Based on your ‘Practice Change Project’, elaborate an article for publication.

Final Practice Change Project Proposal

Implementing an Educational Intervention to Improve Healthcare Provider's Knowledge of Eating and Nutrition for Hemodialysis Patients.

(Final Proposal to the School of Nursing)

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In the medical field, making sure that hemodialysis patients get the food they need is very important for their health. Hemodialysis is very important for people with end-stage renal disease (ESRD), but making sure they eat well is very hard. Even though doctors and nurses play a big part in helping patients, studies show that they don't fully understand the food needs of this group.

This project offers an educational intervention that will help healthcare professionals learn more about what hemodialysis patients should eat and how to keep them healthy. By focusing on these information gaps, the intervention aims to give providers the skills they need to provide complete care, which will improve patient outcomes and quality of life.

Based on previous research, we explain why this kind of action is needed and suggest an organized learning program for healthcare professionals who work with hemodialysis patients. The goal of this program is to connect theory and practice by giving providers evidence-based tools and methods for dealing with the specific nutritional problems hemodialysis patients face.

This intervention aims to help people from different fields work together and share their ideas, including nephrologists, dietitians, nurses, and others. The goal is to get a full picture of how nutrition, kidney function, and overall health are all connected in the context of hemodialysis. We want to improve the level of care for hemodialysis patients by giving providers up-to-date information and useful skills. This will help them get the most out of their nutrition, avoid problems, and feel better overall.

Significance of the Practice Problem

Healthcare providers face a complex and demanding challenge with Chronic Kidney Disease Hemodialysis Dependent Patients (CKD), as patients necessitate specialized care for effective management of their advanced kidney disease (Adenwalla et al., 2024). Patients with Chronic Kidney Disease (CKD) who are dependent on hemodialysis receive superior treatment beyond standard medical attention. It becomes essential to use a multidisciplinary strategy that addresses the patient's psychological, social, and emotional well-being in addition to their medical needs (Bekker et al., 2023). It is imperative that healthcare personnel possess extensive knowledge and training in order to provide patients with Chronic Kidney Disease (CKD) who are dependent on hemodialysis with the best possible treatment. In addition to improving providers' competence in caring for Chronic Kidney Disease Hemodialysis Dependent Patients (CKD), the project at hand aims to optimize treatment outcomes, promote a patient-centered approach that goes beyond clinical measures, and ultimately improve the overall quality of life for those affected by CKD. It is designed to bridge knowledge and skill gaps among providers.

The goal of this initiative is to equip medical professionals with the fundamental know-how, abilities, and resources required to handle the complex requirements of patients with chronic kidney disease who are dependent on hemodialysis (CKD). We believe that by emphasizing education and training that addresses evidence-based approaches, effective communication, cultural competency, and holistic patient-centered care, we will better prepare our workforce to handle the particular difficulties presented by CKD. The potential for improving patient outcomes and increasing job satisfaction among healthcare personnel is emphasized. This could even have a significant impact on the transformation of care delivery for Chronic Kidney Disease Hemodialysis Dependent Patients (CKD) into a more comprehensive and compassionate approach, which could lead to the development of an effective model for improving clinical outcomes (Engle et al., 2021).

In order to optimize the care of patients who are dependent on hemodialysis for chronic kidney disease (CKD), a strong and comprehensive educational framework that provides healthcare personnel with advanced knowledge, skills, and a patient-centered approach must be established.

PICOT Question

For healthcare providers (P), does education on the National Institute of Diabetes and Kidney Diseases Health Information on Eating and Nutrition for Hemodialysis Patients (I), compared with no education (C), increase knowledge on self-management in End- Stage Renal Disease Patients (O), within 8 weeks (T)?

Theoretical Framework

The six areas of efficiency, safety, patient-centeredness, effectiveness, timeliness, and accessibility are becoming more and more critical in determining healthcare quality, and this has hastened change in the adoption of initiatives and the realization of their results to meet external standards. Because of this, theories of change are very pertinent to the field of medicine, particularly in addressing the evolving needs of complex services (Harrison et al., 2021)

Unfreezing involves creating awareness and motivation for change by destabilizing existing norms or practices (Datta et al., 2021). In the context of CKD HD-dependent patient services, this might involve highlighting the importance of continuous learning and improvement to enhance patient care outcomes.

