Renal Health - A New Tool for Chronic Kidney Disease:

Application Development and a Proposal for Interventional Study

Juliana Gomes Ramalho de Oliveira

, José Eurico Vasconcelos Filho

and Geraldo Bezerra da Silva

Junior

Public Health Graduate Program, University of Fortaleza. Fortaleza, Ceará, Brazil

Laboratory of Innovation in Information Technology, University of Fortaleza. Fortaleza, Ceará, Brazil

School of Medicine, Public Health and Medical Sciences Graduate Programs, University of Fortaleza. Fortaleza, Brazil

Keywords: Chronic Renal Insufficiency, Health Education, Biomedical Technology, Dialysis, Kidney Transplantation.

Abstract: The aim of this study was to create an application for smartphones for chronic kidney disease (CKD). The

development of the application was conducted in three phases: data collection, conception and development

of an application called “Renal Health”. In the first phase, a literature review was conducted to ground the

necessity of a tool to teach the general population about CKD and to give support to CKD patients in their

treatment. Semi-structured interviews were then conducted with CKD patients (in hemodialysis or kidney

transplant) and the general population to enhance out understanding of the main knowledge gaps about

kidney disease. Individuals without CKD reported not knowing the disease (66.7%). Patients on

hemodialysis reported difficulties with medication intake and diet (>50%). Transplanted patients had no

problems with medication intake and showed to want more nutritional advices. After the development of the

application, an usability test was done with CKD patients and specialists to evaluate its clarity and

performance, and its acceptance was 89.6%. The use of Renal Health application can be an important tool

for the general population, for knowledge acquisition, patients, health care workers, as well as patients’

family and caregivers of elderly and children patients.

1 INTRODUCTION

Chronic kidney disease (CKD) is defined as the

presence of abnormalities in structure or function of

the kidneys for more than 3 months. Its classification

is based on cause, glomerular filtration rate (GFR)

and albuminuria (KDIGO, 2013). Its high incidence

and prevalence puts CKD as a severe public health

problem worldwide (Garcia-Garcia; Jha, 2015).

Access to renal replacement therapy (RRT),

which includes hemodialysis (HD), peritoneal

dialysis and kidney transplantation, is still unequal

in the world. In countries such as Peru, for example,

there is approximately 50% of the population

without access to CKD treatment (Herrera-Anazco

et al., 2015). In the Latin-American Dialysis and

Transplantation Registry it is observed that HD is

the treatment of choice in the region (75%) and the

prevalence of RRT is related with the gross national

product and the life expectancy (Pecoits-Filho, et al.,

2015). Regarding data from Brazil, according to the

Brazilian Dialysis Census, the number of patients

receiving dialytic treatment in 2015 was 111,303

(SBN, 2015) and according to the Brazilian

Association for Organ Transplantation, a total of

5,556 renal transplantations were done in 2015,

which is far from the real requirement in this country

(ABTO, 2015).

RRT is recognized by the high demand of care,

such as maintenance of specific diet for metabolic

equilibrium, liquids consumption control, vascular

access care, assiduity to the dialysis sessions and

medical follow-up consultations, adhesion to drug

therapy and comorbidities control (hypertension,

diabetes and others). This complex context demands

a high level of involvement by patients and parents

for the self-administration of health care (Jain et al.,

2016).

To decrease the incidence of CKD

complications, one alternative is to put together the

therapeutic options and technology. We believe that

Oliveira, J., Filho, J. and Junior, G.

Renal Health - A New Tool for Chronic Kidney Disease - Application Development and a Proposal for Interventional Study.

DOI: 10.5220/0006533302610265

In Proceedings of the 11th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2018) - Volume 5: HEALTHINF, pages 261-265

ISBN: 978-989-758-281-3

261

patients with CKD need a better knowledge about

their disease, having access to technological tools

containing clear and secure information about the

disease, such as etiology, risk factors, signs and

symptoms, treatment and preventive measures.

The aim of this study was to build a health

technology (mHealth) about CKD, incorporating

information and services to help patients with CKD

to manage their treatment and also give information

to the general public, through an application for

smartphones.

2 METHODS

The development of the application, which we called

“Renal Health” was conducted in three phases: data

collection, conception and development of a

technological artifact (application for smartphones)

and evaluation of the application. In the first phase, a

literature review was conducted to ground the

necessity of a tool to teach the general population

about CKD and to give support to CKD patients in

their treatment.

