Impact of stepped verbal and written reinforcement of fluid balance advice within an outpatient haemodialysis unit: a pilot study

Non-adherence to hemodialysis regimens among patients on maintenance hemodialysis in sub-Saharan Africa: an example from Cameroon

Background

Non-adherence (NA) to hemodialysis regimens is one of the contributors to the high morbidity and mortality observed in patients with end-stage kidney disease (ESKD). We aimed to determine the prevalence and predictors of NA to hemodialysis (HD) regimens among patients on maintenance HD in Cameroon.

Methods

A cross-sectional study in two HD centers in Cameroon was conducted from January to February 2016. Consenting patients on HD for ≥3 months were included. NA to fluid restriction was defined as a mean interdialytic weight gain (IDWG) in the past month >5.7% of the dry weight, NA to dietary restriction as a pre dialysis serum phosphorus >5.5 mg/dl in a patient on phosphate binders and who is well-nourished, and NA to HD sessions as skipping at least one session in the past month. The study was approved by the institutional ethics board.

Results

A total of 170 (112 males) participants with a median age of 49 years (range 14–79) were included. The median dialysis vintage was 35 months (range 3–180 months). The prevalence of NA was 15.3% to fluid restriction, 26.9% to dietary restriction, and 21.2% to dialysis sessions. Age ≤49 years (p = .006, OR: 5.07, 95% CI: 1.59–16.20) and unmarried status (p = .041, OR: 2.63, 95% CI: 1.04–6.66) were independently associated with NA to fluid restrictions. No factor was associated with NA to dietary restrictions and HD sessions.

Conclusions

NA to HD regimens is common amongst patients in Cameroon. Younger age and being unmarried were the predictors of NA to fluid restriction.

Repercusiones del tratamiento psicoterapéutico sobre indicadores psicosomáticos en el paciente en hemodiálisis

Introducción: Aunque las relaciones psico-somáticas y los efectos del tratamiento psicológico en el desarrollo de enfermedades ha sido un tema de interés en las últimas décadas, no existen estudios con pacientes renales en hemodiálisis. Objetivo: Evaluar las repercusiones psicológicas y físicas de la aplicación de psicoterapia en el paciente renal en hemodiálisis. Material y Método: Estudio cuasi experimental. 39 personas recibieron atención psicológica entre 3 y 18 meses. Se les aplicaron los cuestionarios de depresión de Beck y Ansiedad-Rasgo antes y después del tratamiento con psicoterapia, y mientras duró dicho tratamiento también se registraron los valores de frecuencia cardiaca, tensión arterial, peso seco y ganancia hídrica inter-sesiones. Resultados: Tras el tratamiento psicológico los niveles de depresión descendieron en todos los pacientes excepto en aquellos con depresión leve, y en el caso de la ansiedad, tan sólo descendió en los pacientes con ansiedad elevada. La única variable fisiológica que mostró variaciones durante el tratamiento psicológico fue la ganancia hídrica inter-diálisis, que describió una tendencia lineal descendiente en 24 casos. Conclusiones: Las repercusiones del tratamiento psicológico pueden verse reflejadas en una variación de los niveles de ansiedad y depresión, así como en una disminución de las ganancias de líquido interdiálisis.

An integrative review of the methodology and findings regarding dietary adherence in end stage kidney disease

BACKGROUND

Dietary modification is an important component of the management of end stage kidney disease (ESKD). The diet for ESKD involves modifying energy and protein intake, and altering sodium, phosphate, potassium and fluid intake. There have been no comprehensive reviews to date on this topic. The aims of this integrative review were to (i) describe the methods used to measure dietary adherence (ii) determine the rate of dietary adherence and (iii) describe factors associated with dietary adherence in ESKD.

METHODS

The Web of Science and Scopus databases were searched using the search terms 'adherence' and 'end stage kidney disease'. Of the 787 potentially eligible papers retrieved, 60 papers of 24,743 patients were included in this review. Of these papers, 44 reported the rate of dietary adherence and 44 papers described factors associated with adherence.

RESULTS

Most of the evidence regarding dietary adherence is derived from studies of hemodialysis patients (72% of patients). The most common method of measuring dietary adherence in ESKD was subjective techniques (e.g. food diaries or adherence questionnaires). This was followed by indirect methods (e.g. serum potassium, phosphate or interdialytic weight gain). The weighted mean adherence rate to ESKD dietary recommendations was 31.5% and 68.5% for fluid recommendations. Adherence to protein, sodium, phosphate, and potassium recommendations were highly variable due to differences in measurement methods used, and were often derived from a limited evidence base. Socioeconomic status, age, social support and self-efficacy were associated with dietary adherence. However, factors such as taste, the impact of the diet on social eating occasions; and dietetic staffing also appear to play a role in dietary adherence.