The moving stage focuses on implementing the desired changes effectively (Hussain et al., 2020). This may entail providing educational resources, training programs, and support mechanisms to empower staff members to acquire new knowledge and skills related to CKD HD-dependent management and patient care. CKD HD-dependent services can adapt to evolving healthcare trends and improve patient care quality by fostering continuous learning and professional development.

The refreezing stage aims to solidify and integrate the changes into the organizational culture. This involves reinforcing new behaviors, norms, and practices through recognition, feedback mechanisms, and ongoing support (Lowe, M et al., 2022). By embedding educational actions within the fabric of CKD HD-dependent services, organizations can sustain positive changes over the long term and foster a culture of excellence and innovation.

Lewin's force field analysis idea offers a framework for determining the factors that propel and inhibit development in CKD HD-dependent services. Organizations may maximize the efficacy of their educational programs by proactively addressing obstacles and leveraging strengths by gaining insight into the elements that support or impede educational activities.

A practical quick list to implement this theory could be:

1. Determine the necessity of change and create a feeling of urgency.

2. Assist the change endeavor by assembling a coalition of important stakeholders.

3. Express the need for change and come up with a common future vision.

4. Give staff members the freedom to lead the transformation initiative.

5. Offer the tools and training required to help the change initiative.

6. Apply the modifications gradually and thoughtfully.

7. Evaluate the impact of the modifications and make any necessary corrections.

8. Strengthen the modifications via continued training, encouragement, and acknowledgment of accomplishments.

9. To ensure the long-term viability of the improvements, integrate them into the organization's culture (Hussain et al., 2020).

Organizations, whether they are part of the health system, can successfully manage change and achieve their desired outcomes by following these steps. It is important to note that change is a complex process that may require additional steps or modifications depending on the situation (Hussain et al., 2020). This model continues to be used in practice, inside and outside healthcare settings. A recent application of this model is stated in the work of Abd and colleagues (2019).

Lewin states that a cognitive action complex is formed when tasks are skillfully reorganized cognitively. This complex can be engaged with a "single impulse of will," which unleashes the behavior sequence subconsciously automatically.

The challenge facing criticism of his theory now, after a century of research that has yielded a plethora of fresh data contradicting some of its principles, is to show that the "hardcore" premise of action energization via association is tenable (Eder & Dignath, 2022). Lewin, a devoted experimentalist and a philosopher of science, would be pleased with these results. Once more, Lewin´s theory continues to be an early example of the contemporary action control viewpoint, which advocates carrying out a cognitively generated “action plan” with the least amount of conscious intervention.

Its validity and corroborated theory are the first reasons why it was decided to use this theory to potentialize and support this project.

Synthesis of the Literature

The Journal of Renal Nutrition released an article by Brauer et al. (2019) titled "Improvement in hyperphosphatemia using phosphate education and planning talks" that summarized their qualitative research. The goal of the study was to address the common problem of hyperphosphatemia in hemodialysis patients with end-stage renal disease. Conventional approaches, including phosphate binders and low-phosphate diets, frequently don't work. In order to tackle this issue, the research presented a unique strategy: a sequence of Phosphate Education and Planning (PEP) seminars that employ behavioral modification strategies to promote compliance with phosphate binders and dietary adjustments. The study included forty-six hyperphosphatemia hemodialysis patients who were eligible to undergo a four-talk PEP series with defined objectives for long-term serum phosphate level management. Serum phosphate levels were the main outcome measure used in the qualitative data obtained during each discussion. Patients who finished the complete PEP talk series showed a slight improvement (-0.31 mg/dL) in their serum phosphate levels. Patients noted that non-tailored prescriptions for phosphate binder and a dearth of resources for suitable dietary modifications were significant obstacles. In outpatient dialysis units, persistent hyperphosphatemia is successfully managed with the PEP talk series strategy. This strategy combines pharmacotherapy, dietary modifications, and behavioral interventions to identify patient-specific barriers and provide resources to overcome them, leading to long-lasting improvements in serum phosphate levels for hemodialysis patients experiencing persistent elevation (Brauer et al., 2019). Brown et al. carried out a review study that was methodical. In 2021, their findings were published in a publication titled "Dietary Interventions with Dietitian Involvement in Adults with Chronic Kidney Disease: A Systematic Review" in the Journal of Human Nutrition and Dietetics. In order to support dietary recommendations for managing adult chronic kidney disease (CKD), the study focused on the effects of dietary interventions with dietitian involvement on a range of outcomes, including renal risk factors, nutritional status, and clinical outcomes. Databases like the Cochrane Central Register of Controlled Trials, CINAHL, MEDLINE, PsycINFO, and EMBASE.com were among those they searched from January 2000 to November 2019. Intentional weight reduction and studies focusing on a specific nutrient were excluded, and bias was evaluated using the Cochrane risk-of-bias method. In individual investigations, effectiveness was evaluated by computing the mean difference between groups for each outcome. Twelve controlled trials with 1906 people were included in the study. The results showed that a multidisciplinary hospital and community care approach, along with a high fruit and vegetable intake, helped halt the decline in glomerular filtration rate in persons with stage 3–4 CKD. Patients receiving hemodialysis consumed more protein and calories when nutrition-related limitations were addressed. Additionally, the lipid profiles of kidney transplant recipients were improved by a Mediterranean diet and a diet high in n-3 polyunsaturated fatty acids. While a small number of research, mostly focusing on diet quality, revealed benefits from dietetic interventions provided by dietitians, there was no evidence addressing the main outcome of nutritional status or investigating the frequency and timing of nutritional assessments. This emphasizes the requirement for a larger, higher caliber body of evidence to back up recommendations made by dietitians about the type and dosage of dietetic interventions they should provide to adults with chronic kidney disease (Brown et al., 2021).

