An Educational Nursing Program to Improve Self-Care in Chronic Kidney Disease: A Multiple Case Study

Abstract

The rising prevalence of CKD, particularly within aging populations, demands effective and accessible self-management strategies. Three middle-aged and older adult inpatients (one female, two males; mean age 58.6 years ± 23) with CKD and preserved cognitive capacity (Mini-Mental State Examination) participated. A multiple case study was conducted in a Portuguese nephrology unit between November 2024 and February 2025, utilizing baseline assessments that included the Braden, Barthel, and Morse scales, as well as the KDQOL-SF. A targeted educational program addressed key CKD management aspects: disease understanding, vascular access care, medication regimens, and dietary restrictions. Pre- and post-intervention assessments measured knowledge gains. Results indicated improvements in participants’ knowledge and self-management capabilities across several domains. These included enhanced understanding of the disease process, vascular access for hemodialysis, dietary requirements, and fluid restrictions. Participants also demonstrated improved self-assessment of support systems, coping mechanisms, and family involvement. A 15% average increase in knowledge scores post-intervention was observed. This study provides preliminary evidence supporting the efficacy of a structured educational nursing program in improving CKD self-management. The significant improvements in knowledge and self-reported confidence suggest that targeted education is a valuable component of comprehensive CKD care. Future research should incorporate larger, more diverse samples and explore the long-term impact of the intervention. Furthermore, the integration of technological tools, such as personalized learning platforms and digital health, holds a significant promise for enhancing the accessibility and effectiveness of such educational programs.

1. Introduction

Chronic kidney disease (CKD) represents a significant and escalating global health challenge, affecting over 800 million individuals worldwide, equating to more than 10% of the population. This pervasive burden, coupled with the profound negative impact of CKD on quality of life and healthcare systems, necessitates innovative approaches to prevention and treatment strategies [1]. In Portugal, the epidemiological landscape reflects this global trend; data from the Portuguese Society of Nephrology’s Chronic Kidney Disease Registry Office reported 2208 new hemodialysis patients in 2023, contributing to a total prevalence of 13,087 patients. Notably, Portugal stands among European countries with a high prevalence of individuals undergoing renal replacement therapy, experiencing a 1.6% increase compared to 2022, albeit with a continuing decline in the mortality rate (12.4%) and an average hemodialysis patient age remaining high at approximately 68 years [2].

Effectively managing chronic diseases like CKD poses one of the most substantial challenges to contemporary health systems [3]. It is increasingly recognized that individuals living with chronic conditions possess unique and evolving needs, demanding regular, continuous, and systematic monitoring [4,5]. Such care must be inherently geared towards fostering patient empowerment, enhancing self-management capacities, and facilitating sustainable behavioral change. The prevailing scarcity of healthcare resources further accentuates the imperative for highly efficient and effective care delivery models. This drives the continuous pursuit of sustainable, person-centered health services that optimize the management of cases through the judicious utilization of available resources [6]. Within this context, promoting continuous quality improvement in care, particularly within hemodialysis units, becomes paramount, necessitating the adoption of new care models that also champion robust communication among the multidisciplinary team, the patient, their family, and caregivers [7].

Nurse-led case management emerges as a critical strategy to address the multifaceted challenges posed by CKD, aiming to optimize patient outcomes, mitigate care fragmentation, and cultivate self-care competencies, particularly among patients undergoing hemodialysis [8]. A synthesis of recent evidence highlights several facilitating strategies integral to comprehensive nurse-led interventions, broadly categorized into core domains: (i) the implementation of structured care models; (ii) the application of motivational interviewing techniques; (iii) the provision of targeted health education programs; (iv) the integration of psychosocial support; (v), and the commitment to continuous clinical monitoring and evaluation [9]. For instance, structured nursing protocols have been shown to reduce symptom burden and improve therapeutic adherence [10], while person-centered communicative approaches like motivational interviewing foster behavioral change and regimen adherence by supporting realistic goal setting [11]. Health education, foundational to self-management, enhances informed decision-making [12]. Addressing psychosocial needs is crucial given the high prevalence of distress in CKD patients, with comprehensive nurse-led interventions improving emotional well-being [11]. Continuous monitoring facilitates early complication detection and adaptive care planning [10]. This body of evidence collectively underscores the potential of structured educational nursing interventions grounded in these evidence-based strategies to strengthen patient autonomy, improve quality of life, and enhance clinical outcomes for individuals living with CKD [13].

