Drug adherence in chronic kidney diseases and dialysis

Managing cardiovascular risk factors in patients with chronic kidney disease: pharmacological and non-pharmacological interventions in the Copenhagen CKD Cohort

Background

Although cardiovascular morbidity and mortality are substantial in patients with chronic kidney disease (CKD), guideline-directed treatment of cardiovascular risk factors remains a challenge.

Methods

Observational, cross-sectional study including patients aged 30-75 years with CKD stage 1-5 without kidney replacement therapy from a tertiary hospital outpatient clinic. Data were obtained through patient interview, clinical examination, biochemical work-up, and evaluation of medical records and prescription redemptions. Guideline-directed treatment was evaluated as pharmacological interventions: antihypertensive and lipid-lowering therapy including adverse effects and adherence estimated as medication possession ratio (MPR); and non-pharmacological interventions: smoking status, alcohol consumption, body mass index (BMI), and physical activity.

Results

The cohort comprised 741 patients, mean age 58 years, 61.4% male, 50.6% CKD stage 3, 61.0% office blood pressure ≤140/90 mmHg. Antihypertensives were prescribed to 87.0%, median number of medications 2 (IQR 1;3), 70.1% received renin-angiotensin system inhibition, 25.9% reported adverse effects. Non-adherence (MPR < 80%) was present in 23.4% and associated with elevated blood pressure (OR 1.53 (95% CI 1.03;2.27)) and increased urinary albumin excretion, P < 0.001. Lipid-lowering treatment was prescribed to 54.0% of eligible patients, 11.1% reported adverse effects, and 28.5% were non-adherent, which was associated with higher LDL cholesterol, P = 0.036. Overall, 19.2% were current smokers, 16.7% overconsumed alcohol according to Danish health authority recommendations 69.3% had BMI ≥ 25 kg/m2, and 38.3% were physically active <4 hours/week. Among patients prescribed antihypertensives, 51.9% reported having received advice on non-pharmacological interventions.

Conclusions

Improved management of cardiovascular risk in patients with CKD entails intensified medical treatment and increased focus on patient adherence and non-pharmacological interventions.

Feeling gutted in chronic kidney disease (CKD): Gastrointestinal disorders and therapies to improve gastrointestinal health in individuals CKD, including those undergoing dialysis

Chronic kidney disease (CKD) affects 9.1% of the population worldwide. CKD may lead to structural and functional gastrointestinal alterations, including impairment in the intestinal barrier, digestion and absorption of nutrients, motility, and changes to the gut microbiome. These changes can lead to increased gastrointestinal symptoms in people with CKD, even in early grades of kidney dysfunction. Gastrointestinal symptoms have been associated with lower quality of life and reduced nutritional status. Therefore, there has been considerable interest in improving gastrointestinal health in this clinical population. Gastrointestinal health can be influenced by lifestyle and medications, particularly in advanced grades of kidney dysfunction. Therapies focused on gastrointestinal health have been studied, including the use of probiotics, prebiotics, and synbiotics, yielding limited and conflicting results. This review summarizes the alterations in the gastrointestinal tract structure and function and provides an overview of potential nutritional interventions that kidney disease professionals can provide to improve gastrointestinal health in individuals with CKD.

Ten tips from the Swiss Working Group on Sustainable Nephrology on how to go green in your dialysis unit

The health-care system and particularly renal replacement therapy has a significant carbon footprint adding to global warming and extreme weather conditions. Improving sustainability has become the focus of national and international working groups. Many reviews underline the need for improvement of sustainability in nephrology, in particular dialysis, and provide recommendations on how to reduce waste, energy, and water consumption. However, how to implement these recommendations, and where to start, is not always clear. This paper summarizes discussions within the 'working group on sustainable nephrology' of the Swiss Society of Nephrology. We do not provide a detailed review of the topic but instead present a practical 10-point action plan to help health-care workers in nephrology make a start and improve the carbon footprint of their dialysis centres. We emphasize the importance of ongoing research, cooperation, and dialogue, and welcome additional ideas from the wider renal community.

Role of a Pharmacist in Postdischarge Care for Patients With Kidney Disease: A Scoping Review

OBJECTIVE

The objective was to explore and describe the role of pharmacists in providing postdischarge care to patients with kidney disease.

DATA SOURCES

PubMed, Embase (Elsevier), CINAHL (Ebscohost), Web of Science Core Collection, and Scopus were searched on January 30, 2023. Publication date limits were not included. Search terms were identified based on 3 concepts: kidney disease, pharmacy services, and patient discharge. Experimental, quasi-experimental, observational, and qualitative studies, or study protocols, describing the pharmacist's role in providing postdischarge care for patients with kidney disease, excluding kidney transplant recipients, were eligible.

STUDY SELECTION AND DATA EXTRACTION

Six unique interventions were described in 10 studies meeting inclusion criteria.

DATA SYNTHESIS

Four interventions targeted patients with acute kidney injury (AKI) during hospitalization and 2 evaluated patients with pre-existing chronic kidney disease. Pharmacists were a multidisciplinary care team (MDCT) member in 5 interventions and were the sole provider in 1. Roles commonly identified include medication review, medication reconciliation, medication action plan formation, kidney function assessment, drug dose adjustments, and disease education. Some studies showed improvements in diagnostic coding, laboratory monitoring, medication therapy problem (MTP) resolution, and patient education; prevention of hospital readmission was inconsistent. Limitations include lack of standardized reporting of kidney disease, transitions of care processes, and differences in outcomes evaluated.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

This review identifies potential roles of a pharmacist as part of a postdischarge MDCT for patients with varying degrees of kidney disease.

CONCLUSIONS

The pharmacist's role in providing postdischarge care to patients with kidney disease is inconsistent. Multidisciplinary care teams including a pharmacist provided consistent identification and resolution of MTPs, improved patient education, and increased self-awareness of diagnosis.

Medication Adherence Among Patients With Kidney Disease: An Umbrella Review

Chronic kidney disease (CKD) imposes a significant medication burden on patients due to the necessity of multiple treatments to slow disease progression, manage coexisting conditions, and address complications. The complex medication regimen, in turn, has implications for clinical and patient-centered outcomes. This umbrella review provides comprehensive evidence on extent of medication nonadherence among adults with CKD, as well as associated risk factors, outcomes, and the effectiveness of interventions by synthesizing evidence from published systematic reviews and/or meta-analyses. We identified 37 works that met our inclusion criteria. These reviews covered various aspects of treatment adherence in people with CKD, which can be categorized into four main themes: (i) prevalence of treatment nonadherence; (ii) factors associated with (non)adherent behaviors; (iii) outcomes associated with treatment (non)adherence; and (iv) interventions to improve treatment adherence or overall self-management practices. Approximately half of the included studies (15/34) focused on interventions aimed at improving medication adherence or overall CKD management, while outcomes associated with medication (non)adherence were relatively underexplored in the literature. The reported prevalence rates of medication nonadherence varied widely among reviews and stages of CKD. The determinants of adherence identified included socioeconomic variables, disease or clinical conditions, and psychosocial factors. Common interventions to improve adherence included nurse-led interventions, pharmaceutical services, and eHealth technologies, which had varying effects on medication adherence or dialysis sessions.

Does Renal Denervation a Reasonable Treatment Option in Hemodialysis-Dependent Patient with Resistant Hypertension? A Narrative Review

PURPOSE OF REVIEW

This narrative review aims to assess the pathophysiology, diagnosis, and treatment of resistant hypertension (RH) in end-stage kidney disease (ESKD) patients on dialysis, with a specific focus on the effect of renal denervation (RDN) on short-term and long-term blood pressure (BP) control. Additionally, we share our experience with the use of RDN in an amyloidotic patient undergoing hemodialysis with RH.

RECENT FINDINGS

High BP, an important modifiable cardiovascular risk factor, is often observed in patients in ESKD, despite the administration of multiple antihypertensive medications. However, in clinical practice, it remains challenging to identify RH patients on dialysis treatment because of the absence of specific definition for RH in this context. Moreover, the use of invasive approaches, such as RDN, to treat RH is limited by the exclusion of patients with reduced renal function (eGFR < 45 mL/min/1.73 m3) in the clinical trials. Nevertheless, recent studies have reported encouraging results regarding the effectiveness of RDN in stage 3 and 4 chronic kidney disease (CKD) and ESKD patients on dialysis, with reductions in BP of nearly up to 10 mmhg. Although multiple underlying pathophysiological mechanisms contribute to RH, the overactivation of the sympathetic nervous system in ESKD patients on dialysis plays a crucial role. The diagnosis of RH requires both confirmation of adherence to antihypertensive therapy and the presence of uncontrolled BP values by ambulatory BP monitoring or home BP monitoring. Treatment involves a combination of nonpharmacological approaches (such as dry weight reduction, sodium restriction, dialysate sodium concentration reduction, and exercise) and pharmacological treatments. A promising approach for managing of RH is based on catheter-based RDN, through radiofrequency, ultrasound, or alcohol infusion, directly targeting on sympathetic overactivity.

Effect of medication therapy management services on medication-burden quality of life in hemodialysis patients

BACKGROUND

Hemodialysis (HD) patients commonly receive polypharmacy leading to increased likelihood of drug related problems (DRPs) and poor quality of life. Medication Therapy Management (MTM) services discover and resolve DRPs and may specifically improve Medication-burden Quality of life (MBQoL) in HD patients. We aimed to assess the effect of MTM services on DRPs and MBQoL among HD patients.