2.1 Data collection

Initially a literature review was done to investigate

the necessity of the application. After this, semi-

structured interviews were done with CKD patients

(in hemodialysis and kidney transplanted patients)

and the general population to know the main

knowledge gaps about kidney disease. The sample

size was defined by saturation, a method that stops

new inclusions based on repetition of answers

(FONTANELLA; RICAS; TURATO, 2008). The

general population sample was randomly assigned in

public places, and the patients were randomly

chosen from different healthcare facilities.

2.2 Conception and design of the

application

This was a laboratory phase, conducted at the

Laboratory of Innovation in Information

Technology, University of Fortaleza, Brazil, from

July to October 2016, based on user’s centered

interaction design (PREECE et al., 2013). This

method is composed by four activities: identify the

necessities and establish requirements, design and

redesign of the artifact, building of an interactive

version (functional prototype) and evaluation

(usability).

2.3 Evaluation of the application (test

with specialists)

A test with specialists in Nephrology (Physicians,

Nurses, Nutritionists and Psychologists) was

conducted to assess their opinions about the

applications and which changes they would advise to

improve the application. Selection criteria were

being a specialist and work in the area for more than

5 years. This test was done to evaluate the content

and usability of the application.

3 RESULTS AND DISCUSSION

In the first phase, a total of 30 individuals without

CKD and not on treatment were interviewed. The

main characteristics of this sample are summarized

in Table 1.

Table 1: Main characteristics of the interviewed

individuals without chronic kidney disease (CKD),

Fortaleza, Brazil, 2016.

Characteristics

Mean±SD or n (%)

Age

35.8±7.9

Gender

Male

Female

21 (70)

9 (30)

Marital status

Single

Married

Others

17 (56.7)

10 (33.3)

3 (10)

Religion

Catholic

Evangelicalism

Others

20 (66.7)

6 (20)

4 (13.4)

Schooling

Elementary school

High school

College

3 (10)

17 (56.7)

10 (33.3)

The majority of them (66.7%) reported not to

know about CKD; 40% said not to know its risk

factors and 53.3% associated CKD to the low water

consumption. Regarding prevention, 53.3% reported

not to know; 60% cited interest in knowing how to

prevent CKD, and 43.3% wanted to know its causes.

Past studies evidences that knowledge by the

general population about CKD is limited (Wang et

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al., 2015; Stanifer et al., 2016; Roomizadeh et al,

2014), including people with its main risk factors –

hypertension and diabetes (Oluyombo et al., 2016).

These facts, along with the increasing CKD

incidence, lead us to the reflection that giving more

information to people and increasing “knowledge in

health” (“health literacy”) can stimulate the adoption

of preventive measures and capacitate people to take

better decisions about life style and health care.

Among patients in HD, 73% were males, with

mean age of 32.7 years. Mean time on dialysis was

6.3 years. Regarding medications, 53.8% reported

difficulties in controlling its intake, half of them

reported difficulty to adopt the prescribed diet and

56.7% said not to have problem in controlling water

intake. Regarding information that they would like

to receive about CKD and its treatment, half of the

interviewed cited diet/feeding and 23% reported

other treatment modalities, with emphasis in renal

transplantation.

Due to the complexity of the ideal “renal diet”, a

multidisciplinary work with General Physicians,

Nephrologists and Nutritionists is essential to

achieve an adequate care for people with CKD (Lu;

Vakilzadeh; Teta, 2015; Martins, 2013).

A total of 7 renal transplant patients were

interviewed, of whom 5 were females, with mean

age of 41.1 years. Mean time of transplantation was

10.4 years. Regarding assiduity to post-transplant

medical consultations, all interviewed said not to

have problems, and the majority (4) reported not

having difficulties to take medications. Regarding

information they would like to have, the majority

cited nutritional orientation.

In the second phase of the study, based on phase

1 results (expressed in Table 2), an application was

developed, which was called “Renal Health”.

Table 2: Main doubts about chronic kidney disease (CKD)

found among interviewed individuals (general population,

patients in hemodialysis and renal transplantations),

Fortaleza, Brazil, 2016.