Chaiyakittisopon and colleagues, in 2021, published a significant article consisting of a systematic review and meta-analysis titled "Evaluation of the cost-utility of phosphate binders as a treatment option for hyperphosphatemia in chronic kidney disease patients: a systematic review and meta-analysis of the economic evaluations" in "The European Journal of Health Economics." Uncontrolled hyperphosphatemia in chronic kidney disease (CKD) patients is linked with vascular calcification and heightened risk of cardiovascular disease. Phosphate binders (PBs), including calcium-based (CBPBs) and non-calcium-based (NCBPBs) options, are commonly employed for hyperphosphatemia treatment. This study utilizes meta-analysis to assess the cost-utility of PBs in CKD patients with hyperphosphatemia.

Relevant studies published prior to June 2019 were gathered from PubMed, Scopus, the Cochrane Library, the National Health Service Economic Evaluation Database, and the Cost-Effectiveness Analysis Registry. Inclusion criteria comprised studies involving CKD patients with hyperphosphatemia, comparing various PBs, and reporting economic outcomes. Meta-analysis was utilized to aggregate incremental net benefit (INB), categorized by country income.

The analysis encompassed 25 studies with 32 comparisons. Lanthanum carbonate, an NCBPB, emerged as a more cost-effective option than CBPBs in high-income countries (HICs). As a second-line option for pre-dialysis patients, the pooled INB was $3984.4 (599.5–7369.4). As a second-line option, the INBs were $4860.2 (641.5–9078.8) and $4011.0 (533.7–7488.3) for upper middle-income countries. Sevelamer, another NCBPB, was not more cost-effective as a first-line option compared to CBPBs, with pooled INBs of $6045.8 (−23,453.0 to 35,522.6) and $34,168.9 (−638.0 to 68,975.7) in HICs and upper-middle-income countries, respectively.

Lanthanum carbonate exhibited significant cost-effectiveness as a second-line option for hyperphosphatemia in pre-dialysis patients in HICs. However, sevelamer was not found to be more cost-effective as a first-line option than CBPBs (Chaiyakittisopon, et al., 2021).

De Oliveira and colleagues conducted an integrative literature review, and the results of this research were published in 2020 in an article titled "Vitamin K Role in Mineral and Bone Disorder of Chronic Kidney Disease." This article was also be published in Clinica Chimica Acta in 2020.

In order to activate proteins involved in blood coagulation, apoptosis, bone mineralization control, and vascular health, vitamin K is an essential cofactor. Research indicates that matrix-Gla protein and activated osteocalcin play important roles in bone and vascular health, and that both are significantly impacted by chronic kidney disease (CKD). Because of things like poor vitamin K recycling, intestinal malfunction, and dietary limitation, chronic kidney disease (CKD) is a special case of vitamin K insufficiency.

This research examined the possible advantages of vitamin K supplementation for individuals with chronic kidney disease (CKD), taking into account the effects on mortality rates, vascular calcification, and bone quality. However, a number of matters need to be clarified. These include the best range of concentrations for supplementation in various CKD subgroups and standardized techniques for assessing vitamin K levels.