METHODS

A prospective pre-post study was conducted on 104 patients in an HD unit in Alexandria, Egypt. MBQoL was assessed at baseline and after three months of MTM sessions, using the Arabic, validated version of the Patient Reported Outcomes Measure of Pharmaceutical Therapy (PROMPT) questionnaire. Cohen's d test and multiple linear regression were used to assess the effect size of MTM and the factors affecting MBQoL, respectively. DRPs, adverse events and adherence were also monitored.

RESULTS

MBQoL improved significantly after the implementation of MTM (Cohen's d=0.88, p < 0.01) with the largest effect size in the "medicine information and relation with healthcare providers" domain. DRPs decreased significantly after MTM implementation (11.97 ± 4.65 versus 7.63 ± 3.85 per patient, p<0.001). The mean adverse events per patient were also reduced (9.69 ± 4.12 versus 6.56 ± 3.77, p < 0.001).

CONCLUSION

Applying MTM services presents an opportunity to improve care for HD patients by improving MBQoL, decreasing DRPs and adverse events.

Cardiovascular complications in chronic kidney disease: a review from the European Renal and Cardiovascular Medicine Working Group of the European Renal Association

Chronic kidney disease (CKD) is classified into five stages with kidney failure being the most severe stage (stage G5). CKD conveys a high risk for coronary artery disease, heart failure, arrhythmias, and sudden cardiac death. Cardiovascular complications are the most common causes of death in patients with kidney failure (stage G5) who are maintained on regular dialysis treatment. Because of the high death rate attributable to cardiovascular (CV) disease, most patients with progressive CKD die before reaching kidney failure. Classical risk factors implicated in CV disease are involved in the early stages of CKD. In intermediate and late stages, non-traditional risk factors, including iso-osmotic and non-osmotic sodium retention, volume expansion, anaemia, inflammation, malnutrition, sympathetic overactivity, mineral bone disorders, accumulation of a class of endogenous compounds called 'uremic toxins', and a variety of hormonal disorders are the main factors that accelerate the progression of CV disease in these patients. Arterial disease in CKD patients is characterized by an almost unique propensity to calcification and vascular stiffness. Left ventricular hypertrophy, a major risk factor for heart failure, occurs early in CKD and reaches a prevalence of 70-80% in patients with kidney failure. Recent clinical trials have shown the potential benefits of hypoxia-inducible factor prolyl hydroxylase inhibitors, especially as an oral agent in CKD patients. Likewise, the value of proactively administered intravenous iron for safely treating anaemia in dialysis patients has been shown. Sodium/glucose cotransporter-2 inhibitors are now fully emerged as a class of drugs that substantially reduces the risk for CV complications in patients who are already being treated with adequate doses of inhibitors of the renin-angiotensin system. Concerted efforts are being made by major scientific societies to advance basic and clinical research on CV disease in patients with CKD, a research area that remains insufficiently explored.

A Questionnaire Survey of Prescription Preferences and Leftover Medication Conversations: Comparisons Among Kidney Disease Patients and Healthcare Professionals

BACKGROUND

Patients with chronic kidney disease (CKD) and patients with kidney failure receiving hemodialysis (HD) receive various types of medications. However, little is known about the differences in medication preference and how to deal with leftover medication among CKD patients and HD patients. The purpose of this study was to investigate the differences in medication preference and ways of dealing with leftover medication between CKD patients, HD patients, physicians, and pharmacists via a questionnaire survey.

METHODS

The ethics committee of Oita University, Oita, Japan, approved this survey. Outpatients undergoing treatment by a nephrologist in four facilities in Oita prefecture, Japan, were asked to answer a questionnaire on their preference for medication and how to deal with leftover medication. Respondents gave their informed written consent. The same questionnaire was administered to nephrologists and pharmacists online.

RESULTS

In this survey, 383 patients (260 patients with CKD and 123 patients with HD), 22 nephrologists, and 28 pharmacists responded. The response rate of valid responses was more than 90% for each of the groups. In particular, 41% of patients with CKD and 56% of patients with HD never inform their doctor about leftover medication or only inform them when there is a lot of leftover medication. On the other hand, 23% of physicians have never asked their patients about them. Ordinary logistic regression analysis indicated that there is no significant relationship between how often patients talk about leftover medication, patients' preferences, or patient states.

CONCLUSIONS

Despite the age and state of the patients, it is important to discuss the perception of medication with each other and confirm the condition of the remaining medication to improve concordance and obtain the desired treatment effect.

Pharmacokinetics and Drug-Drug Interaction of Ocedurenone (KBP-5074) in vitro and in vivo

BACKGROUND AND OBJECTIVES

Ocedurenone (KBP-5074) is a novel nonsteroidal mineralocorticoid receptor antagonist that has demonstrated safety and efficacy in clinical trials in patients with uncontrolled hypertension and stage 3b/4 chronic kidney disease. This study evaluated the involvement of cytochrome P450 (CYP) isozymes and drug transporters in the biotransformation of ocedurenone, and whether ocedurenone inhibited or induced CYP enzymes and transporters. Clinical pharmacokinetic drug-drug interaction (DDI) of ocedurenone with CYP3A inhibitor and inducer were investigated in healthy volunteers.

METHODS

In vitro tests were conducted to determine which CYP enzymes were involved in ocedurenone's metabolism and whether ocedurenone inhibited or induced these CYP enzymes; ocedurenone substrate characteristics for efflux and uptake transporters and its inhibitory potential on major drug transporters were also assessed. A clinical DDI study was conducted in healthy volunteers to evaluate the effects of a strong CYP3A inhibitor (itraconazole) and inducer (rifampin) on ocedurenone's pharmacokinetics.

RESULTS

The in vitro study showed that ocedurenone was primarily metabolized by CYP3A4 and that it did not inhibit CYP enzymes. Ocedurenone appeared to be a substrate of BCRP and P-gp efflux transporters and inhibited BCRP, BSEP, MDR1, MATE1 and 2-K, OATP1B1/3, and OCT1. The clinical DDI study showed that itraconazole reduced ocedurenone's oral clearance by 51% and increased area under the plasma concentration-time curve extrapolated to infinity (AUC_0-inf) by 104%, while rifampin increased its oral clearance by 6.4-fold and decreased plasma AUC_0-inf by 84%.

CONCLUSION

Ocedurenone was shown to be a CYP3A substrate, with no inhibition potential on major drug metabolizing CYP enzymes and transporters at clinical efficacious doses. Ocedurenone did not induce CYP1A2 and 3A4 activity in cultured human primary hepatocytes. Clinical DDI study indicated ocedurenone was well tolerated when administered as a single 0.5-mg dose both alone and with itraconazole or rifampin, and while itraconazole had a weak effect on ocedurenone's pharmacokinetics, rifampin had a significant effect reducing systemic exposures.

The Effect of Genotyping on the Number of Pharmacotherapeutic Gene–Drug Interventions in Chronic Kidney Disease Patients

Patients with chronic kidney disease (CKD) stage 3–5 are polypharmacy patients. Many of these drugs are metabolized by cytochrome P450 (CYP450) and CYP450. Genetic polymorphism is well known to result in altered drug metabolism capacity. This study determined the added value of pharmacogenetic testing to the routine medication evaluation in polypharmacy patients with CKD. In adult outpatient polypharmacy patients with CKD3-5 disease, a pharmacogenetic profile was determined. Then, automated medication surveillance for gene–drug interactions was performed based on the pharmacogenetic profile and the patients’ current prescriptions. Of all identified gene–drug interactions, the hospital pharmacist and the treating nephrologist together assessed clinical relevance and necessity of a pharmacotherapeutic intervention. The primary endpoint of the study was the total number of applied pharmacotherapeutic interventions based on a relevant gene–drug interaction. A total of 61 patients were enrolled in the study. Medication surveillance resulted in a total of 66 gene–drug interactions, of which 26 (39%) were considered clinically relevant. This resulted in 26 applied pharmacotherapeutic interventions in 20 patients. Systematic pharmacogenetic testing enables pharmacotherapeutic interventions based on relevant gene–drug interactions. This study showed that pharmacogenetic testing adds to routine medication evaluation and could lead to optimized pharmacotherapy in CKD patients.

Digital health technologies to support medication adherence in chronic kidney disease

Non-adherence to medications is a critical challenge in the management of people with chronic kidney disease (CKD). This review explores the complexities of adherence in this population, the unique barriers and enablers of good adherence behaviours, and the role of emerging digital health technologies in bridging the gap between evidence-based treatment plans and the real-world standard of care. We present the current evidence supporting the use of digital health interventions among CKD populations, identifying the key research questions that remain unanswered, and providing practical strategies for clinicians to support medication adherence in a digital age.

Predictors of somatic symptom persistence in patients with chronic kidney disease (SOMA.CK): study protocol for a mixed-methods cohort study

INTRODUCTION

Seven of 10 patients with non-dialysis chronic kidney disease (CKD) experience burdensome persistent somatic symptoms (PSS). Despite the high prevalence and relevance for quality of life, disease progression and mortality, the pathogenesis of PSS in CKD remains poorly understood. The SOMA.CK study aims to investigate biopsychosocial predictors and their interactions for PSS in non-dialysis CKD and to develop a multivariate prognostic prediction model for PSS in CKD.

