Treatment Interventions

Although significant research exists on difficulties in psychosocial and cognitive adjustment in children with CKD, little research has been reported regarding treatment interventions. In fact, few CKD-specific data are available for either pediatric or adult populations, and studies of pediatric patients have generally been limited to single case studies or small case series.

Walker (1985) found that a group treatment of girls with CKD proved to be of therapeutic value in improving self-image and reducing levels of emotional stress. Wysocki et al. (1990) reported the results of a behavior modification approach for managing disruptive and noncompliant behaviors in four adolescent males undergoing hemodialysis. Results showed that all four subjects experienced improvements in either behavior or health status during the intervention, which was both inexpensive and well accepted by the patients, families, and staff.

More data have been reported on psychothera-peutic interventions in adults with CKD. Sleep disturbance, for example, is a commonly reported complaint of adults receiving dialysis (Iliescu et al. 2004; Novak et al. 2006). In a randomized, controlled prospective study, 24 adults who were undergoing peritoneal dialysis and who had insomnia were given a 4-week trial intervention with cognitive-behavioral therapy (CBT) (Chen et al. 2008). Results from the study included improvements in sleep quality and decreased daytime fatigue. In another investigation, a group CBT intervention was used to enhance adherence to fluid restriction in a group of adults receiving hemodialysis (Sharp et al. 2005). During the 4-week treatment, no significant improvement was seen in the immediate-treatment group when compared to a delayed-treatment group. However, the group receiving immediate treatment did demonstrate significant improvements at a 10-week follow-up assessment.

Investigations have shown some success in improving adherence to fluid restriction in adults. Hegel et al. (1992) compared a cognitive intervention with a behavioral intervention of positive reinforcement, shaping, and self-monitoring. They reported that the behavioral intervention was superior to the cognitive intervention in preventing long-term weight gain but that those subjects who received combined cognitive and behavioral interventions experienced no added benefit. Fisher et al. (2006) demonstrated long-term success in reducing volume overload in a small group of hemodialysis patients by using CBT techniques and motivational interviewing. Tong et al. (2008) conducted a systematic review of interventions for informal caregivers (family or friends) who care for CKD patients. They identified only three studies, all of which focused on the effect of educational material on caregivers' knowledge, and found that the provision of infor mation improved caregivers' knowledge. Further details of the individual and family therapy approaches for children with physical illness are given in Chapters 28 and 29, respectively.

Data are limited regarding pharmacological treatment in patients with CKD. In adults with ESRD, pharmacotherapy, including selective serotonin re-uptake inhibitors, is recommended when clinically indicated, and such treatment typically has no significant contraindications (Cohen et al. 2007). One study of adults receiving peritoneal dialysis demonstrated that depressive symptoms were markedly decreased following 12 weeks of treatment with sertraline, bupropion, or nefazodone (Wuerth et al. 2003). Further details on the pharmacological treatment of children with physical illness are given in Chapter 30.

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