Examining the effects of vitamin K shortage and supplementation on CKD-associated mineral and bone diseases (CKD-MBD), the review digs into the body of scientific research already in existence. It is believed that both clinical research and basic science provide a thorough grasp of the topic.

Although clinical evidence indicates that vitamin K status in individuals with chronic kidney disease (CKD) is modifiable, more research is necessary to address concerns about the possible advantages of supplementing, ideal concentration ranges, and assessment techniques. This review offers views for further study in this field and sheds light on our present understanding of vitamin K's involvement in CKD-MBD (De Oliveira et al., 2020).

Garagarza and colleagues conducted a longitudinal prospective multicenter study over twelve months to ascertain the optimal nutritional pattern for hemodialysis patients. They authored a report titled "Mediterranean Diet: A Dietary Pattern Related to Nutritional Benefits for Hemodialysis Patients," published in the Journal of Renal Nutrition.

Despite recent recommendations suggesting the prescription of a Mediterranean diet pattern for adults with chronic kidney disease (CKD) not undergoing dialysis, evidence regarding specific dietary patterns for hemodialysis (HD) patients is lacking. The goal of this study was to determine the food habits of HD patients and examine the relationships between those habits and survival, physical activity, and nutritional status.

Over the course of a year, 582 HD patients from 37 dialysis facilities participated in the longitudinal prospective multicenter trial. Clinical indicators, food consumption, and physical activity were all included in the evaluation. Dietary pattern analysis was conducted using principal component analysis, with a p-value of less than 0.05 considered statistically significant.

Three dietary patterns became apparent: "Western," "Mediterranean," and "low animal protein." Patients in the group following the Mediterranean pattern consumed more protein (P =.040), omega-3 fatty acids (P <.001), and different vitamins (B12, B6, C, D, and folic acid) and engaged in more moderate physical activity (P =.010). Despite having fewer deaths, the lower mortality risk did not reach statistical significance in the Mediterranean pattern group (P = .096).

The Mediterranean dietary pattern was linked to a favorable nutritional intake profile and lifestyle factors, including increased engagement in moderate physical activity among HD patients. Although a lower mortality risk was observed in the Mediterranean pattern group, it did not reach statistical significance (Garagarza et al., 2023).

Guo and collaborators conducted a meta-analysis to investigate the impact of magnesium supplementation on chronic kidney disease. They published a report in the Journal of Renal Nutrition in 2023 titled "Effect of magnesium supplementation on chronic kidney disease-mineral and bone disorder in hemodialysis patients: A meta-analysis of randomized controlled trials."

This meta-analysis sought to investigate the effects of magnesium (Mg) supplementation on various indicators related to chronic kidney disease-mineral bone disorder (CKD-MBD) in individuals requiring dialysis, in light of the contradictory research on the subject among hemodialysis (HD) patients.

A search for English-language research up to September 2020 was done using the PubMed and EMBASE databases. Changes in serum magnesium, calcium (Ca), phosphate, parathyroid hormone (PTH), C-reactive protein, and carotid intima-media thickness (CIMT) after magnesium supplementation were important markers. Using subgroup analyses depending on the kind and duration of the intervention, weighted mean difference (WMD) and confidence intervals (CIs) were used to assess the efficacy of magnesium.

The meta-analysis comprised eight studies with 309 HD patients. Mg supplementation alone exhibited a negative effect on serum PTH levels (WMD = -236.56; 95% CI -349.71 to -123.41) and CIMT (WMD = -0.18; 95% CI -0.34 to -0.01). Subgroup analysis by intervention type revealed significant improvements in serum Mg (WMD = 1.08; 95% CI 0.51-1.64) and Ca (WMD = -0.50; 95% CI -0.77 to -0.23) levels when Mg was administered via dialysate and oral medication, respectively. Different intervention durations had no impact on serum Mg levels. Mg supplementation showed no significant effect on serum phosphate (WMD = -0.25; 95% CI -0.64 to 0.14) and C-reactive protein levels (WMD = -0.02; 95% CI -2.80 to 2.76). Magnesium g supplementation alone positively modulated CKD-MBD by regulating serum Ca and PTH metabolism and reducing CIMT in HD patients (Guo et al., 2022).