METHODS AND ANALYSIS

The study is a mixed-methods cohort study with assessments at baseline, 6 and 12 months. It aims to include 330 patients with CKD stages G2-4 (eGFR=15-89 mL/min/1.73 m²). Primary outcome is the CKD-specific somatic symptom burden assessed with the CKD Symptom Burden Index. Secondary outcomes include quality of life, general somatic symptom burden and functioning. The interplay of biomedical (eg, biomarkers, epigenetics), treatment-related (eg, therapies and medication) and psychosocial variables (eg, negative affectivity, expectations) will be investigated to develop a prognostic prediction model for PSS. In an embedded mixed-methods approach, an experimental study in 100 patients using an affective picture paradigm will test the effect of negative affect induction on symptom perception. An embedded longitudinal qualitative study in 40-50 newly diagnosed patients will use thematic analysis to explore mechanisms of symptom development after receiving a CKD diagnosis. SOMA.CK is part of the interdisciplinary research unit 'Persistent SOMAtic Symptoms ACROSS Diseases'.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of the Hamburg Medical Association (2020-10195-BO-ff). Findings will be disseminated through peer-reviewed publications, scientific conferences, the involvement of our patient advisory board and the lay public. Focusing on subjective symptom burden instead of objective disease markers will fundamentally broaden the understanding of PSS in CKD and pave the path for the development of mechanism-based tailored interventions.

TRIAL REGISTRATION NUMBER

ISRCTN16137374.

Treatment Adherence in CKD and Support From Health care Providers: A Qualitative Study

Rationale & Objective

Adherence to recommended medical treatment is critical in chronic kidney disease (CKD) to prevent complications and progression to kidney failure. Overall adherence to treatment is low in CKD, and as few as 40% of patients with kidney failure receive any documented CKD-related care. The purpose of this study was to explore the experiences of patients with CKD and their adherence to CKD treatment plans, and the role their health care providers played in supporting their adherence.

Study Design

One-on-one interviews were conducted in 2019-2020 using a semi-structured interview guide. Participants described experiences with adherence to treatment plans and what they did when experiencing difficulty.

Setting & Participants

Participants were recruited from the Chronic Renal Insufficiency Cohort (CRIC) study. All CRIC participants were older than 21 years with CKD stages 2-4; this sample consisted of participants from the University of Pennsylvania CRIC site.

Analytical Approach

Interviews were recorded, transcribed, and coded using conventional content analysis. Data were organized into themes using NVivo 12.

Results

The sample (n = 32) had a mean age of 67 years, 53% were women, 59% were non-White, with a mean estimated glomerular filtration rate of 56.6 mL/min/1.73 m2. From analysis of factors relevant to treatment planning and adherence, following 4 major themes emerged: patient factors (multiple chronic conditions, motivation, outlook), provider factors (attentiveness, availability/accessibility, communication), treatment planning factors (lack of plan, proactive research, provider-focused treatment goals, and shared decision making), and treatment plan responses (disagreeing with treatment, perceived capability deficit, lack of information, and positive feedback).

Limitations

The sample was drawn from the CRIC study, which may not be representative of the general population with CKD.

Conclusions

These themes align with Behavioral Learning Theory, which includes concepts of internal antecedents (patient factors), external antecedents (provider factors), behavior (treatment planning factors), and consequences (treatment plan responses). In particular, the treatment plan responses point to innovative potential intervention approaches to support treatment adherence in CKD.

Sex differences in ambulatory blood pressure levels, control and phenotypes of hypertension in hemodialysis patients

BACKGROUND AND AIMS

Ambulatory blood pressure (BP) control is worse in men than women with chronic kidney disease or kidney transplantation. So far, no study investigated possible sex differences in the prevalence, control, and phenotypes of BP according to predialysis and 48-h ambulatory blood pressure monitoring (ABPM) in hemodialysis patients. Further, no study has evaluated the diagnostic accuracy of predialysis BP in male and female hemodialysis patients.

METHOD

One hundred and twenty-nine male and 91 female hemodialysis patients that underwent 48-h ABPM were included in this analysis. Hypertension was defined as: (1) predialysis SBP ≥140 or DBP ≥90 mmHg or use of antihypertensive agents, (2) 48-h SBP ≥130 or DBP ≥80 mmHg or use of antihypertensive agents.

RESULTS

Predialysis SBP did not differ between groups, while DBP was marginally higher in men. 48-h SBP (137.2 ± 17.4 vs. 132.2 ± 19.2 mmHg, P  = 0.045), DBP (81.9 ± 12.1 vs. 75.9 ± 11.7 mmHg, P  < 0.001) and daytime SBP/DBP were higher in men. The prevalence of hypertension was not different between groups with the use of predialysis BP or 48-h ABPM (92.2% vs. 89%, P  = 0.411). However, concordant lack of control was more frequent in men than women (65.3% vs. 49.4%, P  = 0.023). The prevalence of white-coat and masked hypertension did not differ between groups; the misclassification rate with the use of predialysis BP was marginally higher in women. In both sexes, predialysis BP showed low accuracy and poor agreement with ABPM for diagnosing ambulatory hypertension [area-under-the-curve in receiver-operating-curve analyses (SBP/DBP): men, 0.681/0.802, women: 0.586/0.707].

CONCLUSION

Ambulatory BP levels are higher in male than female hemodialysis patients. Although hypertension prevalence is similar between sexes, men have worse rates of control. The diagnostic accuracy of predialysis BP was equally poor in men and women.

Clinical and Quality-of-Life Outcomes Following Invasive vs Conservative Treatment of Patients With Chronic Coronary Disease Across the Spectrum of Kidney Function

Importance

Prior trials of invasive vs conservative management of chronic coronary disease (CCD) have not enrolled patients with severe chronic kidney disease (CKD). As such, outcomes across kidney function are not well characterized.

Objectives

To evaluate clinical and quality-of-life (QoL) outcomes across the spectrum of CKD following conservative and invasive treatment strategies.

Design, Setting, and Participants

Participants from the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) and ISCHEMIA-Chronic Kidney Disease (CKD) trials were categorized by CKD stage: stage 1 (estimated glomerular filtration rate [eGFR] 90 mL/min/1.73m2 or greater), stage 2 (eGFR 60-89 mL/min/1.73m2), stage 3 (eGFR 30-59 mL/min/1.73m2), stage 4 (eGFR 15-29 mL/min/1.73m2), or stage 5 (eGFR less than 15 mL/min/1.73m2 or receiving dialysis). Enrollment took place from July 26, 2012, through January 31, 2018, with a median follow-up of 3.1 years. Data were analyzed from January 2020 to May 2021.

Interventions

Initial invasive management of coronary angiography and revascularization with guideline-directed medical therapy (GDMT) vs initial conservative management of GDMT alone.

Main Outcomes and Measures

The primary clinical outcome was a composite of death or nonfatal myocardial infarction (MI). The primary QoL outcome was the Seattle Angina Questionnaire (SAQ) summary score.

Results

Among the 5956 participants included in this analysis (mean [SD] age, 64 [10] years; 1410 [24%] female and 4546 [76%] male), 1889 (32%), 2551 (43%), 738 (12%), 311 (5%), and 467 (8%) were in CKD stages 1, 2, 3, 4, and 5, respectively. By self-report, 18 participants (<1%) were American Indian or Alaska Native; 1676 (29%), Asian; 267 (5%), Black; 861 (16%), Hispanic or Latino; 18 (<1%), Native Hawaiian or Other Pacific Islander; 3884 (66%), White; and 13 (<1%), multiple races or ethnicities. There was a monotonic increase in risk of the primary composite end point (3-year rates, 9.52%, 10.72%, 18.42%, 34.21%, and 38.01% respectively), death, cardiovascular death, MI, and stroke in individuals with higher CKD stages. Invasive management was associated with an increase in stroke (3-year event rate difference, 1%; 95% CI, 0.3 to 1.7) and procedural MI (1.6%; 95% CI, 0.9 to 2.3) and a decrease in spontaneous MI (-2.5%; 95% CI, -3.9 to -1.1) with no difference in other outcomes; the effect was similar across CKD stages. There was heterogeneity of treatment effect for QoL outcomes such that invasive management was associated with an improvement in angina-related QoL in individuals with CKD stages 1 to 3 and not in those with CKD stages 4 to 5.

Conclusions and Relevance

Among participants with CCD, event rates were inversely proportional to kidney function. Invasive management was associated with an increase in stroke and procedural MI and a reduced risk in spontaneous MI, and the effect was similar across CKD stages with no difference in other outcomes, including death. The benefit for QoL with invasive management was not observed in individuals with poorer kidney function.

Vaccination against connective tissue growth factor attenuates the development of renal fibrosis

There is a critical need for efficient treatment of chronic kidney disease (CKD). Renal fibrosis is a final common pathway to end-stage renal disease independent of the underlying etiology, and connective tissue growth factor (CTGF) is a well-recognized profibrotic factor in fibrosis of various organ systems. Here, we developed a novel peptide vaccine against CTGF to attenuate the development of renal fibrosis. Three inoculations with this CTGF vaccine at 2-week intervals elicited antibodies specifically binding to human full-length CTGF, and the antigen-specific serum IgG antibody titers were maintained for > 30 weeks. The efficacy of the CTGF vaccine on renal fibrosis was evaluated in adenine-induced CKD and unilateral ureteral obstruction (UUO) murine models. In adenine-induced CKD model, immunization with the CTGF vaccine attenuated renal interstitial fibrosis. Vaccinated mice showed low levels of serum creatinine and urea nitrogen and low urine albumin–creatinine ratio compared with vehicle-treated mice. In UUO model, the CTGF vaccination also suppressed the onset of renal fibrosis. In an in vitro study, CTGF vaccine-elicited IgG antibodies efficiently suppressed CTGF-induced- and transforming growth factor-β-induced α-smooth muscle actin expression in kidney fibroblasts. These results demonstrate that the CTGF vaccine is a promising strategy to attenuate the development of renal fibrosis.

