Chronic Kidney Disease (CKD) is a progressive condition that frequently advances to End-Stage Renal Disease (ESRD), necessitating renal replacement therapy in the form of dialysis or transplantation. Hemodialysis, the most common modality of renal replacement therapy in low- and middle-income countries, is associated with multiple challenges beyond the clearance of uremic toxins. Patients undergoing dialysis often experience poor treatment adherence, inadequate dialysis adequacy, and fluctuations in biochemical and hematological parameters such as hemoglobin, serum potassium, and serum phosphorus, which contribute to morbidity and mortality (1,2). Urea Reduction Ratio (URR) remains a widely used and reliable measure of dialysis adequacy, and it is strongly correlated with patient survival (3). Maintenance of stable biochemical indicators, including hemoglobin, potassium, and phosphorus, is equally important for reducing cardiovascular complications, improving functional capacity, and enhancing survival (4).

While pharmacological and dietary interventions are routinely employed to regulate these parameters, psychosocial interventions such as support group programmes have received less attention in nephrology literature. Support groups provide a structured platform for patients to share experiences, receive peer encouragement, learn coping strategies, and acquire knowledge about dietary and treatment-related practices. Evidence suggests that improved self-care behaviors and adherence, often facilitated by peer-led or group-based interventions, can translate into favorable changes in dialysis adequacy and biochemical stability (5,6). However, studies directly examining the impact of structured support group programmes on clinical indicators such as URR, hemoglobin, potassium, and phosphorus remain limited, particularly in the Indian context where socio-economic and cultural factors strongly influence health outcomes (7,8).

Therefore, the present study was undertaken to evaluate the effect of a structured support group programme on selected clinical indicators—namely URR, hemoglobin, potassium, and phosphorus—among patients undergoing maintenance hemodialysis.

Research Approach and Design

A quantitative research approach with a quasi-experimental pre-test–post-test control group design was adopted to evaluate the effect of a structured support group programme on clinical indicators among patients undergoing hemodialysis.

Setting and Population

The study was conducted in the hemodialysis unit of a selected tertiary-care hospital in Ernakulam, Kerala. The target population consisted of patients aged 30–65 years diagnosed with End-Stage Renal Disease (ESRD) and undergoing maintenance hemodialysis twice weekly for a minimum of six months using an arteriovenous fistula or tunneled catheter.

Eligibility Criteria

Inclusion criteria: Patients aged 30–65 years, able to read and understand Malayalam, undergoing hemodialysis twice weekly for ≥6 months, and willing to participate.
Exclusion criteria: Patients with reported hearing or visual impairments, psychiatric or cognitive disorders, altered level of consciousness, clinical deterioration during the study, or those who missed sessions or relocated to another treatment centre.

Sample Size and Sampling Technique

The required sample size was calculated using the sample size equation for two-way repeated measures mixed ANOVA, with α = 0.05, power = 80%, anticipated clinically significant difference = 5, and intraclass correlation coefficient (ICC) = 0.3. This yielded a minimum of 53 participants per group. After accounting for a 10% attrition rate, the final sample size was fixed at 60 in each group. A purposive sampling technique was used. 

Group Allocation

• Experimental group (n = 60): Received the structured support group programme in addition to routine care.
• Control group (n = 60): Received routine hemodialysis care only.

Intervention Protocol

The structured support group programme was based on Cognitive Behavioral Therapy (CBT) principles and included four sessions with reinforcement:

1. Session 1: Introduction to CBT and thought log (Week 1, 45 min, individual).
2. Session 2: Dialysis stressors, emotion mapping, relaxation and mindfulness practice, homework (Week 2, 50 min, individual).
3. Session 3: Cognitive restructuring and experience sharing through virtual group discussion (Week 4, 60 min).
4. Session 4: Coping strategies including relaxation and mindfulness with homework (Week 5, 90 min, virtual).

Follow-up reviews were conducted during dialysis sessions in Weeks 3 and 6.

Data Collection Tools

1. Data Collection Sheet: Used to record baseline demographic variables, clinical details, and clinical indicators (URR, hemoglobin, potassium, phosphorus) from laboratory reports.