Hiramatsu and colleagues conducted a noncontrolled observational study involving 47 hemodialysis patients. After their investigation, they published an article titled "Hypocalcemia and bone mineral changes in hemodialysis patients with low bone mass treated with denosumab: a 2-year observational study" in "Nephrology Dialysis Transplantation."

Hemodialysis patients with chronic renal disease have observed increases in bone mineral density (BMD) after a single denosumab dose, as well as a higher rate of denosumab-associated acute hypocalcemia (DAAH). This study sought to evaluate the long-term effects of denosumab on bone mineral density in patients receiving hemodialysis as well as clinical risk factors linked to diabetic acute anemia. There was a non-controlled observational research done on 47 hemodialysis participants. Using multivariate regression analysis, independent risk factors for percentage increases in serum calcium (Ca) levels associated with denosumab were identified. In order to determine the best prognostic indicators for DAAH, receiver operating characteristic analysis was used. Furthermore, throughout a 24-month period, percentage changes in BMD at the lumbar spine (LS) and femoral neck (FN) were assessed.

After denosumab, the incidence of DAAH (serum corrected Ca ≤8 mg/dL) was 25.5%. The results of multivariate regression analysis showed an independent correlation (β = -0.407, P = 0.008) between baseline bone alkaline phosphatase and percentage changes in corrected Ca levels. With an ideal cut-off level of 670 mU/mL with sensitivity of 0.727 and specificity of 0.733, tartrate-resistant acid phosphatase-5b was found to be the most accurate marker for DAAH prediction, with an area under the curve of 0.750 (95% confidence interval 0.546-0.954; P = 0.02). At 24 months, BMD rose significantly by 5.9 ± 1.7% (P = 0.01) at LS and 4.2 ± 1.5% (P = 0.04) at FN.

In hemodialysis patients, high bone turnover emerged as an independent risk factor for denosumab-induced declines in serum calcium. Despite DAAH concerns, denosumab significantly increased BMD at both the lumbar spine and femoral neck over a 24-month period (Hiramatsu et al., 2021).

In 2019, Hjemås and a group of collaborators conducted a research study to investigate patient knowledge, beliefs, and adherence to phosphate binders in chronic dialysis patients and assess the impact of one-to-one pharmacist-led education and counseling on adherence and serum phosphate levels. The study was titled “Interventional study to improve adherence to phosphate binder treatment in dialysis patients.”

A single-arm, pre-post study involving chronic dialysis patients (≥18 years) using phosphate binders was conducted at a Norwegian hospital. The primary endpoint was the change in the proportion of patients achieving serum phosphate levels below 1.80 mmol/L. Changes in patient beliefs, knowledge, and adherence as determined by questionnaires (Patient Knowledge, Medication Adherence Report Scale – MARS-5, Beliefs about Medicines Questionnaire – BMQ) were among the secondary objectives. Before and after pharmacist-led instruction, data were gathered, and additional drugs taken were registered.

There were 69 patients in the trial. Although not statistically significant, there was a higher likelihood of obtaining serum phosphate levels < 1.80 mmol/L following the intervention. Patients' views on the need for therapy and their knowledge of phosphate binder treatment both rose, but their fears declined (BMQ). Nevertheless, as self-reported adherence was already high prior to the intervention, this did not result in a statistically significant increase as measured by MARS-5.

The likelihood of reaching goal serum phosphate levels was increased by brief, one-on-one instruction from pharmacists, however this effect was not statistically significant. The average serum phosphate levels did not drop, and the degree of self-reported adherence did not decline. However, patients demonstrated increased knowledge about phosphate binders, improved understanding of adherence, and reduced concerns about medication side effects (Hjemås et al., 2019).

Kendrick and colleagues conducted a study titled “A one-year historical cohort study of the phosphate binder sucroferric oxyhydroxide in patients on maintenance hemodialysis” aimed to evaluate the real-world effectiveness of sucroferric oxyhydroxide (SO), a phosphate binder with a low pill burden, in managing serum phosphorus in prevalent hemodialysis patients over one 1-year. This involved historical cohort analyses based on de-identified electronic medical records.

In-center hemodialysis patients who transitioned from another phosphate binder to SO therapy as part of routine care, with 12 months of uninterrupted SO prescriptions recorded and documented serum phosphorus levels, were eligible for inclusion. The 91-day window prior to SO beginning (baseline) and four successive 91-day windows of SO therapy (Q1–Q4) were compared in the study. Achieving target phosphorus levels (≤5.5 mg/dL) and the average number of daily phosphate binder pills were important outcome metrics.