Poor perception of chronic kidney diseases and its influencing factors among diabetics patients

Purpose We aimed to determine predictors of chronic kidney disease (CKD) prevention among patients with diabetes. Method A cross-sectional study was conducted on 1000 selected respondents based on socio-demographic, socio-economic, general CKD perception knowledge, self-monitoring advocacy, preventive behavior, treatment compliance, and psychosocial factors. Using multiple logistic regression, variables and their association with impaired perception of CKD prevention were analyzed. Results Overall, 74% had poor perception regarding CKD prevention (68.7% of men and 31.3% of women). In multivariable analysis, those with weak illness identity fear were two times more likely to have poor perceptions (95% CI 1.563–3.196, p < 0.001). Respondents with weak medical practice (AOR = 2.33, 95% CI 1.609–2.381, p < 0.001) and weak cooperation (AOR = 1.563; 95% CI 1.099–2.224, p < 0.001) were more likely to have poor perceptions on CKD prevention. Concerning poor perception, significant predictors were self-employment, housewives, working in private jobs, weak knowledge on clear glycosuria, sleep problems, print media, digital media, illness identity fear, weak medical practice, and weak co-operation factors. Conclusion Media support is crucial for supporting and improving positive views regarding CKD knowledge. Interventions to reach people with limited awareness on CKD prevention, lower socioeconomic status, and poor social support may improve identification of patients with early-stage CKD. Particular care should be taken to recognize and provide necessary services regarding the early detection of CKD.

Sex differences in ambulatory blood pressure levels, control, and phenotypes of hypertension in kidney transplant recipients

OBJECTIVES

Ambulatory blood pressure (BP) control is worse in men compared with women with chronic kidney disease (CKD) and this may partially explain the faster CKD progression in men. This is the first study investigating possible sex differences in prevalence, control and phenotypes of hypertension in kidney transplant recipients (KTRs) with office-BP and 24-h ambulatory BP monitoring (ABPM).

METHODS

This cross-sectional study included 136 male and 69 female stable KTRs who underwent office-BP measurements and 24-h ABPM. Hypertension thresholds for office and ambulatory BP were defined according to the 2017 ACC/AHA and 2021 KDIGO guidelines for KTRs.

RESULTS

Age, time from transplantation, eGFR and history of major comorbidities did not differ between groups. Office SBP/DBP levels were insignificantly higher in men than women (130.3 ± 16.3/77.3 ± 9.4 vs. 126.4 ± 17.8/74.9 ± 11.5 mmHg; P = 0.118/0.104) but daytime SBP/DBP was significantly higher in men (128.5 ± 12.1/83.0 ± 8.2 vs. 124.6 ± 11.9/80.3 ± 9.3 mmHg; P = 0.032/P = 0.044). No significant between-group differences were detected for night-time BP. The prevalence of hypertension was similar by office-BP criteria (93.4 vs. 91.3%; P = 0.589), but higher in men than women with ABPM (100 vs. 95.7%; P = 0.014). The use of ACEIs/ARBs and CCBs was more common in men. Office-BP control was similar (43.3 vs. 44.4%, P = 0.882), but 24-h control was significantly lower in men than women (16.9 vs. 30.3%; P = 0.029). White-coat hypertension was similar (5.1 vs. 7.6%; P = 0.493), whereas masked hypertension was insignificantly more prevalent in men than women (35.3 vs. 24.2%; P = 0.113).

CONCLUSION

BP levels, hypertension prevalence and control are similar by office criteria but significantly different by ABPM criteria between male and female KTRs. Worse ambulatory BP control in male compared with female KTRs may interfere with renal and cardiovascular outcomes.

Beliefs about medication and their association with adherence in Chinese patients with non-dialysis chronic kidney disease stages 3-5

There is a scarcity of research into the impact of medication beliefs on adherence in patients with non-dialysis chronic kidney disease (CKD). This study is to determine the psychometric properties of the Chinese version of the Beliefs about Medicines Questionnaire (BMQ)-Specific among patients with non-dialysis CKD stages 3-5, and to assess the beliefs of CKD patients and their association with medication adherence.A cross-sectional study was conducted in CKD patients who recruited at the nephrology clinics of Xi'an Central Hospital, Xi'an, Shaanxi, China. The original BMQ-Specific was translated into Chinese. The internal consistency and test-retest reliability of the Chinese version of the BMQ-Specific scale were assessed, while exploratory and confirmatory factor analyses were also applied to determine its reliability and validity. The Kruskal-Wallis test and multiple ordered logistic regression were performed to identify the relationship between beliefs about and adherence to medication among CKD patients.This study recruited 248 patients. Cronbach's α values of the BMQ-Specific necessity and concern subscales were 0.826 and 0.820, respectively, with intraclass correlation coefficients of 0.784 and 0.732. Factor analysis showed that BMQ-Specific provided a good fit to the two-factor model. The adherence of patients was positively correlated with perceived necessity (r = 0.264, P < .001) and negatively correlated with concern (r = -0.294, P < .001). Medication adherence was significantly higher for the accepting group (high necessity and low concern scores) than for the ambivalent group (high necessity and concern scores; β = -0.880, 95% confidence interval [CI] = -1.475 to -0.285), skeptical group (low necessity and high concern scores; β = -2.620, 95% CI = -4.209 to -1.031) and indifferent group (low necessity and concern scores; β = -0.918, 95% CI = -1.724 to -0.112).The Chinese version of BMQ-Specific exhibited satisfactory reliability and validity for use in patients with non-dialysis CKD stages 3-5 and has been demonstrated to be a reliable screening tool for clinicians to use to predict and identify the non-adherence behaviors of patients.

A longitudinal qualitative study to explore and optimize self-management in mild to end stage chronic kidney disease patients with limited health literacy: Perspectives of patients and health care professionals

OBJECTIVES

Limited health literacy (LHL) is associated with faster kidney deterioration. Health care professionals (HCPs) promote self-management to maintain kidney function, which is difficult for patients with LHL. Evidence lacks on perceived barriers and best strategies to optimize their self-management. Our study aims to explore experiences with and barriers for self-management from the perspectives of LHL patients and HCPs to identify strategies to optimize self-management.

METHODS

We performed a longitudinal qualitative study with semi-structured in-depth interviews and focus group discussions among CKD patients and LHL (n = 24) and HCPs (n = 37) from general practices and hospitals.

RESULTS

Four themes arose among patients: (1) CKD elusiveness, (2) suboptimal intake of knowledge (3) not taking a front-seat role, and (4) maintaining change. Among HCPs, three themes emerged: (1) not recognizing HL problems, (2) lacking effective strategies, and (3) health care barriers.

CONCLUSION

We suggest three routes to optimize self-management: providing earlier information, applying person-centered strategies to maintain changes, and improving competencies of HCPs.

PRACTICE IMPLICATIONS

HCPs need to explain CKD self-management better to prevent kidney deterioration. New interventions, based on behavioral approaches, are needed to optimize self-management. HCPs need training to improve recognition and support of LHL patients.

New Aspects in the Management of Hypertension in Patients with Chronic Kidney Disease not on Renal Replacement Therapy

With chronic kidney disease (CKD) being a global arising health problem, strategies for delaying kidney disease progression and reducing the high cardiovascular risk inherent to CKD, are the main objectives of the actual management of patients with kidney diseases. In these patients, the control of arterial hypertension is essential, as high blood pressure (BP) is a strong determinant of worst cardiovascular and renal outcomes. Achieving target blood pressures recommended by international guidelines is mandatory and often demands a multiple levels management, including several pharmacological and lifestyle measures. Even in the presence of adequate BP control, the residual cardiovascular risk remains high. In this respect, the recent demonstration that novel agents such as sodium glucose transporter 2 (SGLT2) inhibitors or the new non-steroidal mineralocorticoid antagonist finerenone can retard the progression of kidney diseases and reduce cardiovascular mortality on top of standard of care treatment with renin-angiotensin system inhibitors represent enormous progresses. These studies also demonstrate that cardiovascular and renal protection can be obtained beyond blood pressure control. Other promising novelties are still to come such as renal denervation and endothelin receptor antagonists in the setting of diabetic and non-diabetic kidney diseases. In the present review, we shall discuss the classic and the new aspects for the management of hypertension in CKD, integrating the new data from recent clinical studies.

Medication Burden and Prescribing Patterns in Patients on Hemodialysis in the USA, 2013-2017

INTRODUCTION

The medication burden of patients with end-stage renal disease (ESRD) on hemodialysis, a patient population with a high comorbidity burden and complex care requirements, is among the highest of any of the chronic diseases. The goal of this study was to describe the medication burden and prescribing patterns in a contemporary cohort of patients with ESRD on hemodialysis in the USA.

METHODS

We used the United States Renal Data System database from January 1, 2013, and December 31, 2017, to quantify the medication burden of patients with ESRD on hemodialysis aged ≥18 years. We calculated the average number of prescription medications per patient during each respective year (January-December), number of medications within classes, including potentially harmful medications, and trends in the number of medications and classes over the 5-year study period.