For nurses to effectively lead these interventions, the development of comprehensive intervention plans, rooted in a care partnership framework that prioritizes safety and quality, is essential. Such plans must conscientiously account for the limitations imposed by chronic illness and integrate effective management strategies. Theoretical nursing models, such as Dorothea Orem’s Self-Care Deficit Theory [14] and Idalina Gomes’ Theory of Self of the Care [15], provide helpful guidance. These models emphasize nursing interventions by promoting the concept of self-care and fostering a collaborative partnership between the patient and their family in managing their health, thereby facilitating better adaptation to the state of health/illness. Gomes’ [15] model, with its five phases of construction and intervention—revealing oneself, getting involved, empowering or enabling, committing oneself, and taking care of oneself or ensuring the care of others—specifically promotes adaptation and encourages the development of personal skills for decision-making aimed at improving quality of life, while also empowering patients with greater capacity to manage their disease process. Nurses, therefore, must cultivate leadership skills to ensure coordinated and integrated service delivery, meticulously analyzing, coordinating, planning, and evaluating available options to ensure patients’ access to necessary resources for comprehensive care and effective chronic disease management [16]. This study aims to describe the effects of a nurse-led educational program in enhancing self-care capacity among hospitalized patients with chronic kidney disease.

2. Materials and Methods

The methodology follows multiple case studies, which are a descriptive and exploratory method widely used in nursing to explore and describe health phenomena in real contexts, allowing for an in-depth understanding of case management and its effects on small samples [17,18].

2.1. Sample

The study sample consisted of three people admitted to a Medical Specialties Service of a Local Health Unit in Lisbon and Vale do Tejo, diagnosed with chronic kidney disease.

The study included individuals aged 18 years or older who agreed, after receiving informed consent, to participate and who had preserved cognitive ability as assessed by the Mini-Mental State Examination (MMSE ≥ 23 points), a reference value considered the cut-off for suspected cognitive impairment [19,20]. The sample was non-probabilistic for convenience [21].

2.2. Data Collection Instruments

The cases of three patients with chronic kidney disease, admitted to a Medical Specialties Service at a Hospital Centre in the Lisbon and Tagus Valley region, were analyzed during the period from 15 November 2024 to 28 February 2025. This study was previously authorized by the Ethics Committee of the Local Health Unit, with a favorable judgment no. 014P/CE/INV/2024. Data collection was carried out by obtaining informed consent, signed by the researcher and the person under study, thus ensuring compliance with the ethical principles of research, namely confidentiality and anonymity, using fictitious codes (A1, A2, and A3).

Data collection was carried out using the Kidney Disease Quality of Life–Short Form Questionnaire [22], to assess the perception of quality of life related to chronic kidney disease and the use of various assessment scales: the Morse Scale [23], to identify the risk of falls; the Braden Scale [24], to assess the risk of pressure ulcers; the Barthel Index [25], to assess the degree of dependence in activities of daily living; and the Medication Adherence Scale [26], which allowed the level of therapeutic adherence to be assessed.

To assess the impact of a structured nursing intervention focused on self-care education in individuals with chronic kidney disease (CKD), a tailored questionnaire was implemented based on ICNP^® nursing diagnoses and levels of dependency. The instrument comprised four key dimensions, encompassing a total of 19 items. The first dimension evaluated general knowledge about CKD, including understanding of its pathophysiology, etiology, risk factors, clinical manifestations, and perceived impact on daily functioning. The second dimension assessed knowledge regarding vascular access for hemodialysis, including awareness of the types of access, associated care practices, and the adequacy of the information received. The third dimension focused on nutrition and hydration, measuring participants’ knowledge and self-reported practices related to dietary restrictions and fluid management. The fourth and final dimension addressed disease management and psychosocial support, capturing emotional well-being, satisfaction with care, family involvement, and motivation to acquire further knowledge about the disease.

Responses were recorded using a transformed Likert-type scale aligned with dependency levels: scores ranging from 64 to 100 indicated mild dependency, 34 to 63 moderate dependency, and 0 to 33 severe dependency. Higher scores reflected greater knowledge, confidence, or agreement with the statements. This scoring framework enabled a more nuanced analysis of changes in participants’ knowledge and self-management abilities before and after the educational nursing intervention.

