RPM can improve the management and the quality of life of patients with chronic disease. In this study we evaluated the related paper to find possible clinical and social advantages derived from remote patient monitoring.

Home dialysis require a continuous monitoring (including peritoneal dialysis and home hemodialysis) and offers a variety of benefits over in-center hemodialysis. Studies show evidence of benefits for both peritoneal dialysis (PD) and home hemodialysis (HHD) patients related to survival, quality of life, transportation costs, increased patient autonomy and clinical benefits including enhanced blood pressure and phosphorus control.1–5 Home dialysis is particularly advantageous in the pediatric population given the greater schedule flexibility for school and play, importance of psychosocial aspects, and the limited geographic distribution of pediatric dialysis centers. Furthermore, the cost of delivery of care of home modalities in most countries is less than that of in-center hemodialysis.6–8

The efficient use of RPM in Nephology requires the HCP capacitation and patient training to develop a variety of self-management skills to effectively deliver and manage their disease at home. RPM may provide the HCP with tools to better assist the patients and the patients with accessible information to develop the skills and knowledge they require to manage their treatment. This review aims to identify and evaluate RPM interventions in supporting clinicians and patients of nephrology units.

The ultimate goal of ICT interventions would be to reduce adverse events (i.e., hospitalization), and improve survival, and patient-reported outcomes such as treatment satisfaction and quality of life while reducing healthcare resources and costs.9,10

As this is an extremely complex disease, multidisciplinary care is needed to provide complete and continuous care. The use of RPM in Nephrology aims to improve the interventions of Health Care Professionals and the patient self-management intervention to facilitate an individual's ability to make lifestyle changes as needed.11 The effectiveness of these interventions on patients with kidney disease is limited by the integration of these new tools into the common procedure of the Nephrology units. In this study, we applied a systematic review to investigate whether the RPM intervention improves healthcare in the Nephology units.

Due to the complexity of patients on dialysis, telehealth12 may complement but not replace the in-person visit and provide better oversight of care with remote monitoring. It is not surprising that patients receiving peritoneal dialysis (PD) have responded positively to telehealth. Telehealth and home dialysis both foster greater home-based care, less travel time, and fewer trips to the clinic and leverage the principles of patient and care partner autonomy and self-care. Telehealth may also help facilitate patient education about home dialysis modalities, and self-care.13

Using technology and telemedicine to educate patients will be important in a connected world while trying to decrease face-to-face interactions.

It is important to have a system where the processes of patient care, areas of technological progress, and various issues of applied RPM are interconnected. This work is dedicated to using RPM in healthcare to support and improve the care for Patients with Kidney disease in Nephrology Units. The main problems and burdens on the way to the implementation of RPM in Nephrology have been analyzed and compiled in the column of limitations and future research in Table 1.

Following in the footsteps of the important work already accomplished by the AAKP in the United-States, the Decade of the Kidney™ will gather relevant stakeholders and partners to accelerate this change in Europe. Through a wide range of advocacy activities, the campaign will raise awareness of the challenges and unmet needs in kidney disease, with a focus on the importance of prevention, data collection and sharing, home therapies14 personalized medicine, patient education and empowerment, and regenerative medicine.

Examples of such technologies include home-based point-of-care labs based on finger sticks and home-based diagnostics and care. As such, we must continue to make it better; we must continue to make it easier; and we must continue to make it available to anyone and everyone in need of care by addressing technology literacy, and infrastructure.15

The challenges to appropriately utilize home modalities have been multifold, including low start rates, high attrition rates, and inadequate infrastructure in all facets of medical service providers to care for the home dialysis patient16 (e.g., nursing facilities, trained access operators, transition to home, etc.).