RESULTS

We included a total of 163,228 to 176,133 patients from 2013 to 2017. The overall medication burden decreased slightly, from a mean of 7.4 (SD 3.8) medications in 2013 to 6.8 (SD 3.6) medications in 2017. Prescribing of potentially harmful medications decreased over time (74.0% with at least one harmful medication class in 2013-68.5% in 2017). In particular, the prescribing of non-benzodiazepine hypnotics, benzodiazepines, and opioids decreased from 2013 to 2017 (12.2%-6.3%, 23.4%-19.3%, and 60.0%-53.4%, respectively). This trend was consistent across subgroups of age, sex, race, and low-income subsidy status.

CONCLUSIONS

Patients with ESRD on hemodialysis continued to have a high overall medication burden, with a slight reduction over time accompanied by a decrease in prescribing of several classes of harmful medications. Continued emphasis on assessment of appropriateness of high medication burden in patients with ESRD is needed to avoid exposure to potentially harmful or futile medications in this patient population.

Is the KDIGO Systolic Blood Pressure Target <120 mm Hg for Chronic Kidney Disease Appropriate in Routine Clinical Practice?

Meticulous management of hypertension is important in chronic kidney disease (CKD) to reduce the risk of cardiovascular disease, mortality, and progression of CKD. The recently published Kidney Disease Improving Global Outcomes (KDIGO) guideline on blood pressure (BP) management in CKD stresses the importance of standardized BP measurement and strict control of BP. This is a useful document that will help to improve the management of hypertension in CKD globally. However, the recommendation of systolic BP target of <120 mm Hg by KDIGO is controversial. It is based on weak evidence derived mainly from a single randomized controlled trial and its CKD subgroup analysis. Here, we review the current evidence surrounding BP target in CKD. We argue that the target recommended by KDIGO is not generalizable to the majority of people with CKD. Standardized BP measurements are challenging to implement outside specialist hypertension and research clinics, and the target of <120 mm Hg BP systolic cannot be extrapolated to routine clinic BP measurements. If applied to routine BP measurement, this target will expose the multimorbid and frail CKD patients to the risk of adverse events including falls and fractures. Furthermore, it will not be achievable in the majority of CKD patients. The target recommended by KDIGO is an outlier among contemporary major international hypertension guidelines and is likely to perplex clinicians. We believe the KDIGO-recommended target systolic BP <120 mm Hg for CKD is inappropriate in the majority of CKD patients and it may even be harmful for patients managed in routine clinical practice.

Phase 2 Study of the Factor XI Antisense Inhibitor IONIS-FXIRx in Patients With ESRD

Introduction

Patients with end-stage renal disease (ESRD) requiring hemodialysis (HD) have an increased risk of thrombotic events and bleeding. Antisense reduction of factor XI (FXI) with IONIS-FXI_Rx is a novel strategy that may safely reduce the risk of thrombotic events.

Methods

This multicenter study enrolled 49 patients receiving HD in 2 parts. First, 6 participants (pharmacokinetics [PK] cohort) received 1 open-label 300 mg dose of IONIS-FXI_Rx both before and after HD. Subsequently, 43 participants were treated in a double-blind, randomized design with 200 mg or 300 mg IONIS-FXI_Rx or placebo for 12 weeks. The PK, pharmacodynamics (PD), and adverse events of IONIS-FXI_Rx were evaluated (ClinicalTrials.gov: NCT02553889).

Results

The PK of IONIS-FXI_Rx was consistent with previous studies and similar whether injected before or after HD. No accumulation of IONIS-FXI_Rx was observed after repeat administration. By day 85, mean levels of FXI activity fell 56.0% in the 200 mg group, 70.7% in the 300 mg group, and 3.9% in the placebo group compared with baseline. FXI antigen levels paralleled FXI activity. Dose-dependent prolongation of activated partial thromboplastin time (aPTT) was observed, with no changes in international normalized ratio (INR). IONIS-FXI_Rx was not associated with drug-related serious adverse events. In the randomized phase of the study, major bleeding events occurred in 0 (0.0%; 200 mg), 1 (6.7%; 300 mg), and 1 (7.7%; placebo) patients and were not considered related to treatment.

Conclusion

IONIS-FXI_Rx reduced FXI activity in patients with ESRD receiving HD. Further studies are needed to determine the benefit-risk profile of FXI as a therapeutic target for patients who require HD.

Examination of factors affecting oral health in patients receiving haemodialysis

BACKGROUND

Patients receiving haemodialysis suffer from oral problems, pain, deteriorated nutrition, and decreased self-confidence and quality of life. Nurses have a critical role in the evaluation and care of oral health.

OBJECTIVES

The aim was to investigate the associations between socio-demographic characteristics, medication use, and biochemical blood levels and oral health in adult patients receiving haemodialysis treatment.

DESIGN

This study was conducted as a descriptive study.

PARTICIPANTS

The sample study was made up of one hundred and fifty individuals treated with haemodialysis between March and June 2018.

MEASUREMENTS

Patient diagnosis and Bedside Oral Exam guide was the tool used to examine oral health.

RESULTS

It was seen that patients' oral health worsened as the number of dental caries increased. It was found that low level of education, those with nonregular oral care and brushing teeth, those using parathyroid hormone-lowering agents and who stated they complied with the drug and diet therapy had higher mean Bedside Oral Exam guide scores, meaning their oral health was statistically significantly worse (p < 0.05). Bedside Oral Exam guide scores were weakly negatively correlated with predialysis serum potassium levels (r = -0.213; p = 0.009), weakly positively correlated with the daily fluid amount consumed (r = -0.185; p = 0.024), and decayed teeth (r = -0.224; p = 0.006).

CONCLUSIONS

Use of parathyroid hormone-lowering agents, low level of education, insufficient oral care, decayed teeth, compliance with diet and medication, daily liquid consumption, and low potassium levels could lead to an increased severity of poor oral health in patients receiving haemodialysis. Oral and dental health protocols should be developed for all haemodialysis units.

Sudden cardiac death in dialysis patients: different causes and management strategies

Sudden cardiac death (SCD) represents a major cause of death in end-stage kidney disease (ESKD). The precise estimate of its incidence is difficult to establish because studies on the incidence of SCD in ESKD are often combined with those related to sudden cardiac arrest (SCA) occurring during a haemodialysis (HD) session. The aim of the European Dialysis Working Group of ERA-EDTA was to critically review the current literature examining the causes of extradialysis SCD and intradialysis SCA in ESKD patients and potential management strategies to reduce the incidence of such events. Extradialysis SCD and intradialysis SCA represent different clinical situations and should be kept distinct. Regarding the problem, numerically less relevant, of patients affected by intradialysis SCA, some modifiable risk factors have been identified, such as a low concentration of potassium and calcium in the dialysate, and some advantages linked to the presence of automated external defibrillators in dialysis units have been documented. The problem of extra-dialysis SCD is more complex. A reduced left ventricular ejection fraction associated with SCD is present only in a minority of cases occurring in HD patients. This is the proof that SCD occurring in ESKD has different characteristics compared with SCD occurring in patients with ischaemic heart disease and/or heart failure and not affected by ESKD. Recent evidence suggests that the fatal arrhythmia in this population may be due more frequently to bradyarrhythmias than to tachyarrhythmias. This fact may partly explain why several studies could not demonstrate an advantage of implantable cardioverter defibrillators in preventing SCD in ESKD patients. Electrolyte imbalances, frequently present in HD patients, could explain part of the arrhythmic phenomena, as suggested by the relationship between SCD and timing of the HD session. However, the high incidence of SCD in patients on peritoneal dialysis suggests that other risk factors due to cardiac comorbidities and uraemia per se may contribute to sudden mortality in ESKD patients.

Effectiveness of Clinical Pharmacist Service on Drug-Related Problems and Patient Outcomes for Hospitalized Patients with Chronic Kidney Disease: A Randomized Controlled Trial

(1) Background: The study aimed to analyze the effectiveness of clinical pharmacist services on drug-related problems (DRPs) and patient outcomes in inpatients with chronic kidney disease (CKD). (2) Methods: In a randomized controlled trial, the participants in the intervention group received pharmacist services, including medication reconciliation, medication evaluation and management, and discharge pharmaceutical care transition services. Participants in the control group received usual care. The primary outcome was the number of DRPs per patient at discharge. (3) Results: The baseline characteristics of 100 participants included the following: mean age, 52.5 years; median eGFR, 9.2 mL/min/1.73 m². The number of DRPs in the intervention group during hospitalization increased significantly with decreasing eGFR (PR, 0.970; 95% CI, 0.951–0.989) and an increasing number of unintentional medication discrepancies at admission (PR, 1.294; 95% CI, 1.034–1.620). At discharge, the number of DRPs per patient was 0.94 ± 1.03 and 1.96 ± 1.25 in the intervention and control groups, respectively (p < 0.001). The service had a significant effect on the reduction of the unintentional discrepancies at discharge (p < 0.001). (4) Conclusion: Hospital pharmacists play an important role in the prevention of DRPs at discharge and unintentional medication discrepancies in inpatients with CKD.

Sleep Quality and Compliance to Medical Therapy Among Hemodialysis Patients With Moderate-to-Severe Depression: A Cross-Sectional Study

Background

Depression is a fairly common finding among end-stage renal disease (ESRD) patients and is an independent risk factor for morbidity and mortality. The psychiatric manifestations of the disease may affect their compliance to medications and alter sleep quality that is often overlooked. This translates into poor quality of life and poorer disease prognosis. Our study aims to assess the prevalence of depression and its association with compliance to medical therapy and sleep quality among ESRD patients on hemodialysis.