2.3. Procedures

To contextualize the intervention, it is pertinent to describe the usual care protocol on the inpatient ward where the study was conducted. Standard care for patients with chronic kidney disease (CKD) admitted to the unit primarily focuses on managing the acute condition that prompted hospitalization. This includes daily medical rounds, which involve comprehensive 24 h nursing support, encompassing the management of the clinical plan while attending to the patient’s comfort and psychosocial needs. The plan is supported by integrated input from a multidisciplinary team, including nutrition and physical therapy, as required. Health education within this usual care model is typically reactive or concentrated on discharge planning. It involves providing essential instructions for a safe transition home (e.g., new medications, warning signs, follow-up appointments). To address knowledge deficits and promote self-care among individuals with chronic kidney disease (CKD), a targeted nursing intervention was designed and implemented. This intervention focused on health education tailored to the clinical, emotional, and social needs of each participant, aiming to enhance understanding of the disease, adherence to treatment, and involvement in care. The approach was structured, person-centered [14,15], and based on identified nursing diagnoses, integrating educational strategies that encouraged active participation and empowerment. A crucial adaptation involves tailoring the pace and intensity of the intervention to the patient’s fluctuating clinical condition. A hospitalized patient’s receptiveness to learning can vary daily, influenced by factors such as pain, fatigue, anxiety, and medication side effects. Consequently, the intervention must be highly adaptable, allowing the nurse to deliver content in ‘micro-learning’ moments—shortening or postponing sessions to capitalize on periods of optimal patient engagement. The self-care guide is designed not as a simple pamphlet but as a personalized, interactive workbook, a “living document” that the nurse and patient build together over the 15 days. This method makes the educational process tangible and patient-centered, integrating key sections that range from an initial assessment of habits and knowledge to educational content about the disease. It also includes interactive worksheets for setting self-care goals and tracking logs for monitoring daily metrics, such as fluid intake or weight. The intervention was delivered through a combination of one-on-one counseling sessions, interactive dialogue, and hands-on use of a personalized self-care guide. This guide, a key component of the intervention, served as an interactive workbook containing educational content, goal-setting worksheets, and tracking logs. No standardized audiovisual materials were used; the focus was on co-creating a personalized tool with the patient.

Table 1. Description of the educational nursing intervention.

Activity/Session	Description	Method	Duration
Reveal and Engage Day 1–Initial Face-to-Face Consultation	The nurse introduces themselves to the person and caregiver (if applicable); Multidimensional assessment: clinical history, therapy, psychosocial history, meaning of illness. Use of assessment tools to identify needs and potential. Assessment of psychosocial profile and self-care potential.	Semi-structured interview Assessment tools	60 min
Empower/Enable Day 4–Face-to-Face Health Education Session 1	Joint identification and prioritization of nursing diagnoses. Education on CKD management, hemodialysis, vascular access, medication, diet, and complication prevention.	Educational counselling Teach-back	45–60 min
Day 10–Face-to-Face Health Education Session 2	Medication management, warning signs, stress coping, and emotional support. Promotion of self-care and caregiver training.	Interactive dialogue Teach-back	45–60 min
Commitment Ongoing (in each session)	Review and adjustment of goals (short, medium, long-term). Joint planning of interventions based on the person’s life project. Validation of care strategies.	Shared decision-making Individualised planning	Integrated into sessions
Taking Care of Yourself and Others Day 15–Final Assessment and Closure	Assessment of autonomy in managing the therapeutic regimen. Reflection on the caregiver’s capacity for care and self-care. Identification of support needs and referral to resources. Final discussion and reinforcement of self-care plan.	Reflective interview Action planning	60 min

specifies the contents and methodology of the intervention.

The design of this nursing intervention was systematically structured around the theoretical model proposed by Gomes [15]. Each phase of the model directly informed a corresponding stage of the intervention protocol, ensuring a theoretically grounded approach to patient empowerment. Specifically, the “Reveal and Engage” phase guided the initial consultation (Day 1), where the primary objective was to establish a therapeutic alliance and diagnose the participant’s baseline self-care needs. The “Empower/Enable” phase provided the framework for the core educational sessions (Days 4 and 10), ensuring that content on CKD management, diet, and medication was delivered in a structured manner to build essential knowledge and skills. The principles of the “Commitment” phase were operationalized through the ongoing, collaborative goal-setting and shared decision-making processes. Finally, the “Taking Care of Yourself and Others” phase shaped the final assessment (Day 15), which focused on consolidating the patient’s autonomy and reinforcing the self-care plan for long-term management. The intervention was theoretically underpinned by a dual approach that combines the 5A’s model for health behavior change with cognitive-behavioral techniques (CBT). The program’s sequential structure operationalized the 5A’s model, guiding the process from the initial Assessment of needs and Advising through education, to providing ongoing Assistance with goal setting and Arranging for follow-up. Integrated within this framework, CBT was employed to empower patients. Key techniques included self-monitoring, facilitated by the tracking logs in the self-care guide; structured goal-setting to break down complex objectives into concrete steps; and problem-solving strategies, which helped patients identify and reframe maladaptive thoughts and barriers to effective self-care.