CKD, especially end-stage renal failure (ESRF), represents a major public health problem in developed and developing countries. Healthcare statistics in mainland China show that ESRF has become one of the major health problems in the adult Chinese population. PD is a kind of renal replacement therapy (RRT) that is often presented as an easier and less cumbersome dialysis modality. However, long-term PD impacts the patient's physical, psychological, and social well-being, leading to frequent re-hospitalization and may impose a considerable burden on patients and families, which induces great demands on integrated health and social care to maintain a desirable quality of life, decrease morbidity during the course of the disease and improve health outcomes of ESRF patients.17

The current evidence is mainly based on disparate case reports and small observational studies. In this study, we aimed to ascertain the studies exploring the use of RPM in the context of renal health care.

The main purpose of RPM is to increase efficiency and to achieve the quality of healthcare, its modernization, and improvement.

The systematic review aims to determine that RPM can contribute to improving the healthcare for patients with kidney disease. The main purpose of RPM is to increase efficiency and to achieve the quality of healthcare, its modernization, and improvement.

We decided to perform an exhaustive search in several databases such as Web of Science, PubMed, Scopus, Science Direct, SciELO, and Cochran Library to find papers concerning RPM as TIC intervention tool to manage Nephrology patients. To refine the research, we contacted some experts in Nephrology, from Portuguese organizations of Nephrology, Spanish organizations of Nephrology, and European Kidney Health Alliance (EKHA). We also participated in several scientific events on the subject of Nephrology around the world.

RPM – Remote Patient Management Intervention in Nephrology use to be performed using several kinds of ICT interventions tools.

RPM is a subcategory associated to homecare telehealth that enables patients to use mobile-related ICTs and technology to gather patient-generated health data (PGHD) and make it available to healthcare professionals. Common physiological data that can be collected with RPM programs include vital signs, weight, blood pressure, and heart rate. Once collected, patient data is available to a physician's office through the use of a telehealth computer system or software application that can be installed on a computer, smartphone, or tablet.

RPM is frequently used to assist healthcare professionals and their patients who require chronic or acute care. By connecting high-risk patients with remote monitoring, it can notify healthcare organizations of potential health issues or keep track of patient data between visits.18

This systematic review search was conducted by searching for studies published from 2005 to May 2022 in several electronic databases as mentioned above. Randomized, Non-randomized, Qualitative and Quantitative controlled trials describing an improved intervention using RPM (e.g., Home based RRT, Telehealth, Telemedicine, Tele-nephrology. mHealth, Self-Management). RPM in patients with some stage of kidney disease were included. Studies that assessed patients and/or HCPs using RPM and/or studies that involve any life-sustaining kidney or renal replacement therapy (e.g., kidney transplantation; pre-dialysis; hemodialysis or peritoneal dialysis) were eligible.

We used as the primary search term “Remote patient monitoring and management in kidney care”.

To refine the search and limit to the papers that fit our objective, we use the following specific terms:

• •

  “RPM” AND “Kidney Disease”; “Remote patient*” AND “CKD”; “RPM” AND “RRT”; “RPM” AND “HD”; “RPM” AND “PD”; “RPM” AND “HHD”; “RPM” AND “Dialysis” “RPM” AND “Kidney Transplantation”.

Nevertheless, the publications that we achieved by using those filters were not all entirely within the study scope.

Data extraction was independently performed by two reviewers that evaluate study quality and extracted characteristics, aims, outcomes, limitations, and among patients under RRT within the intervention of RPM for each trial. Reference lists from relevant review articles and reviews were also searched. Studies were first screened according to title and abstract, and the full texts of any study considered relevant according to the selection criteria were assessed for eligibility by both reviewers (AML and ARP). Disagreements between the reviewers concerning decisions to include or exclude studies were resolved by consensus, and if necessary, consultation with a third reviewer (JJSO).

The search strategy yielded 2774 records (see Fig. 1). After removing 248 duplicates and excluding 2357 articles in the title and abstract screening, we assessed 86 full-text articles for eligibility, including 8 records identified from searching the reference lists of included articles. Fifty-three articles did not meet the inclusion criteria, which led to 42 articles being included in the systematic review (Table 1 in the appendix).

Fig. 1.