Methodology

In this cross-sectional study, a total of 288 hemodialysis patients with a confirmed diagnosis of ESRD were evaluated for depression using Patient Health Questionnaire-9 (PHQ-9) scale. Only patients with moderate-to-severe depressive symptoms on PHQ-9 were further evaluated for sleep quality and compliance to medications using Pittsburgh Sleep Quality Index (PSQI) and Drug Attitude Inventory-10 (DAI-10), respectively. The characteristics of ESRD patients with depression were also assessed. Median PHQ-9, DAI-10, and PSQI scores were calculated, and the correlation between study variables was assessed using Spearman’s correlation.

Results

Of the 288 included participants, 188 (65.27%) had depression as evaluated via PHQ-9. Of these 188 patients, 114 were males while 74 were females. A total of 113 (60.01%) of depressed patients had poor compliance to medication while 137 (72.87%) patients had poor sleep quality. Higher PHQ-9 scores were positively correlated with disease duration, dialysis years, and time between diagnosis and therapy (r = 0.41, 0.39, and 0.43, respectively) and negatively with marital and employment status (r = -0.32 and -0.49, respectively). Spearman’s correlation showed a significant negative correlation of PHQ-9 scores with DAI-10 scores but a significant positive correlation with PSQI scores. The correlation between DAI-10 and PSQI was a significant negative correlation.

Conclusions

This study indicated a high prevalence of moderate-to-severe depression among ESRD patients on hemodialysis. Poor sleep quality and non-adherence to medications are frequent among ESRD patients with depression. These psychiatric components must be considered to optimize medical treatment and improve the quality of life in this subset of patients. More studies should be conducted to assess the risk factors of depression in patients with ESRD.

How Do I Manage Hypertension in Patients with Advanced Chronic Kidney Disease Not on Dialysis? Perspectives from Clinical Practice

In the general population, the prevalence of moderate and severe chronic kidney disease (CKD) is usually below 5% but this figure is often higher in specific groups of patients such as those with type 2 diabetes. Patients with advanced CKD (CKD stage 3b and 4) are at high or very high cardiovascular risk, and their risk of progressing towards end-stage kidney disease (CKD stage 5) and the need of renal replacement therapy are elevated. Hypertension is a major cause of poor cardiovascular and renal outcomes in severe CKD. Therefore, an adequate control of blood pressure (BP) is mandatory. However, normalizing BP is often challenging in these patients because the clinical management of hypertension in advanced CKD is not well defined and rarely supported by large randomized controlled trials. In the present review, we discuss the characteristics of hypertension in advanced CKD, excluding dialysis, and its management integrating data from recent clinical studies and a pragmatic approach enriched by a long-standing clinical experience.

A narrative review of peer support barriers and facilitators in kidney care

Introduction

Patients with chronic kidney disease often experience emotional/mental challenges and benefit from peer support, as it provides insight/information from others with the same condition. Previous studies show it is effective in improving health outcomes and aids in treatment decisions.

Literature Review

There is low peer support uptake among patients with chronic kidney disease in the United Kingdom and staff do not utilise peer support services fully. Few studies within the United Kingdom have focused on peer support barriers/facilitators, so this narrative review aimed to understand them from staff and patient perspectives.

Materials and Methods

A comprehensive search strategy and inclusion/exclusion criteria were applied with a two‐step process of article selection employed using two reviewers. Thematic analysis was applied.

Results

Five articles were included and six themes emerged. Low referrals and difficulty matching were staff barriers; concern regarding the relationship dynamic and the format/delivery were patient barriers. Promotion of the service aided the uptake from staff, while patients valued inclusivity.

Discussion

Increased promotion of peer support benefits through training/awareness may improve staff referrals and there should be greater exposure nationally. A flexible format is essential to ensure ample opportunity for access.

Conclusion

This review highlights the current literature on peer support barriers/facilitators. Further study is needed to evidence which approaches best overcome staff‐ and patient‐barriers.

Evaluation of medication adherence and predictors of sub-optimal adherence among pre-dialysis patients with chronic kidney disease

Background:

Multiple medications are required to effectively manage chronic kidney disease (CKD) and associated complications, posing the risk of poor medication adherence.

Objectives:

To measure medication adherence levels and to investigate the potential predictors of sub-optimal medication adherence in pre-dialysis patients with CKD.

Methods:

A prospective study was conducted in the medical and nephrology outpatients’ clinics in Maiduguri. Non-dialysis patients with CKD stages 1–4 aged 18 years and above were recruited through their physicians. The level of medication adherence was determined using Morisky Medication Adherence Scale. Descriptive statistics were used to summarize patients’ background characteristics. Multivariate binary logistic regression analyses were performed to investigate the significantly potential predictors of sub-optimal medication adherence at a p < 0.05.

Results:

There were 107 participants (48.6%) who had high medication adherence, while 97 (44.1%), and 16 (7.3%) of them had moderate adherence, and low adherence, respectively. The univariate analysis revealed that medication adherence level differed significantly with the number of medications taken daily by patients (p < 0.05). Multivariate logistic regression analyses did not reveal a significant independent predictor of sub-optimal medication adherence.

Conclusion:

A majority of the participants reported sub-optimal medication adherence. The independent variables considered did not significantly predict sub-optimal medication adherence in the study population. Nevertheless, the study findings highlight the importance of clinical pharmacists’ CKD management supportive care to help improve medication adherence.

New oral spherical carbon adsorbent effectively reduces serum indoxyl sulfate levels in moderate to advanced chronic kidney disease patients: a multicenter, prospective, open-label study

BACKGROUND

Elevated levels of serum indoxyl sulfate (IS) have been linked to cardiovascular complications in patients with chronic kidney disease (CKD). Oral sorbent therapy using spherical carbons selectively attenuates IS accumulation in CKD patients. This study aimed to investigate whether oral administration of a new oral spherical carbon adsorbent (OSCA), reduces serum IS levels in moderate to severe CKD patients.

METHODS

This prospective, multicenter, open-label study enrolled patients with CKD stages 3-5. Patients were prescribed OSCA for 8 weeks (6 g daily in 3 doses) in addition to standard management. Serum IS levels were measured at baseline and 4 and 8 weeks of treatment with OSCA.

RESULTS

A total of 118 patients were enrolled and 87 eligible patients completed 8 weeks of study. The mean age of the study subjects was 62.8 ± 13.7 years, and 80.5% were male. Baseline levels of serum IS were negatively correlated with estimated glomerular filtration rate (eGFR) (r = - 0.406, P < 0.001) and increased with increasing CKD stages (stage 3, 0.21 ± 0.21 mg/dL; stage 4, 0.54 ± 0.52 mg/dL; stage 5, 1.15 ± 054 mg/dL; P for trend = 0.001). The patients showed significant reduction in serum total IS levels as early as 4 weeks after OSCA treatment (22.5 ± 13.9% reduction from baseline, P < 0.001) and up to 8 weeks (31.9 ± 33.7% reduction from baseline, P < 0.001). This reduction effect was noted regardless of age, kidney function, or diabetes. No severe adverse effects were reported. Gastrointestinal symptoms were the most commonly reported adverse effects. In total, 21 patients withdrew from the study, with dyspepsia due to heavy pill burden as the most common reason. The medication compliance rate was 84.7 ± 21.2% (min 9%, max 101%) for 8 weeks among those who completed the study.

CONCLUSIONS

OSCA effectively reduced serum IS levels in moderate to severe CKD patients. Gastrointestinal symptoms were the most commonly reported complications, but no treatment-related severe adverse effects were reported.

TRIAL REGISTRATION

Clinical Research Information Service ( KCT0001875 . 14 December 2015.).

The current and future landscape of dialysis

The development of dialysis by early pioneers such as Willem Kolff and Belding Scribner set in motion several dramatic changes in the epidemiology, economics and ethical frameworks for the treatment of kidney failure. However, despite a rapid expansion in the provision of dialysis — particularly haemodialysis and most notably in high-income countries (HICs) — the rate of true patient-centred innovation has slowed. Current trends are particularly concerning from a global perspective: current costs are not sustainable, even for HICs, and globally, most people who develop kidney failure forego treatment, resulting in millions of deaths every year. Thus, there is an urgent need to develop new approaches and dialysis modalities that are cost-effective, accessible and offer improved patient outcomes. Nephrology researchers are increasingly engaging with patients to determine their priorities for meaningful outcomes that should be used to measure progress. The overarching message from this engagement is that while patients value longevity, reducing symptom burden and achieving maximal functional and social rehabilitation are prioritized more highly. In response, patients, payors, regulators and health-care systems are increasingly demanding improved value, which can only come about through true patient-centred innovation that supports high-quality, high-value care. Substantial efforts are now underway to support requisite transformative changes. These efforts need to be catalysed, promoted and fostered through international collaboration and harmonization.

Dialysis is a life-saving therapy; however, costs of dialysis are high, access is inequitable and outcomes are inadequate. This Review describes the current landscape of dialysis therapy from an epidemiological, economic, ethical and patient-centred framework, and describes initiatives that are aimed at stimulating innovations in the field to one that supports high-quality, high-value care.

The global dialysis population is growing rapidly, especially in low-income and middle-income countries; however, worldwide, a substantial number of people lack access to kidney replacement therapy, and millions of people die of kidney failure each year, often without supportive care.