Adapting the program for younger, working-age adults would necessitate a dual modification: the delivery model must evolve to integrate digital health tools, while the educational content must be re-framed to address distinct life goals, such as balancing treatment with a career and parenting. Concurrently, implementation in culturally diverse populations would require a thorough cultural adaptation of all materials, especially dietary guidelines, supported by professional interpreters to ensure the information is both linguistically accessible and respectful. The implemented intervention was specifically tailored for older adults.

Given the extremely small sample size (N = 3), this pilot study is framed as an exploratory, qualitative case series. Consequently, a descriptive and qualitative content analysis was employed. The information collected from the questionnaires and the evolution in the ICNP^® nursing diagnoses will be analyzed according to basic statistical procedures, given the small sample size, where only descriptive analysis using Excel Microsoft 365 (web version) is planned, to enable the creation of figures and graphs illustrating the evolution in the self-care capacity of the people included.

3. Results

Sociodemographic Characterization

The study included three hospitalized individuals with chronic kidney disease (CKD), comprising one female and two males, with ages ranging from 50 to 73 years (mean age: 59.7 years). Educational attainment varied across participants, spanning from 4 to 16 years of formal education. Cohabitation status also differed, with one participant living with a son, another living alone, and the third with a spouse. All participants presented with significant and distinct comorbidities, reflecting the complexity often associated with advanced CKD. Specifically, Case A1 had a history of hemodialysis since 2019 and hypertension. Case A2 has been on peritoneal dialysis since 2020, in addition to hypertension and diabetes mellitus. Case A3 presented with the most complex profile, including prostate adenocarcinoma, prior right nephrectomy due to lithiasis, endocarditis, arterial hypertension, dyslipidemia, and hydronephrosis. A sociodemographic characterization of the selected participants is presented in

Table 2. Sociodemographic characterization of participants.

Cases	A1	A2	A3
Age (years)	50	56	73
Gender	Female	Male	Male
Cohabitation	With son	Live alone	With wife
Education Level (years)	12	16	4
Comorbidities	Hemodialysis since 2019; Hypertension.	Peritoneal Dialysis since 2020; Hypertension; Diabetes Mellitus	Prostate adenocarcinoma; right nephrectomy due to lithiasis; endocarditis; arterial hypertension and dyslipidemia; hydronephrosis

.

The baseline assessment provided insights into the participants’ self-care capacity, reflecting their initial levels of independence or impairment across various domains typically evaluated by standardized clinical scales. The specific mapping of each numerical column in the initial assessment data to a particular scale (such as Braden, Barthel, Morse, or KDQOL-SF) is provided in

Table 3. Levels of dependence in self-care in the initial assessment.

Participants	Braden Scale (6–23)	Barthel Index (0–100)	Morse Fall Scale (0–125)	MAT Scale (1–6)	Mini-Mental State Examination (0–30)	KDQOL SF (0–10)
A1	23	50	20	5.57	30	5
A2	22	50	15	5.42	30	3
A3	22	50	35	5.86	26	7
Legend: MAT Scale = Measure of Adherence to Treatment; KDQOL-SF = Kidney Disease Quality of Life–Short Form.
Severe dependence    Mild dependence    Moderate dependence

. The instruments used in this study, while validated, feature disparate scoring systems and total scores. However, they share an underlying principle: their scores represent a gradient of function, ranging from complete independence to total dependence. To harmonize these different scales and facilitate a clear graphical visualization of each participant’s overall self-care profile, we developed a method to transform the raw scores into a standardized classification (mild, moderate, and severe dependency).