Flow chart of search and study selection process.

From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71.

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Forty-seven studies, met the inclusion criteria involving, comprising a total of 5323 patients at any stage of kidney disease, taking into account all known types of treatment. The number of HCPs involved was only mentioned in three studies.19 Of those studies, some were quantitative, some used qualitative methods, and others adopted mixed methods. Most of the research originated in America (45%) and Europe (27%), the rest are from Asia (14%) and Australia (14%).

In some studies, more than one ICT Intervention is involved in RRT management. We found remote patient management (RRP) present in twenty-one studies; Telehealth in ten studies; Home Dialysis was found in ten studies as well; PC/Tablet/Mobil Phone applications in seven studies; web or Patient Portal in four studies; Telemedicine in five studies; Remote Management Therapy (RMT) in one study; Self-Management in one study; Tele homecare in two studies; and Artificial Intelligence in one study. The objective of RPM platform in all these studies was to improve healthcare for CKD patients.

Table 1 briefly lists most of these findings or outcomes, barriers, and limitations. One of the main challenges is a lack of comfort and familiarity amongst patients and nephrologists, probably due to inadequate education or information. Other common issues include a lack of trained and willing operators to place and troubleshoot dialysis accesses, as well as inadequate infrastructure to care for home dialysis patients.

We describe in the last column of Table 1 the limitations and future research to tackle these challenges and adopt strategies to overcome some of these limitations and expanded home dialysis.

The available results suggest that, overall, RPM can influence the healthcare of patients with kidney disease (e.g., improve access to healthcare services, enhance the quality of life, empower the individual to follow a healthy lifestyle, significantly reduce the rate of readmissions, decrease costs, and so forth). Despite the broad interest in the development of platforms of RPM in the clinical management of chronic diseases, only one specific investigation has been carried out on the use of RPM to prevent kidney disease and assist primary care physicians in its early detection.20 The purpose of this study was to fill this gap by exploring this issue using a systematic review approach.

In this systematic review, the outcome measures were deliberately kept broad to include all potential outcomes of RRT described in the literature. The review included qualitative studies, quantitative studies, including observational, quasi-experimental, and mixed-method study designs, as well as gray literature, and studies not written in English. Such heterogeneity is recommended against meta-analysis. Once duplicates were removed, the titles and abstracts were screened and, after that, full-text articles were assessed to establish eligibility for inclusion. Finally, verification was performed to avoid discrepancies.

Findings and types of outcomes

The included studies used RPM and its subcategory (e.g., Telehealth, mHealth, Home Dialysis, Telemedicine, Self-management), Interventions on Nephrology or RRT.

Overall, the included studies aimed to highlight the effects of using RPM to improve renal replacement therapy modalities.

The types of outcomes collected from the included papers embrace the following:

Outcome improvements were found in several studies affecting important treatment issues such as subjects adherence to treatments, care, therapy confidence, quality of life, patient autonomy, patient education, patient and staff satisfaction, home care patients, supply management, patient confidence, patients’ feeling of been connected with HCP, patient independence, prescription/treatment personalization.

Lower hospitalizations were mentioned as a consequence of ICT interventions in 5 studies in which the authors concluded that ICT intervention contribute to a reduction in hospitalizations, a fewer hospital consultation, and reduction of hospital workload and emergency visit.

Increase patient satisfaction and acceptance appear as outcome in the following studies in which telemedicine enable to increasing the nephrologist's coverage area and was positive mainly because it increase patient confidence and sense of care during HHD, reduces patient anxiety and increases confidence in the management of their chronic disease condition, tele-monitoring is a useful tool to increase satisfaction with and confidence in home hemodialysis, increased real-time communication between patient and the dialysis center.