The costs of dialysis care are high and will likely continue to rise as a result of increased life expectancy and improved therapies for causes of kidney failure such as diabetes mellitus and cardiovascular disease.

Patients on dialysis continue to bear a high burden of disease, shortened life expectancy and report a high symptom burden and a low health-related quality of life.

Patient-focused research has identified fatigue, insomnia, cramps, depression, anxiety and frustration as key symptoms contributing to unsatisfactory outcomes for patients on dialysis.

Initiatives to transform dialysis outcomes for patients require both top-down efforts (that is, efforts that promote incentives based on systems level policy, regulations, macroeconomic and organizational changes) and bottom-up efforts (that is, patient-led and patient-centred advocacy efforts as well as efforts led by individual teams of innovators).

Patients, payors, regulators and health-care systems increasingly demand improved value in dialysis care, which can only come about through true patient-centred innovation that supports high-quality, high-value care.

Cost-Effectiveness Analysis of Patiromer in Combination with Renin-Angiotensin-Aldosterone System Inhibitors for Chronic Kidney Disease in Sweden

OBJECTIVES

Patients with chronic kidney disease (CKD) are commonly treated with renin-angiotensin-aldosterone system inhibitors (RAASi) in order to delay progression of renal disease. However, research has shown that RAASi in CKD patients increases hyperkalaemia (HK) prevalence, which leads to RAASi discontinuation or dose reduction with the loss of benefits on the kidney. Patiromer is a novel therapy for HK treatment and may enable patients to remain on their RAASi regimen. This study aimed to assess the cost-effectiveness of patiromer from a Swedish healthcare perspective.

METHODS

A Markov model was developed to evaluate the economic outcomes of patiromer versus no patiromer in HK patients with stage 3-4 CKD taking RAASi. The model consisted of six health states reflecting disease progression and hospitalisations. The analysis mainly considered clinical data from the OPAL-HK trial and national costs. The main outcomes of interest were incremental costs (euro [EUR] 2016) and quality-adjusted life years (QALYs), discounted at 3%, and the incremental cost-effectiveness ratio (ICER). Extensive uncertainty analyses were performed.

RESULTS

In comparison to no patiromer, a patiromer patient gained 0.14 QALYs and an incremental cost of EUR 6109 (Swedish krona [SEK] 57,850), yielding an ICER of EUR 43,307 (SEK 410,072)/QALY gained. The results were robust to a range of sensitivity analyses. At a willingness-to-pay threshold of EUR 52,804 (SEK 500,000)/QALY, patiromer had a 50% chance of being cost-effective.

CONCLUSIONS

The results indicate that patiromer may demonstrate value for money in Swedish patients with stage 3-4 CKD, by enabling RAASi treatment. However, there is a considerable degree of uncertainty.

Automated Remote Monitoring for Peritoneal Dialysis and Its Impact on Blood Pressure

Introduction: Peritoneal dialysis (PD) provides a safe, home-based continuous renal replacement therapy for patients. The adherence of the patients to the prescribed dialysis fluids cannot always be monitored by physicians. Remote monitoring automated peritoneal dialysis (RM-APD) can affect patients’ compliance with treatment and, thus, clinical outcomes. Objective: We aimed to evaluate the clinical outcomes of patients with a remote access program. Methods: This was an observational study. We analyzed the effect of RM-APD on treatment adherence, dialysis adequacy, and change in blood pressure control, sleep quality, and health-related quality of life during the 6 months of follow-up. Results: A total of 15 patients were enrolled in this study. It was found that there was a significant decrease (99 ± 19 vs. 89 ± 11 mm Hg) in mean arterial blood pressure of patients, and a considerable increase in Kt/V was observed in the sixth month after the RM-APD switch (2.11 ± 0.4 vs. 2.25 ± 0.5). A significant increase was found when comparing the 3-month and 6-month ultrafiltration amounts before RM-APD and the ultrafiltration amount within 6 months after RM-APD (800 mL [500–1,000] and 752 mL [490–986] vs. 824 mL [537–1,183]). The daily antihypertensive pill need (4 [0–7] vs. 2 [0–6]) and alarms received from the device decreased (from 4 [3–8] to 2 [0–3]) at the sixth month of the switch. There was no significant change in sleep quality and health-related quality of life within 6 months. Conclusion: This study showed that treatment adherence and ultrafiltration amounts of patients increased with the use of RM-APD, as well as better blood pressure control with fewer antihypertensive drugs.

Cinacalcet adherence in dialysis patients with secondary hyperparathyroidism in Lombardy Region: clinical implications and costs

Background

Patients on dialysis often have secondary hyperparathyroidism (SHPT), a disorder associated with renal osteodystrophy, progressive vascular calcification, cardiovascular disease, and death. The objective of this retrospective observational study was to evaluate, in dialysis patients with SHPT, the impact of different levels of adherence to cinacalcet therapy on hospitalisations and direct healthcare costs charged to the Lombardy Regional Health Service (Italy).

Methods

Data recorded in the administrative databases on all citizens undergoing dialysis between 1 January 2011 and 31 December 2011 were selected. For the aim of this study, patients with SHPT already on dialysis in the first 6 months of 2009 who had been treated with cinacalcet for at least 365 days were selected and retrospectively analysed through to end of 2012. Healthcare resource utilisation, cinacalcet adherence, and costs for medication, hospitalisations, and diagnostic/therapeutic procedures were estimated.

Results

A total of 994 patients were identified (mean age 63.0 years, females 43.5%). The first patient tertile had an adherence to cinacalcet of <64.1%, whereas the third had an adherence of over 91.5%. Patients in the third adherence tertile experienced fewer all-causes hospitalisations than those in the first tertile (-19.2%; p=0.01423), fractures (-37.1%; p=0.59422), cardiovascular disease (-23.8%; p=0.04025), and sepsis (-32.3%; p=0.01386). The increase in costs for cinacalcet-adherent patients is almost completely offset by the reduction in costs for hospitalisations.

Conclusions

The results of the analysis suggest that there may be some correlation between a high level of cinacalcet adherence and a decrease in hospitalisations.

Control of hyperparathyroidism with the intravenous calcimimetic etelcalcetide in dialysis patients adherent and non-adherent to oral calcimimetics

Background

In dialysis patients, non-adherence to oral cinacalcet adds complexity to the control of secondary hyperparathyroidism. The present study aims to evaluate the use of intravenous calcimimetic, etelcalcetide, in the control of secondary hyperparathyroidism in patients adherent and non-adherent to oral calcimimetics.

Method

The Simplified Medication Adherence Questionnaire was used to identify non-adherence. Almost half of the patients were non-adherent to the treatment with cinacalcet. Twenty-five patients (15 non-adherent) were switched from cinacalcet to etelcalcetide and were followed-up monthly for 8 months.

Results

Cinacalcet was discontinued for 1 week before the initiation of etelcalcetide. After this period, the serum PTH levels increased by2-fold in adherent patients, whereas it did not change in non-adherent patients suggesting that they were not taking the medication. Etelcalcetide progressively reduced serum parathyroid hormone (PTH) (mean ± standard deviation) from 818 ± 395 to 367 ± 289 pg/mL (P < 0.001) in non-adherents, and from 496 ± 172 to 228 ± 111 pg/mL (P < 0.01) in adherent patients with a mean dose of 7.0 ± 2.3 and 5.1 ± 1.2 mg in non-adherent and in adherent patients, respectively. Etelcalcetide increased the percentage of patients with PTH on target from 28% to 58%. Patients with serum calcium <8.4 mg/dL increased from 8% to 40%, although they remained asymptomatic. The percent of patients with serum phosphate on target increased from 40% to 65%.

Conclusion

The lack of adherence to cinacalcet is a possible cause of the apparent lack of response to oral calcimimetic. The use of etelcalcetide ensures compliance and control of secondary hyperparathyroidism in both non-adherent and adherent patients.

Could drug burden be associated with severe periodontitis in patients receiving haemodialysis?

BACKGROUND

Periodontitis increases the risk of cardiovascular disease in the general population by triggering systemic inflammation.

AIM

To investigate the relationship between systemic inflammation and periodontitis, and clarify any association between severe periodontitis and the medications used by patients receiving haemodialysis.

DESIGN

A cross-sectional study.

PARTICIPANTS

The study was undertaken with 56 patients receiving haemodialysis.

MEASUREMENTS

Demographic and laboratory data and prescribed drugs regularly used by patients were recorded from hospital records. During the dialysis session, a validated Xerostomia Inventory score was completed. A complete dental/periodontal examination was also undertaken on all patients by the same periodontist.

RESULTS

In the study population, stage I periodontitis was determined in 41%, stage II periodontitis in 17%, stage III periodontitis in 21%, and stage IV periodontitis in 21%. Male gender, hypertension, coronary artery disease, β antagonists, calcium channel blockers, sodium polystyrene sulphonate, teeth brushing less than twice a day and high sensitive C-reactive protein > 8 mg/l were significantly associated with severe periodontitis.

CONCLUSION

Drugs, including β antagonists, calcium channel blockers, polystyrene sulphonate, co-morbid conditions and poor or insufficient oral care could facilitate an increase in the severity of periodontitis in patients receiving haemodialysis. Severe periodontitis also seems to be associated with cardiovascular disease and inflammation in patients with chronic renal disease.

Elimination of intravenous alendronate by hemodialysis: A kinetic study

INTRODUCTION

The potential utility of intravenous alendronate for the treatment of osteoporosis in hemodialysis patients was recently reported. However, the pharmacokinetics of intravenous alendronate in patients on hemodialysis is not clear.