Data Collection Process

• Pre-test (O1): Baseline assessment on Day 1 for both groups.
• Intervention: Conducted over six weeks in the experimental group.
• Post-test 1 (O2): Assessment on Day 42.
• Post-test 2 (O3): Assessment on Day 70.

The control group was assessed at the same intervals without intervention.

Ethical Considerations

Ethical clearance was obtained from the Institutional Ethics Committee of the study site (Ref. No: LH/EC/2022-29). Written informed consent was obtained from all participants, and confidentiality was ensured.

Data Analysis

Data were analyzed using SPSS. Descriptive statistics summarized baseline demographic and clinical variables. The Friedman test was used for within-group comparisons across time points, Wilcoxon signed-rank test for pairwise analyses, and Mann–Whitney U test for between-group comparisons. A p-value < 0.05 was considered statistically significant.

In the present study, the mean age of participants was 51.30 ± 7.49 years in the experimental group and 52.33 ± 4.18 years in the control group, with most subjects belonging to the 51–60 years category (63.3% vs. 76.7%).Our study had a male predominance (75% experimental, 60% control), though the difference was not significant (χ² = 3.077, p = 0.079).

Table 1. Comparison of mean, SD, and SE of clinical indicators (URR, Hemoglobin, Potassium, Phosphorus) in experimental and control groups (n = 120)

The comparison of clinical indicators revealed favorable trends in the experimental group following the support group programme. Urea Reduction Ratio (URR) showed a steady improvement from 66.68% at baseline to 68.49% at post-test 2, while the control group declined slightly from 66.50% to 65.50%. Hemoglobin increased more consistently in the experimental group, reaching 9.97 g/dL compared to 9.80 g/dL in controls, suggesting better anemia management. Serum potassium levels in the experimental group demonstrated a modest but favorable decline (5.30 to 5.01 mmol/L), indicating improved dietary and treatment adherence, whereas the control group remained stable. Phosphorus levels remained largely stable in the experimental group, in contrast to a gradual decline observed in the control group, reflecting better metabolic balance and stability with the intervention. Collectively, these findings indicate that the support group programme contributed to improved dialysis adequacy, better hematological and biochemical regulation, and overall physiological stability among patients undergoing hemodialysis.[Table 1]

Table 2. Within-group comparison of URR, Hemoglobin, Potassium, and Phosphorus in the experimental group (n = 60)

Within the experimental group, Urea Reduction Ratio (URR) improved significantly across the study period, rising from 66.68 ± 7.63 at baseline to 67.82 ± 7.52 at post-test 1 and 68.49 ± 7.53 at post-test 2 (χ² = 113.567, p < 0.001; all Wilcoxon comparisons p < 0.001), indicating a steady enhancement in dialysis adequacy. Hemoglobin levels also showed an overall significant change (χ² = 7.604, p = 0.022), with a meaningful increase from 9.62 ± 0.90 g/dL at baseline to 9.97 ± 0.62 g/dL at post-test 2 (Z = –3.134, p = 0.002), while changes at intermediate points were not statistically significant. Serum potassium decreased favorably from 5.30 ± 0.89 mmol/L at baseline to 5.13 ± 1.03 at post-test 1 (Z = –2.252, p = 0.024) and 5.01 ± 0.78 at post-test 2 (Z = –2.511, p = 0.012), reflecting improved biochemical control. In contrast, serum phosphorus remained stable throughout the study, with baseline values of 5.07 ± 1.54 mg/dL showing no significant differences at post-test 1 (5.15 ± 1.43) or post-test 2 (5.13 ± 1.28) (χ² = 0.363, p = 0.834). Collectively, these results demonstrate that the support group programme effectively improved dialysis adequacy, enhanced hemoglobin, and helped stabilize potassium levels, while phosphorus values remained unchanged. [Table 2]

Table 3. Between-group comparison of URR, Hemoglobin, Potassium, and Phosphorus (Experimental vs. Control; n = 120)