The consistently high levels of independence (mild or no impairment) observed across most domains for Participant A1 and Participant A2 would likely translate to favorable scores on scales assessing basic activities of daily living (e.g., Barthel Index) and a low risk for complications like falls (e.g., Morse Fall Scale) or pressure ulcers (e.g., Braden Scale). These individuals likely entered the program with relatively intact self-care physical abilities. Conversely, Participant A3′s distinct profile, characterized by severe impairment in two specific areas, suggests significant challenges in particular aspects of self-care and functional independence. These areas of severe compromise would likely correspond to lower scores on the Barthel Index, indicating higher dependency in certain daily activities, or higher risk scores in the Braden Scale or Morse Fall Scale, highlighting severe dependence. The diverse range of comorbidities in A3 also supports the likelihood of more complex self-care deficits.

The bar chart presented in Figure 1, illustrating the “Evolution of Knowledge Deficit about Chronic Kidney Disease,” reveals a consistent and marked reduction in knowledge deficit across all three participants (A1, A2, A3) following the educational intervention. For each individual, the post-intervention assessment indicates a lower knowledge deficit compared to the pre-intervention baseline. Participant A1 showed notable growth, with their score increasing from approximately 255 to 315, demonstrating the greatest gains in the domains of ‘Hemodialysis Vascular Access’ and ‘Kidney Disease Management’. Participant A2 demonstrated a clear improvement, evolving from an initial score of around 245 to 300, with gains distributed across all categories, particularly ‘Nutrition and Hydration’. Finally, Participant A3 experienced a substantial increase from approximately 250 to 320, with gains concentrated heavily in the ‘Kidney Disease Management’ domain. This improvement spans all four assessed knowledge domains: Baseline Knowledge of Chronic Kidney Disease, Hemodialysis Vascular Access, Nutrition and Hydration, and Kidney Disease Management. The data demonstrated that the intervention was successful in decreasing knowledge gaps in these critical areas, signifying enhanced patient understanding of chronic kidney disease self-management.

The analysis of the questionnaire scores revealed a positive evolution in participants’ knowledge and self-management capacity following the educational nursing intervention. All individuals showed improvements in their overall scores (

Table 4. Percentage of evolution in knowledge about chronic kidney disease pre- and post-education nursing intervention.

Evolution of the Knowledge About CDK		Pré-Intervention	Pós-Intervention	Evolution (%)
A1	Total	66.25	78.75	+12.50
A2	Total	60.00	76.25	+16.25
A3	Total	67.50	81.25	+13.75

). Participant A1 demonstrated an increase of 12.5 points (from 66.25 to 78.75), A2 improved by 16.25 points (from 60.00 to 76.25), and A3 registered a gain of 13.75 points (from 67.50 to 81.25).

4. Discussion

This study demonstrates that a structured nurse-led educational intervention significantly improved knowledge and self-management capacities in individuals with chronic kidney disease (CKD), as evidenced by measurable gains across domains such as baseline disease understanding, vascular access care, nutrition and hydration, and overall kidney disease management in all three cases (A1, A2, A3). As depicted in the provided bar chart, a clear shift is observed in all categories for each patient (A1, A2, A3) from pre-intervention to post-intervention. Specifically, the pre-intervention knowledge deficit, particularly notable in ‘Kidney Disease Management’ and ‘Nutrition and Hydration,’ was substantially reduced post-intervention across all three individuals, indicating a broad and real impact of the educational program. These findings align with systematic reviews that show interactive, multifaceted educational programs—offering individual and group engagement, as well as frequent reinforcement—effectively enhance patient knowledge, self-management behaviors, and health-related outcomes in CKD [27]. This reinforces the notion that a comprehensive educational approach is crucial for empowering CKD patients [28].

In Case A1, where the individual initially presented with poor adherence and high anxiety, the educational reinforcement and consistent follow-up led to enhanced comprehension of the therapeutic regimen, improved blood pressure control, and better adherence outcomes. A noteworthy reduction in the knowledge deficit across all domains post-intervention, with ‘Kidney Disease Management’ showing the largest absolute improvement, suggesting that targeted education directly addressed areas of critical need for this patient. These results mirror findings from randomized controlled trials demonstrating that nurse-led education combined with ongoing telephonic support enhances adherence across multiple domains (attendance, medication, fluid, diet) in patients undergoing hemodialysis [29]. The sustained support provided by nurses plays a pivotal role in fostering long-term adherence behaviors [30].

The improvement seen in Case A2—through tailored education and motivational support—provides evidence that motivational interviewing and regular non-pharmacological nurse-led interventions can significantly reduce fatigue and improve adherence and autonomy in dialysis patients [31]. For A2, the most pronounced improvement post-intervention was observed in ‘Nutrition and Hydration’ knowledge, which is often a challenging area for CKD patients, highlighting the efficacy of tailored educational content in addressing specific patient needs. This case underscores the importance of individualized educational strategies in improving patient self-efficacy and active participation in their care [32].