The percentage of the 530 patients who underwent analysis reached target serum phosphorus levels more than twice a year after beginning SO therapy; this increased from 17.7% at baseline to 24.5%, 30.5%, 36.4%, and 36.0% at Q1 through Q4 (P <.0001 for all). Regardless of the baseline phosphate binder, decreases in serum phosphorus were seen at all follow-up time periods (P <.0001). During SO therapy, patients' average daily pill burden decreased by 50% (P <.0001) compared to a mean baseline of 8.5 tablets. After switching to SO, there was a significant improvement in phosphorus-attuned albumin and protein consumption (P <.0001). For patients who were women, Hispanic/Latino patients, and black/African-American patients, among other predefined categories, SO's efficacy was constant.

Hemodialysis patients who switched to sucroferric oxyhydroxide had a two-fold increased chance of reaching target phosphorus levels with a reduction of the daily pill burden associated with phosphate binder. Increased nutritional status is suggested by improvements in phosphorus-sensitive albumin and protein intake (Kendrick et al., 2019).

In 2019, Ketteler and colleagues investigated the Long-Term Impact of Phosphate Binders on Mineral and Bone Disorder Indices in Dialysis Patients Suffering from Hyperphosphatemia in Chronic Kidney Disease. Their subsequent publication in Nephrology Dialysis Transplantation was titled "Effects of sucroferric oxyhydroxide and sevelamer carbonate on chronic kidney disease–mineral bone disorder parameters in dialysis patients."

In order to assess the impact of a year-long treatment with phosphate binders, such as sucroferric oxyhydroxide or sevelamer carbonate, on chronic kidney disease-mineral and bone disorder (CKD-MBD) indicators among dialysis patients with hyperphosphatemia, a post hoc analysis of a randomized Phase 3 research was conducted. In this investigation, following a 2- to 4-week washout from prior phosphate binders, 1059 individuals were randomized to receive either sevelamer or sucroferric oxyhydroxide for up to 24 weeks. A 28-week extension was offered to eligible patients, and the analysis was restricted to those who finished ≥1 year of nonstop treatment (n = 549).

Significant and long-lasting 30% decreases in serum phosphorus were observed with both the sucroferric oxyhydroxide and sevelamer treatments (P < 0.001). Over the course of a year, there was a significant 64% drop in median intact fibroblast growth factor-23 (FGF-23) (P < 0.001). After 24 weeks, intact parathyroid hormone dropped dramatically (P < 0.001), but by Week 52, it had nearly restored to baseline levels. There were not much changes in the serum calcium levels. Tarrate-resistant acid phosphatase 5b (TRAP5b) was the bone resorption marker that showed the greatest drop (P < 0.001), although CTx showed a brief increase before reaching baseline levels by Week 52. Over the course of a year of treatment, the bone-specific alkaline phosphatase and osteocalcin indicators increased.

Overall, a year of treatment with sevelamer or sucroferric oxyhydroxide led to marked decreases in serum FGF-23, which is linked to clinical benefits in patients with chronic kidney disease (CKD), as well as a trend toward higher markers of bone formation, suggesting a possible positive impact on bone metabolism (Ketteler et al., 2019).

Li and associates conducted research to determine whether ferric citrate is effective in treating anemia and hyperphosphatemia in individuals with chronic kidney disease (CKD). The Renal Failure Journal published the compilation and analysis of the meta-analysis's findings under the heading "Ferric citrate for treating hyperphosphatemia and anemia in patients with chronic kidney disease: a meta-analysis of randomized clinical trials".

Anemia and hyperphosphatemia are common CKD consequences that are linked to a higher risk of cardiovascular events. Ferric citrate (FC), an iron-based phosphate binder, has been linked to improvements in anemia and hyperphosphatemia in earlier research.

Up until February 21, 2022, a thorough search of the literature was done using databases such as PUBMED, EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials (CCRCT). The goal of the meta-analysis was to evaluate the safety, effectiveness, and financial benefits of treating CKD patients with hyperphosphatemia and anemia with ferric citrate. RevMan (version 5.3) was used for the analysis by two separate reviewers.

The analysis includes 16 randomized clinical trials (RCTs) with a total of 1754 participants. Ferric citrate was found to s

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