Between-group comparisons showed that both experimental and control groups were comparable at baseline across URR, hemoglobin, potassium, and phosphorus (all p > 0.05), confirming initial homogeneity. Over time, the experimental group demonstrated higher URR values (67.82 ± 7.52 vs. 66.03 ± 7.69 at post-test 1; 68.49 ± 7.53 vs. 65.50 ± 7.77 at post-test 2), with differences approaching significance at the final measurement (p = 0.079), suggesting a favorable effect of the support group programme on dialysis adequacy. Hemoglobin also increased more consistently in the experimental group (9.97 ± 0.62 vs. 9.80 ± 0.99 at post-test 2), though the difference was not statistically significant (p = 0.190). Potassium was significantly higher in the experimental group at baseline (5.30 ± 0.89 vs. 4.89 ± 0.94, p = 0.016), but by post-test 2 both groups converged to nearly identical values (5.01 vs. 5.02 mmol/L, p = 0.996), indicating improved stabilization. Phosphorus levels remained statistically comparable between groups across all time points, with minor fluctuations (5.13 ± 1.28 vs. 4.90 ± 1.69 at post-test 2, p = 0.233). Overall, the intervention group displayed favorable upward trends in URR and hemoglobin, improved potassium regulation, and maintained stable phosphorus, highlighting the potential benefits of support group participation in enhancing clinical outcomes among hemodialysis patients. [Table 3]

With respect to dialysis adequacy, URR values were comparable at baseline between the experimental (66.68 ± 7.63) and control (66.50 ± 7.61) groups. Over time, the control group showed a decline (66.03 ± 7.69 to 65.50 ± 7.77), whereas the experimental group improved (67.83 ± 7.52 to 68.49 ± 7.53). Within-group analysis confirmed significant gains in the experimental arm (χ² = 113.567, p < 0.001; Wilcoxon p < 0.001 for all comparisons), though between-group differences did not reach significance (p = 0.079 at post-test 2). Similar improvements in dialysis adequacy have been reported by Zhang et al. [9] following intradialytic resistance exercise, and by Ghezeljeh et al. [10] after structured counselling interventions.

Hemoglobin levels improved more favorably in the experimental group (9.62 ± 0.90 → 9.97 ± 0.62 g/dL, χ² = 7.604, p = 0.022; Wilcoxon baseline vs. post-test 2: p = 0.002) compared with the control group (9.66 ± 1.13 → 9.80 ± 0.99 g/dL, p = 0.190 between groups). These findings echo those of Moattari et al. [11], who demonstrated improved hemoglobin following empowerment programmes, and support observations by Bossola et al. [12] that psychosocial distress is associated with lower hemoglobin levels in dialysis patients.

Serum potassium, significantly higher at baseline in the experimental group (5.30 ± 0.89 vs. 4.89 ± 0.94 mmol/L, p = 0.016), decreased progressively to 5.01 ± 0.78 mmol/L, with significant within-group reductions (Wilcoxon p = 0.024 and p = 0.012) and convergence with controls by post-test 2 (p = 0.996). This stabilization is clinically relevant and aligns with findings from Griva et al. [13], Lindberg et al. [14], and Cupisti et al. [15], who reported improved potassium control following psychosocial or dietary counselling interventions.

By contrast, serum phosphorus remained stable in the experimental group (5.07 ± 1.54 → 5.13 ± 1.28 mg/dL) and declined slightly in controls (5.13 ± 1.44 → 4.90 ± 1.69 mg/dL), with no significant changes between groups. Similar stability was observed by Arenas et al. [16], who showed modest phosphorus improvement following motivational interviewing.

Overall, the support group programme demonstrated beneficial effects on URR, hemoglobin, and potassium regulation, while maintaining stable phosphorus levels. These findings underscore the value of integrating psychosocial support into routine hemodialysis care to complement pharmacological and technical measures.

In conclusion, while baseline values of URR, hemoglobin, potassium, and phosphorus were comparable between the experimental and control groups, the experimental group consistently showed favorable trends following the support group programme. URR and hemoglobin improved steadily, potassium levels stabilized from an initially higher baseline to match control values, and phosphorus remained largely unchanged. Although between-group differences did not reach statistical significance for most parameters, the overall patterns suggest that the support group intervention contributed to better dialysis adequacy, improved hematological status, and greater biochemical stability, underscoring its potential as a supportive adjunct to routine hemodialysis care.

Conflict of interest: Nil

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