CONCLUSION

Dietary adherence rates in people with ESKD are suboptimal. Further research is required on dietary adherence in patients with ESKD from different social, educational, economic and ethnic groups. This research may identify other factors which may impact upon adherence, and could be used to inform the design of future strategies to improve dietary adherence. Future research that reports not just the rate of adherence to individual components of the nutrient prescription but also the overall quality of the diet would be useful.

The dynamic process of adherence to a renal therapeutic regimen: perspectives of patients undergoing continuous ambulatory peritoneal dialysis

BACKGROUND

The nature of end-stage renal disease and the need for continuous ambulatory peritoneal dialysis require patients to manage various aspects of the disease, its symptoms and treatment. After attending a training programme, patients are expected to adhere to the renal therapeutic regimen and manage their disease with the knowledge and skills learned. While patients are the stakeholders of their health and related behaviour, their perceptions of adherence and how they adhere to their renal therapeutic regimen remains unexplored.

AIMS

To understand adherence from patients' perspectives and to describe changes in adherence to a therapeutic regimen among patients undergoing continuous ambulatory peritoneal dialysis.

DESIGN

This study used a mixed methods design with two phases - a survey in phase I and semi-structured interviews in phase II. This paper presents phase II of the study.

SETTINGS

The study was conducted at a renal unit of an acute hospital in Hong Kong.

PARTICIPANTS

Based on the phase I survey results, maximum variation sampling was employed to purposively recruit 36 participants of different genders (18 males, 18 females), ages (35-76 years), and lengths of dialysis experience (11-103 months) for the phase II interviews.

METHODS

Data were collected by tape-recorded semi-structured interviews. Content analysis was employed to analyse the transcribed data. Data collection and analysis were conducted simultaneously.

FINDINGS

Adherence was a dynamic process with three stages. At the stage of initial adherence, participants attempted to follow instructions but found that strict persistent adherence was impossible. After the first 2-6 months of dialysis, participants entered the stage of subsequent adherence, when they adopted selective adherence through experimenting, monitoring and making continuous adjustments. The stage of long-term adherence commenced after 3-5 years of dialysis, when participants were able to assimilate the modified therapeutic regimen into everyday life.

CONCLUSIONS

The process of adherence was dynamic as there were fluctuations at each stage of the participants' adherence. With reference to each stage identified, nursing interventions can be developed to help patients achieve smooth transition throughout all the stages.

Psychometric Validation of the Self-Efficacy for Restricting Dietary Salt in Hemodialysis Scale

The development and progression of left ventricular hypertrophy is a consequence of multiple comorbid conditions associated with end-stage renal disease and large variations in interdialytic weight gains. The literature suggests that dietary sodium restriction alone significantly reduces interdialytic weight gains. A total of 124 hemodialysis participants in an ongoing randomized control trial participated in the validation in which psychometric properties of a self-efficacy survey were a secondary analysis. We evaluated the internal consistency, construct validity, and convergent validity of the instrument. The overall Cronbach α was 0.93. Three factors extracted explain 67.8% of the variance of the white and African American participants. The Self-Efficacy Survey has adequate internal consistency and construct and convergent validity. Future research is needed to evaluate the stability and discriminant validity of the instrument.

[Interest of a specific programme in patient education for dialysis in out-center patients]

The development of therapeutic patient education for dialysis patients is recent and concerns mainly out-center patients. To our knowledge, only two papers centred on therapeutic education with out-center patients have been published. The particularities of this dialysis modality (unit close to the home, more autonomy, a nurse for six patients, organisation of unit, better quality of life and psychological status) highlight the interest to develop specific educational programs for patients treated in out-center sitting. The example of a program in Aquitaine (France) composed of mainly collective sessions (representations of the disease, dietetic recommendations, hygiene and protection of the vascular access, drugs compliance…) allows to propose several practical implications to initiate the development of specific programs in therapeutic education for out-center dialysis: educative sessions during the sessions of dialysis, group patients, multidisciplinary team, evaluation of the program from a medical and psychosocial point of view…

Adherence to anti-hypertensive medication: proposing and testing a conceptual model

OBJECTIVES

A conceptual model of the psychological factors underpinning adherence to anti-hypertensive medication is proposed and tested. The model suggests that adherence is influenced by three sets of variables: demography, health status, and perceived effects of medication; cognitions and motivation; and intention to adhere.

METHODS AND DESIGN

Patients with known hypertension were recruited from three primary care practices in South-East England and were asked to complete a postal questionnaire. A total of 1,070 responses were received. The questionnaire asked about the three sets of predictor variables, and adherence. Eight weeks after the first questionnaire, a second was posted to all respondents, this time asking about adherence over the intervening period.

