to the excessive economic cost of end-stage renal
disease (ESRD) treatment, the situation of developing
countries is particularly worrisome because many of them
currently have very high incidence rates, mostly due to dia-
betes (4).
Address reprint requests to: Dr. Alfonso M. Cueto-Manzano, Unidad
de Investigacion Medica en Enfermedades Renales, Hospital de Especiali-
dades, CMNO, IMSS, Belisario Domnguez No. 1000, Col. Independencia,
Guadalajara, Jalisco, Mexico; Phone: 52 (33) 36683000, ext. 32204;
FAX: 52 (33) 36245050; E-mail: a_cueto_manzano@hotmail.com
it has displayed the highest general and diabetic incidence
rates of ESRD over the last years (4), which could be
related, at least partially, with the increased prevalence of
risk factors for developing CKD in our population (5e9)
and the incongruity between CKD patients needs and the
health-care delivery systems, largely designed for manag-
ing acute illnesses (10).
Need for Optimal Care in Patients with Early Chronic
Renal Disease
In some developing countries like Mexico, there is an
increasingly high prevalence of overweight and obesity
from early ages, associated with changes in dietary (5)
and physical activity (6) patterns. There is also an increase
of noncommunicable diseases such as type 2 diabetes mel-
litus (DM2) and hypertension (7e9) which, on the other
hand, are the main causes of CKD (4). Moreover, it is very

0188-4409/$ - see front matter. Copyright 2013 IMSS. Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.arcmed.2013.10.013
 Author's personal copy

612 Martnez-Ramrez et al./ Archives of Medical Research 44 (2013) 611e615

common that patients during early stages of CKD do not
meet clinical practice recommendations for an effective
control (3). They have negative lifestyle habits, which are
strongly associated with kidney damage and difficult to
change only with medical intervention (11,12).
Serious difficulties for primary physicians to provide the
optimal management to CKD patients include the over-
whelming work at the primary care units and the limited
time available from their saturated schedule (13). In addi-
tion, current healthcare systems are designed to respond
rapidly and efficiently to any acute illness or injury but they
are poorly configured to treat chronic diseases (10) (such as
CKD), which require cooperation from the patients them-
selves to perform self-care (14). Evidence shows that multi-
disciplinary models should be included from the early
stages of CKD. These models should be based on patients
needs and seek encouragement and promotion of the active
participation of patients to increase self-care and to modify
negative lifestyle habits associated with progression of
renal damage (14e17).
Recently, a call for more resources has been made to
improve renal health in developing countries (1). Better care
of CKD requires more than only economic resources,
including utilization of health research in policy-making
(18) and health systems changes (10) to produce better out-
comes and models to promote effective interactions between
health teams and patients (15,16). A multidisciplinary
approach may facilitate and improve management of patients
from early CKD in the primary healthcare setting.
Multidisciplinary Strategies to Improve Self-care in
Patients with Chronic Kidney Disease
Multidisciplinary approach is a strategy to improve health
care and is very useful to initiate and maintain healthy be-
haviors, promote teamwork, eliminate barriers to achieve
goals and improve the processes of care for each patient
(19e22). Strategies to increase the empowerment and
self-care of patients with early CKD are strongly related
with the involvement of multidisciplinary teams and
include educational processes guided by health profes-
sionals, self-help groups and development of a management
plan (14,19e23).
Educational Processes
Educational processes guided by professionals and focused
on the patients needs can help to increase the skills to solve
problems, improve efficiency and support the application of
knowledge to real situations (19e24). These processes are
related with the better understanding of the disease, in-
crease self-confidence, achieve healthy behaviors, decrease
symptomatology and improve outcomes (19e24). Physi-
cians and the multidisciplinary team interact to identify
and remove barriers and to promote patient education with
available community resources. Success of these strategies,
particularly in patients with CKD, requires an adequately
trained multidisciplinary team (15,16). Additionally, pa-
tients must be supported by the integration of self-help
groups to encourage the development of individual skills
to maintain renal function and general health.
Self-help Groups
The simple transmission of information to patients is in-
sufficient to modify risky behaviors. The most successful
interventions for this purpose are those promoting patient
empowerment (19e24). Integration of patients within self-
help groups may contribute to increase the decision-making
skills, promote the active participation in self-care actions,
and help to increase the motivation in the search for solutions
of common problems (for instance, lack of metabolic control,
hypertension, smoking, sedentary lifestyle, unhealthy diet and
lack of adherence to treatment) (25e28). These groups also in-
crease the self-confidence in patients and promote changes to-
wards healthy behaviors, identifying family, social and health
team support networks (23,24,29). Positive effects of the use
of these kinds of groups have been demonstrated in patients
with early CKD (15e17).
Long-term preservation of healthy behaviors can be sup-
ported by additional community resources such as groups
like Alcoholics Anonymous, Neurotics Anonymous,
Compulsive Eaters Anonymous, Diabetes Clubs, and
Stop-Smoking Clinics, among others (24e29). Patients
may gain experience in self-care actions inspired by models
of community leaders and improve their everyday skills as
well as increase their ability to reinterpret symptoms and
to distinguish discomfort due to illness or other causes
(24e29).
Development of a Management Plan for Chronic Kidney
Disease
The most important action that should be made by the
healthcare team in conjunction with the patient to prevent
or stop the progression of kidney damage is the develop-
ment of a management plan for the disease. This plan
should have specific actions according to the stage of
CKD (14,22,29). The management plan is a dialogue be-
tween the healthcare team and the patient in which the
latter identifies steps, removes barriers and provides the
necessary resources to achieve their goals. The healthcare
team must be aware of the patients motivation and self-
confidence in order to achieve and maintain healthy behav-
ioral changes over time (14,22,29). The healthcare team
should support patients to develop and implement the
management plan for establishing clear and reachable
goals to reduce risk factors of renal damage progression
(14,22,29). With a CKD management plan, the control of
other chronic diseases such as diabetes and hypertension
could be obtained. Strategies to modify risky behaviors
and to improve self-care require the effort and frequent
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Multidisciplinary Intervention Model and Early CKD 613