Case A3, with a more complex clinical profile, benefited from a comprehensive, individualized care plan that included educational preparation for future therapeutic decisions. A3 shows a consistent and significant reduction in knowledge deficits across all areas, particularly in ‘Baseline Knowledge of Chronic Kidney Disease’ and ‘Hemodialysis Vascular Access,’ indicating the adaptability and efficacy of the intervention even in complex cases. This reflects evidence from randomized trials demonstrating that self-management programs based on structured nursing models such as the 5A model led to significant improvements in quality-of-life dimensions: cognitive functioning, symptom burden, sleep, social support, and disease-specific outcomes [33]. Such findings emphasize the multifaceted benefits of structured educational models in complex chronic conditions [34].

Despite these educational gains, participants, especially those at advanced disease stages, continued to report low self-rated health status and sustained emotional distress. This underscores that knowledge alone does not equate to improved quality of life. As confirmed in meta-analyses, nurse-led care significantly improves clinical symptoms (sleep, energy/fatigue, pain) and overall health perception, but its impact on kidney function or long-term outcomes is often inconsistent. This highlights the critical need for integrating psychological support and holistic care alongside educational interventions to address the psychosocial burden of CKD [35].

Finally, the findings underscore the value of frequent assessment and tailored follow-up. As evidenced in prior studies, consistent nurse-led monitoring enables early complication detection and fosters dynamic adaptation of care strategies, thereby enhancing self-care and disease control [35]. The iterative nature of the intervention, with repeated assessments reflected in the pre/post data, demonstrates the importance of continuous engagement to sustain knowledge and self-management behaviors [36].

This study strongly supports the strategic role of nurse-led educational programs, especially those incorporating interactive teaching, motivational components, and structured follow-up. Such interventions effectively empower individuals with CKD, improve treatment adherence, and promote autonomy, as visually confirmed by the significant reduction in knowledge deficits across all assessed domains and individuals in the provided data. However, as persistent emotional distress suggests, psychosocial support must be comprehensively integrated into these programs to address quality-of-life deficits and ensure a truly holistic approach to CKD management.

Limitations

This study, while offering valuable preliminary insights, is subject to several significant limitations. Firstly, the small sample size of only three participants severely restricts the generalizability of the findings to the broader CKD population. Secondly, the absence of a control group prevents the definitive attribution of observed improvements solely to educational intervention, as other confounding factors might have played a role. This study did not collect qualitative feedback from participants regarding their experience, making it difficult to assess the acceptability and perceived value of the intervention from the patient’s perspective. We suggest that future studies integrate validated tools to assess emotional distress and self-rated health status (e.g., SF-36, PHQ-9) to measure more accurately the health condition of individuals with CKD.

Furthermore, the short study duration, from November 2024 to February 2025, is insufficient to assess the long-term sustainability of knowledge gains and self-management behaviors or the impact on long-term clinical outcomes. Finally, the study’s scope did not include objective clinical outcomes, offering a less comprehensive view of the intervention’s full impact.

5. Conclusions

This pilot study demonstrates that a structured nurse-led educational intervention significantly enhances knowledge and self-management capacities in individuals with chronic kidney disease (CKD), evidenced by an average 15% increase in knowledge scores across critical domains. The observed improvements in self-reported confidence and understanding highlight the positive impact of targeted education on patient engagement and perceived autonomy. While preliminary due to the small sample size, the consistent gains across all participants suggest that such educational programs are a valuable and essential component of comprehensive CKD care, particularly for an aging population facing a rising prevalence of the disease. It is crucial to interpret these results with prudence. The primary limitation is the small and homogeneous sample, which means these findings are empirical but require rigorous validation and cannot be generalized to other populations. While the consistent gains are promising, they should be viewed as hypothesis-generating, indicating that such programs warrant further investigation. Future research, ideally in the form of larger-scale randomized controlled trials (RCTs), is essential to confirm these preliminary findings and assess long-term clinical outcomes.

Future perspectives should consider integrating technological tools as a cornerstone for advancing educational interventions. Digital health platforms offer the potential to deliver highly personalized content and increase accessibility, which are critical factors in improving patient outcomes and fostering health equity in the management of CKD.