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      Stages of a Transtheoretical Model as Predictors of the Decline in Estimated Glomerular Filtration Rate: A Retrospective Cohort Study


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          The transtheoretical model (TTM) is composed of the multiple stages according to patient’s consciousness and is believed to lead people to realize the importance of healthier behaviors. We examined the association of TTM stages with the decline of estimated glomerular filtration rate (eGFR).


          We used the annual health checkup data and health insurance claims data of the Japan Health Insurance Association in Kyoto Prefecture between April 2012 and March 2016. TTM stages of change obtained from questionnaires at the first health checkup and categorized into six groups. The primary outcome was defined as a more than 30% decline in eGFR from the first health checkup. We fitted multivariable Cox proportional-hazards model for time-to-event analyses adjusting for age, sex, eGFR, body mass index, blood pressure, blood sugar, dyslipidemia, uric acid, urinary protein, and existence of kidney diseases at first health checkup.


          We analyzed 239,755 employees and the mean follow-up was 2.9 (standard deviation, 1.2) years. As compared with the stage 1 group, the risk of eGFR decline was significantly low in the stage 3 group (hazard ratio [HR] 0.77; 95% confidence interval [CI], 0.65–0.91); stage 4 group (HR 0.80; 95% CI, 0.65–0.98); and stage 5 group (HR 0.79; 95% CI, 0.66–0.95).


          Compared with the precontemplation stage (stage 1), the preparation, action and maintenance stages (stages 3, 4, and 5), were associated with a lower risk of eGFR decline.

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          Most cited references20

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          Revised equations for estimated GFR from serum creatinine in Japan.

          Estimation of glomerular filtration rate (GFR) is limited by differences in creatinine generation among ethnicities. Our previously reported GFR-estimating equations for Japanese had limitations because all participants had a GFR less than 90 mL/min/1.73 m2 and serum creatinine was assayed in different laboratories. Diagnostic test study using a prospective cross-sectional design. New equations were developed in 413 participants and validated in 350 participants. All samples were assayed in a central laboratory. Hospitalized Japanese patients in 80 medical centers. Patients had not participated in the previous study. Measured GFR (mGFR) computed from inulin clearance. Estimated GFR (eGFR) by using the modified isotope dilution mass spectrometry (IDMS)-traceable 4-variable Modification of Diet in Renal Disease (MDRD) Study equation using the previous Japanese Society of Nephrology Chronic Kidney Disease Initiative (JSN-CKDI) coefficient of 0.741 (equation 1), the previous JSN-CKDI equation (equation 2), and new equations derived in the development data set: modified MDRD Study using a new Japanese coefficient (equation 3), and a 3-variable Japanese equation (equation 4). Performance of equations was assessed by means of bias (eGFR - mGFR), accuracy (percentage of estimates within 15% or 30% of mGFR), root mean squared error, and correlation coefficient. In the development data set, the new Japanese coefficient was 0.808 (95% confidence interval, 0.728 to 0.829) for the IDMS-MDRD Study equation (equation 3), and the 3-variable Japanese equation (equation 4) was eGFR (mL/min/1.73 m2) = 194 x Serum creatinine(-1.094) x Age(-0.287) x 0.739 (if female). In the validation data set, bias was -1.3 +/- 19.4 versus -5.9 +/- 19.0 mL/min/1.73 m2 (P = 0.002), and accuracy within 30% of mGFR was 73% versus 72% (P = 0.6) for equation 3 versus equation 1 and -2.1 +/- 19.0 versus -7.9 +/- 18.7 mL/min/1.73 m(2) (P < 0.001) and 75% versus 73% (P = 0.06) for equation 4 versus equation 2 (P = 0.06), respectively. Most study participants had chronic kidney disease, and some may have had changing GFRs. The new Japanese coefficient for the modified IDMS-MDRD Study equation and the new Japanese equation are more accurate for the Japanese population than the previously reported equations.
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            The Transtheoretical Model of Health Behavior Change

            The transtheoretical model posits that health behavior change involves progress through six stages of change: precontemplation, contemplation, preparation, action, maintenance, and termination. Ten processes of change have been identified for producing progress along with decisional balance, self-efficacy, and temptations. Basic research has generated a rule of thumb for at-risk populations: 40% in precontemplation, 40% in contemplation, and 20% in preparation. Across 12 health behaviors, consistent patterns have been found between the pros and cons of changing and the stages of change. Applied research has demonstrated dramatic improvements in recruitment, retention, and progress using stage-matched interventions and proactive recruitment procedures. The most promising outcomes to data have been found with computer-based individualized and interactive interventions. The most promising enhancement to the computer-based programs are personalized counselors. One of the most striking results to date for stage-matched programs is the similarity between participants reactively recruited who reached us for help and those proactively recruited who we reached out to help. If results with stage-matched interventions continue to be replicated, health promotion programs will be able to produce unprecedented impacts on entire at-risk populations.
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              KDOQI US commentary on the 2012 KDIGO clinical practice guideline for the evaluation and management of CKD.

              The National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) guideline for evaluation, classification, and stratification of chronic kidney disease (CKD) was published in 2002. The KDOQI guideline was well accepted by the medical and public health communities, but concerns and criticisms arose as new evidence became available since the publication of the original guidelines. KDIGO (Kidney Disease: Improving Global Outcomes) recently published an updated guideline to clarify the definition and classification of CKD and to update recommendations for the evaluation and management of individuals with CKD based on new evidence published since 2002. The primary recommendations were to retain the current definition of CKD based on decreased glomerular filtration rate or markers of kidney damage for 3 months or more and to include the cause of kidney disease and level of albuminuria, as well as level of glomerular filtration rate, for CKD classification. NKF-KDOQI convened a work group to write a commentary on the KDIGO guideline in order to assist US practitioners in interpreting the KDIGO guideline and determining its applicability within their own practices. Overall, the commentary work group agreed with most of the recommendations contained in the KDIGO guidelines, particularly the recommendations regarding the definition and classification of CKD. However, there were some concerns about incorporating the cause of disease into CKD classification, in addition to certain recommendations for evaluation and management. Copyright © 2014. Published by Elsevier Inc.

                Author and article information

                J Epidemiol
                J Epidemiol
                Journal of Epidemiology
                Japan Epidemiological Association
                5 July 2022
                23 January 2021
                : 32
                : 7
                : 323-329
                [1 ]Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto, Japan
                [2 ]Japan Health Insurance Association Kyoto, Kyoto, Japan
                Author notes
                Address for correspondence. Yuichi Imanaka, MD, DrMedSc, MPH, PhD, Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan (e-mail: imanaka-y@ 123456umin.net ).
                Author information
                © 2021 Daisuke Takada et al.

                This is an open access article distributed under the terms of Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                : 28 August 2020
                : 11 January 2021
                Funded by: Grant-in-Aid for Scientific Research from the Japan Society for the Promotion of Science
                Award ID: 16H02634, 19H01075
                Original Article
                Public Health

                transtheoretical model,chronic kidney disease,kidney injury,stage of change,more than 30% decline in estimated glomerular filtration rate


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