Michel Rosner et al. (2019) and Paloma Gallar et al. (2007)21 mentioned that costs associated with patient travel was referenced as alleviated using RPM or Telemedicine. Sabina Manani et al. (2016) and some other studies found that healthcare costs decreased when using RPM tools for APD22 or mHealth for support CKD in general.23

RPM can improve outcomes and confidence in therapy and is useful tool to increase Satisfaction and confidence in home dialysis.24 Vishal Dey et al. (2016) concluded that satisfaction scores and retention rates suggest a high level of acceptability in PD.25 (Na Liu et al., 2017) come across that RPM made the HCP felt better assured with patients’ status with the use of system and reported improved productivity and satisfaction with the co-presence enhancement mechanism. In studying the effectiveness of a Web-portal eHealth for deliver care to home dialysis patients, (James Kiberd et al., 2018) note that ICT has been shown to improve self-management and in care satisfaction in a variety of settings, with evidence of improved health outcomes in chronically ill populations. The telemonitoring system for CKD patients undergoing PD present some better features such as: Consistency; interactivity, clarity, feedback, applicability; satisfaction, navigability and help documentation (Marcos Antonio García et al., 2018) is the best feature.

In some studies authors detected that RPM improves adherence to follow-up and reduces healthcare utilization and in presence visits for emergency,26 telehealth emphasizes its role in reducing hospital visits. Post discharge nurse-led telephone support is helpful for some aspect of quality of life and reducing readmission and clinic visits of patients on PD.

One of the main advantages of integrating RPM in PD is increased adherence to treatment, reduced travel time, reduced carbon footprint. The ecological advantages are debated but are likely to be relevant especially if patients live far from dialysis unit.27

Patient education was figured in some studies in which the authors concluded that the RPM increased the level of oversight and education, transferred patient medical information from the patient for the delivery of clinical and educational services with an aim to improve health outcomes. Wael Hussein et al. (2021)28 found that the home dialysis participants had higher proportions of younger patients, employment, and higher education and a lower proportion of Hispanic patients. Aditi Nayak et al. (2012) realize that the use of RPM for PD patients clearly demonstrates the clinical advantages of ICT in monitoring that patient population.

This study also suggests the need for additional HCP training and support to help ensure that mobile health communication can lead to significant improvements in patient experience with home dialysis care. Marco Landino et al. (2016) found that Tele-Nephrology may afford potential opportunities to reduce the cost of healthcare in patients with multiple renal conditions.

Most of the studies was performed in America (45%) followed by 26% performed in Europe. Asia and Australia contribute with 14% each one (see Fig. 2).

Fig. 2.

The geographic distribution of publications on world map. As some publications is shared by 2 countries, we considered 0.5 for each country sharing publication.

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Fig. 3 shows the evolution of publications from 2005 to 2022. The year 2016 with 8 published studies was the year with the highest scientific production in this field, followed by 2019 and 2020 with 6 publications.

Fig. 3.

Number of publications about RPM in nephrology per year from 2005 to 2022.

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PD is the RRT that experienced fastest penetration of ICT. The rapid evolution of this treatment modality has been facilitated by the development of new technology and by recent advances in prescription and monitoring. The half of includes studies (50%) is concerning RPM platforms for PD treatment and 25% is for HD (see Fig. 4).

Fig. 4.

RPM penetration – the RRT supported by RPM used in the studies. We used HD for hemodialysis, PD for peritoneal dialysis; TX for transplantation; pre-dialysis and CKD for studies that involve all kind of RRT.

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Our review of the studies in the previous section finds that all research, related to the RPM intervention in Nephrology, have reached an optimal solution to improve Nephrology healthcare relying on RPM solutions to support Renal Replacement. This study shows that peritoneal dialysis is the RRT modality in which RPM impact mostly.

Table 1 shows the main characteristics of the included studies taking into account the objective, lead author, countries and year of publication, the technologies used in the RPM platforms and the RRT, sample size and duration, when reported, findings, results, and finally gaps or limitations and future research.

This systematic review summarizes the literature on RPM intervention in Nephrology. The included studies focused on the role of RPM in supporting and improving healthcare in Nephrology. The increased use of RPM is leading to the need for healthcare professionals and patients to incorporate technological competence in the practice of different RRT modalities.