RESULTS

The three sets of predictor variables were treated as blocks in a hierarchical model, so that each successive block added to the variance in adherence explained by the previous blocks. The data were analysed by hierarchical multiple regression. The predictors accounted for 19% of the variance in adherence at Time 1, and 34% at Time 2. The leading individual predictors at Time 1 were age, gender, conscientiousness, hypertensive identity, perceived behavioural control, and intention. At Time 2, they were the same, except that gender made way for adherence at Time 1.

CONCLUSIONS

The model offers a parsimonious account, and the findings suggest a number of approaches to designing interventions to modify behaviour.

Fluid compliance among patients having haemodialysis: can an educational programme make a difference?

AIM

This paper is a report of a study to examine the effectiveness of a patient education programme on fluid compliance as assessed by interdialytic weight gain, mean predialysis blood pressure and rate of fluid adherence.

BACKGROUND

Patients with end stage renal disease who receive haemodialysis are often non-compliant with their treatment regime, especially adherence to fluid restrictions.

METHOD

An exploratory study was conducted in 2004-05 using a quasi-experimental, single group design to examine the effectiveness of patient education on fluid compliance in a dialysis centre located in a major teaching hospital in Kuala Lumpur, Malaysia. Twenty-six patients with an interdialytic weight gain of greater than 2.5 kg were identified as non-compliant and recruited to the study. The intervention was carried out over a 2-month period and included teaching and weekly reinforcement about diet, fluids and control of weight gain.

FINDINGS

Patients' mean interdialytic weight gain decreased following the educational intervention from 2.64 kg to 2.21 kg (P < 0.05) and adherence to fluid restrictions increased from 47% to 71% following the intervention. Predialysis mean blood pressure did not improve following the intervention, although the maximum recording for predialysis systolic pressure dropped from 220 mmHg to 161 mmHg. Whilst no statistically significant associations were detected between interdialytic weight gain and age, educational level, marital status or employment status, women demonstrated a greater decrease in mean interdialytic weight gain than men.

CONCLUSION

Nephrology nurses often have long-term relationships with their patients and are ideally placed to provide ongoing education and encouragement, especially for those experiencing difficulties in adhering to fluid and dietary restrictions.

Psycho-educational strategies to promote fluid adherence in adult hemodialysis patients: a review of intervention studies

BACKGROUND

We reviewed psycho-educational intervention studies that were designed to reduce interdialytic weight gain (IDWG) in adult hemodialysis patients. Our goals were to critique research methods, describe the effectiveness of tested interventions, and make recommendations for future research.

METHODS

Medline, PsychInfo, and the Cumulative Index to Nursing and Applied Health (CINAHL) databases were searched to identify empirical work. Each study was evaluated in terms of sample, design, theoretical framework, intervention delivery, and outcome.

RESULTS

Nine studies were reviewed. Self-monitoring appears to be a promising strategy to be considered to reduce IDWG. Theory was not usually used to guide interventions, designs generally had control groups, interventions were delivered individually, more than one intervention was delivered at a time, the duration of the intervention varied greatly, there was no long-term follow-up, IDWG was the only outcome, and IDWG was operationalized in different ways.

CONCLUSIONS

Theoretical models and methodological rigor are needed to guide future research. Specific recommendations on design, measurement, and conceptual issues are offered to enhance the effectiveness of future research.

A systematic review of psychological interventions for the treatment of nonadherence to fluid-intake restrictions in people receiving hemodialysis

BACKGROUND

Psychological interventions aimed at improving adherence to fluid-intake restrictions in patients receiving hemodialysis have become increasingly common. To the authors' knowledge, this is the first systematic review of the literature examining the impact of these interventions associated with patient interdialytic weight gain (IWG).

METHODS

A systematic search of the literature was performed on EMBASE, MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and PsychINFO. The search was augmented by manually examining reference lists of reviews and retrieved reports. Study quality was graded according to criteria developed by the authors. Two additional independent researchers separately coded a random sample of studies to avoid bias of rating.

RESULTS

Sixteen studies were identified as eligible for inclusion. Relevant information from each included study was extracted and entered into a standardized table. Nearly all studies showed a postintervention decrease in IWG. A number of method weaknesses in the existing literature were identified.

CONCLUSION

Studies investigating psychological interventions aimed at improving adherence to fluid-intake restrictions appear to indicate some success in decreasing IWG. However, confidence regarding the validity of this finding is circumscribed by the prevalent use of investigative designs with inherently high susceptibility to bias. Future studies would benefit from using larger numbers of participants within controlled designs. Clearer description of intervention protocols would foster greater understanding of the contextual appropriateness of different approaches and which treatment components are key to improving adherence to fluid-intake restrictions in patients receiving hemodialysis.