Participants

Main doubts about CKD

Individuals without

CKD

Preventive measures, Causes,

Symptoms, Treatment

Patients with CKD

in hemodialysis

Diet/feeding, Renal

transplantation, Complications

during dialysis sessions, Blood

pressure control, Causes of disease

Sports practice

Renal transplanted

patients

Diet/feeding, Transplantation

complications, Drugs that must be

avoided, General advices

In the third phase of the study, with Nephrology

specialist (2 Physicians, 2 Nurses, 1 Psychologists

and 1 Nutritionist), the validation instrument was

organized according to Likert scale, which is a

technique with items expressing a point of view

about an issue. In this method the items are

expressed in a positive or negative way about an

issue (Nascimento, 2012). In the evaluation

questionnaire we have included 4 degrees of score

were included to judge the application: 1=

inadequate; 2= partially adequate; 3= adequate; 4=

totally adequate. The evaluators have tested the

application one single time, and they have answered

questions regarding all the interfaces of the

application and the contents displayed.

The application have acceptance of 89.6%

according to specialists evaluation. This was a mean

of the scores rated by specialists. The item with the

lowest score was related to language adequation, and

it was suggested to improve language and font size

to a better understanding of users.

The main screens can be seen in Figure 1.

Renal Health - A New Tool for Chronic Kidney Disease - Application Development and a Proposal for Interventional Study

263

Figure 1. Renal Health application’s screenplays samples.

In the first interface the user have the options for

connecting as “hemodialysis patient”, “transplanted

patient”, “conservative treatment” (people with

CKD not yet on dialysis) or “general population”

(just to get information about CKD and access

laboratory data regarding renal function). It is worth

mentioning that the interface for the general

population will inform the users if they need a

medical consultation. When laboratory tests point to

any abnormality, the application will advice for a

medical consultation. In the dialysis interface, the

user can access a tool for liquids intake, which is

illustrated by a glass of water, informing when the

limit is achieved. This is important because people

on dialysis should have a strict control on liquids

intake in order to prevent fluid overload. Regarding

medication intake, it will be available for both

dialysis and transplant users. Patients can insert the

names and the time of medication intake. The

application will remember when it is time to take teh

medications through alarms and it will also give

information about the medications (its actions, side

effects and other information for patients). Other

interfaces include laboratory tests information,

displaying graphics illustrating the evolution of each

test. It is important because both dialysis and

transplanted patients need to have laboratory tests

every month, and this tool will help to evaluate and

interpret each test.

The application is also intended to interact with

the users, by displaying alarms on medications and

medical consultations, for example. It will also be

connected with some devices to improve adherence

to medication. One of de devices that will be

developed is the “medication smart box”, which will

be connected to the application by Bluetooth. The

aim of this medication box is to detect every time

the patients take the medications, so that it will be

possible to exactly measure medication’s adherence.

The prototype of this box can be seen in Figure 2.

Figure 2. Prototype of the medication smart box to be

connected with Renal health application.

The Renal Health application will be adjusted,

based on patients and health professionals advices

and will be tested in a large number of patients in the

settings of hemodialysis and kidney transplant. The

next phases of this study consists in the

improvement of the application, with the initial

version developed in Portuguese (in Brazil) and an

administrative tool on the web using JAVA

platform. Further translation to English and Spanish

will be done, and new tests will be conducted in

other countries. The data are entered manually in the

application by the patients, automatically, through

the application synchronization to the network of

laboratories responsible for analyzing the monthly

tests, as well as being continuously recorded by

biosensors (blood pressure, heart rate, arrhythmia

detection, weight, percentage of body fat and water).

For people without CKD the application focus on

preventive measures and tools to help interpret

diagnostic tests for kidney function, basically serum

creatinine, glomerular filtration rate and urinalysis.

4 CONCLUSION

There are many gaps in the knowledge about CKD

for both the general population and patients with

CKD, which difficult disease prevention and

treatment. We believe that the use of “Renal Health”

application can be an important tool for the general

population for the acquisition of knowledge about

CKD, as well as for patients, health care workers,

family and caregivers. A prospective longitudinal

study is being proposed to investigate if the

application has a positive impact in clinical

outcomes among patients in dialysis and after kidney

transplantation. We suppose that the use of this

application can decrease CKD complications and

possibly also decrease mortality.

ACKNOWLEDGEMENTS

We would like to thank the International Society of

Nephrology, which is providing financial support for

the development of the next phases of this study

through its Clinical Research Program (Project

number 17-02-0155_BR_Renal Health self-

monitoring application), the Brazilian Society of

Nephrology and the Edson Queiroz

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Foundation/University of Fortaleza, which also

supports this project.

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