Overall, the evidence suggests that RPM has the potential to bring several improvements, as indicated in the Findings, Outcomes and Results column of Table 1.

Currently, the cost of technology to improve most treatments is too high to be borne by the public health system. Therefore, the best approach for kidney disease is to delay the need for dialysis as long as possible. The great challenge is to prevent kidney failure. The economic and environmental cost will be drastically reduced if we apply efforts in the development of RPM platforms to act in the prevention of CKD.

Systematic reviews are the ideal method to rigorously collating, examining, and synthesizing a body of literature. Systematic review methods now exist for most questions that may arise in healthcare. This systematic review found that the ICT intervention in RRT brings many benefits and provides an overview of studies investigating ICT-based interventions to improve the care of patients in need of RRT.

We observed that many home-based tools for nephrology or Renal Replacement Therapy have been developed and widely used by health professionals and patients needed kidney care. Another inference from these studies is that the promise of better outcomes and lower costs can be realized with these tools.

RPM platform to support RRT is getting more attention in nephrology care day by day. Several types of ICT interventions contribute to improving the care of patients who need renal replacement therapy, by improving the outcomes; reducing hospitalization; improve adherence to treatment; improve quality of life. Also reduce the cost of patient travel and the consequent footprint; improve the autonomy and confidence of the patient; better adequacy of the prescription; time saving for HCP and the patient as well. All the benefits listed come from the integration of RPM in the procedures of the nephrology units. Furthermore, RPM platforms can play a very important role in patient education, CKD self-management, home dialysis, tele-nephrology, and remote care of patients, which is a key factor for an effective management strategy to increase patient independence from nephrology units.

Studying the effectiveness of an eHealth web portal in delivering care to home dialysis patients29 note that ICTs have been shown to improve self-management and satisfaction with care in various settings, with evidence of improved health outcomes in populations with kidney disease. RPM or Telemonitoring30 system for CKD patients undergoing PD presents some of the best characteristics such as: Consistency; interactivity, clarity, feedback, applicability; satisfaction navigability and help documentation, noticed.

This study has several strengths. In the first place, the analysis of ICT interventions on all modalities of RRT. The second is the list of all identified benefits of ICT interventions on the disease that represent a big challenge worldwide for the current decade. Many previous studies only analyze the intervention of a specific ICT tool on a specific RRT modality. Our study also listed the limitations of the ICT interventions on the RRT. We concluded that there are about 10 most common types of ICT interventions in the RRT, and this may provide a reference for the future of ICT interventions in RRT. In addition, identified several benefits that ICT interventions bring to RRT. Overall, we conclude that ICT intervention in RRT is the cornerstone of kidney disease management, and optimized RRT management is essential to control the several comorbidities of kidney disease and improving kidney disease management.31

The results collected through this systematic review led to the identification of different advantages concerning the use of ICT in Nephrology care. It is remarkable to conclude that more than twenty-three percent of the included studies have health cost reduction32 as the outcome, and more than twenty-one percent present the improvement of quality of life33 as a finding.

Surprisingly, no studies were found on the use of RPM platform targeting the prevention of kidney disease, even though the progression control only two studies was found. In future studies, there is a need to focus on prevention, to delay disease progression as much as possible with the support of ICT interventions taking in account the new version of KDIGO guidelines that was recently presented at 60th Congress of the European Renal Association (ERA) in Milan.

Not applicable.

Not applicable.

AML conceived and conducted the study. JJSO and ARP reviewed and edited the manuscript and approved the final version of the manuscript. All authors contributed significantly to the study design. Material preparation, data collection and analysis were performed by AML, JJSO and ARP. The first draft of the manuscript was written by AML and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript, no other contributors assisted the authors in this work.

The authors did not receive financial support for the research, authorship and/or publication of this article.

The author(s) declared that there is(are) no potential conflict of interest with respect to the research, authorship and/or publication of this article.