contact with the multidisciplinary team in order to achieve CKD. Most reports, however, have described the outcomes
the goals of training and treatment to assess the patients of patients referred to nephrologists, with linkage to primary
progress and to teach the tools for solving the everyday care, aimed at moderate to late stages of CKD (30e35). The
problems. The approach must be individualized, taking into advantage of a multidisciplinary approach on kidney func-
consideration the cultural and economic status, beliefs and tion in patients with those stages of CKD is controversial.
knowledge of the patients. Multidisciplinary participation is Some studies have failed to demonstrate improvement in
needed to assess the abilities of patients and their demands renal function, mortality or control of risk factors with the
for self-care generation (14,22,29). employment of multidisciplinary teams in patients with
CKD stage 3e5 (31e33), whereas others have shown a bet-
Perspectives of Care for Chronic Kidney Disease ter survival (34) or slower decline in glomerular filtration
rate (35) compared to patients receiving usual care.
The essential elements in any multidisciplinary intervention
Several measures are recognized to decrease the risk or
of care for a chronic condition are based on appropriate and
slow the progression of renal damage and are most effective
early identification of patients, a supportive system for lon-
when initiated early in the course of renal disease (38,39).
gitudinal follow-up evaluation (as opposed to episodic
Interestingly, however, few studies have evaluated the
care), and the implementation of interventions to delay pro-
benefit of multidisciplinary models at early stages of
gression of the condition. In the case of progression of
CKD (before the referral to nephrologists). In this regard,
CKD, the multidisciplinary intervention will also help to
several multidisciplinary strategies have been evaluated
provide a timely preparation for renal replacement therapy
by our group to counteract the progression of renal damage
(dialysis or transplantation) (30).
at early stages of CKD (11,12,15e17). A very early referral
Complexity of the factors involved in the management
to the nephrologist and the adequate training of family phy-
of CKD makes necessary the multidisciplinary approach
sicians preserve significantly better the renal function of
to optimize renal care (14e17,30e35). Several models
DM2 patients with early nephropathy (11,12). However,
with comprehensive approaches have been proposed
several variables strongly related with negative lifestyle
(14e16,30,36,37). Systems developed in some developed
habits (such as metabolic and weight control, and stopping
countries suggest the implementation of models for chronic
tobacco and alcohol intake) were not adequately controlled
care focused on the needs of patients through the imple-
by either nephrologists (11) or by family physicians (12),
mentation of specialized multidisciplinary clinics (30).
probably because of the fact that these factors involve psy-
However, extrapolation or implementation of such systems
chological, sociocultural and economic factors that are
in disadvantaged populations will depend on the capacity of
difficult to modify only by physicians. In another study
the health system in each country. Therefore, evaluation of
(15), in patients without CKD but at high risk for devel-
multidisciplinary strategies must be a constant with the
oping it, the use of educational strategies for patients
available resources that every health system could support
guided by health professionals (a multidisciplinary team
while moving towards a specific model of CKD care
including social worker, dietitian, physical trainer and fam-
(14e16,30,36,37).
ily physician) and supported by self-help groups were
A more feasible strategy in countries with limited resources
effective in modifying negative lifestyle and nutritional
(as Mexico), considering the excessive variability of the CKD
habits (15). Based on the previous results, we recently eval-
management, could be the systematization of care for high-
uated the hypothesis that, in addition to adequate training to
risk patients or patients with early stages of CKD (37). Such
family physicians, a multiple approach guided by a multi-
a management systematization would facilitate the identifica-
disciplinary healthcare team may attain better results on
tion of patients at risk, their clinical assessment, CKD diag-
lifestyle and renal function of DM2 patients with early
nosis and classification as well as the establishment of
CKD compared with a conventional approach in which pri-
a multidisciplinary management plan (Figure 1) (37). This
mary physicians play the major role in treating patients and
conceptual model for CKD care is the backbone of the system-
deciding when to refer them to other health professionals
atic approach; multidisciplinary strategies promoting self-care
(16). This study included multiple and complementary stra-
(educational processes, self-help groups, and the management
tegies to potentiate a positive impact on patients: educa-
plan) must be integrated in the process of care. A successful
tional interventions, self-help groups and group dynamics.
translation of knowledge into practice requires the active
Results showed that a multidisciplinary approach had better
participation of patients, multidisciplinary efforts, and finan-
control of lifestyle variables compared with the conven-
cial and administrative resources (37).
tional approach (16), which supports previous evidence
and reinforces the notion that multidisciplinary strategies
Impact of the Multidisciplinary Approach on Early
could help to improve the care of patients with early
Chronic Kidney Disease
CKD in the primary healthcare setting.
In recent years there has been an interest in the use of multi- In conclusion, the complex and fragmented care
disciplinary approaches for the management of patients with management of patients with CKD associated with poor
 Author's personal copy

614 Martnez-Ramrez et al./ Archives of Medical Research 44 (2013) 611e615

Figure 1. General model of care for chronic kidney disease. (A color figure can be found in the online version of this article.)

outcome enhances the importance of implementing a multi-
disciplinary approach in the management of this disease
from the early stages. Multidisciplinary strategies should
focus on the needs of patients (to increase their empower-
ment) and should be adapted to the resources and health
systems prevailing in each country; its systematic imple-
mentation can help to improve patient care and slow the
progression of CKD.
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