METHODS

Six hemodialysis patients (mean age, 80.5 years) with osteoporosis who had received intravenous alendronate prior to the study were enrolled. The participants received a 30-min infusion of 900-μg alendronate intravenously at the beginning of the dialysis session. The blood flow rate (Qb) and dialysate flow rate (Qd) were set at 200 mL/min and 500 mL/min, respectively. All patients used the same dialyzer (1.5-m² polysulfone membrane). At the completion of administration, plasma and dialysate samples were collected, and alendronate concentrations were determined using metal-free high-performance liquid chromatography (HPLC)-tandem mass spectrometry (MS/MS).

RESULTS

The plasma arterial alendronate concentration was 150.9 ± 46.09 ng/mL. It decreased through the dialyzer to 76.1 ± 34.1 ng/mL (venous alendronate concentration). Mean alendronate clearance was 113.9 ± 25.6 mL/min. Mean alendronate removal by hemodialysis, measured by the difference in arterial-venous concentrations, was 51.8%.

CONCLUSIONS

Fifty percent of intravenous alendronate was removed by hemodialysis, which is nearly equal to elimination of alendronate in patients with normal renal function. The elimination by hemodialysis would decrease the risk of excessive accumulation in bone. UMIN 000027182.

Qualidade de vida relacionada à saúde de pacientes em terapêutica hemodialítica

Resumo Objetivo identificar e mensurar fatores associados à qualidade de vida relacionada à saúde de pacientes renais crônicos em hemodiálise e analisar a associação da qualidade de vida relacionada à saúde e a adesão ao regime terapêutico hemodialítico. Métodos Estudo transversal com 258 pacientes em terapia hemodialítica. Avaliou-se a qualidade de vida relacionada à saúde através do questionário Kidney Disease Quality of Life Short Form. Foram analisados os componentes específicos da doença renal crônica e os componentes sumarizados físico e mental. A análise da não adesão ao regime terapêutico hemodialítico teve como base os indicadores do estudo The Dialysis Outcomes and Practice Patterns Study. Utilizaram-se, para a análise os testes de Mann Whitney e Kruskal Wallis. Resultados Indivíduos do sexo feminino, com menos de 60 anos, brancos, baixo nível socioeconômico, que necessitam de acompanhante, em terapia hemodialítica por menos de 5 anos, que possuem prescrição medicamentosa com dez ou mais fármacos, com baixos níveis séricos de albumina e hemoglobina e que não aderiram à restrição hídrica e à terapia apresentaram piora na qualidade de vida relacionada à saúde. Conclusão A avaliação da qualidade de vida relacionada à saúde dos pacientes em hemodiálise apresentou associação com as características sociodemográficas, clínicas e terapêutica. A monitoração desses parâmetros, bem como a busca do alcance dos padrões recomendáveis poderão subsidiar a prática clínica, aprimorar o planejamento assistencial e trazer melhorias em diversos aspectos da vida dos pacientes.

The effect of hospitalization on potentially inappropriate medication use in older adults with chronic kidney disease

OBJECTIVES

Potentially inappropriate medication (PIM) use is associated with increased morbidity and mortality in chronic kidney disease (CKD). However, there is a paucity of data on how hospitalization affects PIM use in older adults with CKD. Therefore, we aimed to measure the impact of hospitalization on PIM use in older CKD patients, and identify factors predicting PIM use.

METHODS

A retrospective cohort study was conducted in older adults (≥65 years) with CKD admitted to an Australian tertiary care hospital over a 6 month period. PIM use was measured, upon admission and at discharge, using the Medication Appropriateness Index (MAI) and Beers criteria (2015 version) for medications recommended to be avoided in older adults and under certain conditions.

RESULTS

The median age of the 204 patients was 83 years (interquartile range (IQR): 76-87 years) and most were men (61%). Overall, the level of PIM use (MAI) decreased from admission to discharge (median [IQR]: 6 [3-12] to 5 [2-9]; p < .01]). More than half of the participants (55%) had at least one PIM per Beers criterion on admission, which was reduced by discharge (48%; p < .01). People admitted with a higher number of medications (β 0.72, 95% CI 0.56-0.88) and lower eGFR values (β - 0.11, 95% CI -0.18 to -0.04) had higher MAI scores after adjusting for age, sex and Charlson's comorbidity index.

CONCLUSIONS

PIMs were commonly used in older CKD patients. Hospitalization was associated with a reduction in PIM use, but there was considerable scope for improvement in these susceptible individuals.

A randomized trial of vonapanitase (PATENCY-1) to promote radiocephalic fistula patency and use for hemodialysis

OBJECTIVE

Arteriovenous fistulas created in patients with chronic kidney disease often lose patency and fail to become usable. This prospective trial evaluated the efficacy of vonapanitase, a recombinant human elastase, in promoting radiocephalic fistula patency and use for hemodialysis.

METHODS

PATENCY-1 was a double-blind, placebo-controlled trial that enrolled 349 patients on or approaching hemodialysis and being evaluated for radiocephalic arteriovenous fistula creation. Of these, 313 were randomized and 311 treated. Patients were assigned to vonapanitase (n = 210) or placebo (n = 103). The study drug solution was applied topically to the artery and vein for 10 minutes immediately after fistula creation. The primary and secondary end points were primary patency (time to first thrombosis or corrective procedure) and secondary patency (time to abandonment). Tertiary end points included use of the fistula for hemodialysis, fistula maturation by ultrasound, and procedure rates.

RESULTS

The Kaplan-Meier estimates of 12-month primary patency were 42% (95% confidence interval [CI], 35-49) and 31% (95% CI, 21-42) for vonapanitase and placebo (P = .25). The Kaplan-Meier estimates of 12-month secondary patency were 74% (95% CI, 68-80) and 61% (95% CI, 51-71) for vonapanitase and placebo (P = .048). The proportions of vonapanitase and placebo patients were 39% and 25% (P = .035) with unassisted use for hemodialysis and 64% and 44% (P = .006) with unassisted plus assisted use.

CONCLUSIONS

Vonapanitase treatment did not significantly improve primary patency but was associated with increased secondary patency and use for hemodialysis. Further research is needed to evaluate these end points.

Factors associated with parathyroid hormone control in haemodialysis patients with secondary hyperparathyroidism treated with cinacalcet in real-world clinical practice: Mimosa study

Background

Secondary hyperparathyroidism (SHPT) is frequent in haemodialysis (HD) patients. Oral cinacalcet-hydrochloride (HCl) decreases parathyroid hormone (PTH); however, real-life PTH data, according to Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, are still lacking. Our goal is to assess the percentage of cinacalcet-HCl-treated HD patients with controlled SHPT (PTH <9× upper limit of the normal range) after 12 months (M12) of treatment.

Methods

This is a retrospective observational study in HD patients with SHPT treated by cinacalcet-HCl between 2005 and 2015 and dialysed in seven French HD centres using the same database (Hemodial™).

Results

The study included 1268 patients with a mean (standard deviation) follow-up of 21 ± 12 months. Their mean dialysis vintage was 4.3 ± 5.6 years. PTH values were available and exploitable at M12 in 50% of them (645 patients). Among these patients, 58.9% had controlled (mean PTH of 304 ± 158 pg/mL) and 41.1% uncontrolled SHPT (mean PTH of 1084 ± 543) at M12. At the baseline, patients with controlled SHPT were older (66 ± 15 versus 61 ± 17 years), and had lower PTH (831 ± 346 versus 1057 ± 480 pg/mL) and calcaemia (2.18 ± 0.2 versus 2.22 ± 0.19 mmol/L) than uncontrolled patients. In multivariate analysis, these three factors still remained significantly associated with controlled SHPT.

Conclusion

In this real-life study, 41.1% of HD patients with SHPT treated with cinacalcet-HCl remained with a PTH above the KDIGO recommended target after 12 months of treatment. Apart from the possibility of non-compliance, the severity of SHPT appears to be a major factor determining the response to cinacalcet-HCl treatment, reinforcing the importance of treating SHPT at earlier stages.

Adherence assessment practices in haemodialysis settings: A qualitative exploration of nurses and pharmacists' perspectives

AIMS AND OBJECTIVES

To explore clinician assessment of patient adherence and identify strategies to improve adherence assessment practices in haemodialysis settings.

BACKGROUND

Patients with chronic kidney disease undergoing haemodialysis are typically prescribed complex regimens; as such, they are at high risk of medication nonadherence. Current clinical practices focus on prescribing medications; however, little attention is paid to measuring and ensuring patient adherence to their prescribed treatments.

DESIGN

A qualitative study.

METHODS

Semi-structured individual interviews were conducted in November and December 2016, with 12 nurses and 6 pharmacists, working in Australian haemodialysis settings. The study was conducted and reported in accordance with COREQ guidelines.

RESULTS

Participants were 25-60 years old and had 1-27 years of experience in dialysis. Seven themes related to assessing adherence were identified: prioritisation of resources, interplay between workload and available time, awareness of formalised adherence measures and training deficits, concerns about practicality/suitability of adherence measures, communication of assessment services, patient participation and trust. Three themes related to strategies for improving adherence assessment practices were identified: formalisation of adherence assessment process, integration of assessment processes and tools into routine, and use of multidisciplinary support to assess and promote adherence.

CONCLUSIONS

Current adherence assessment practices could be improved through formalisation and integration of the assessment process into dialysis unit policy/procedures. Additionally, as barriers to assessing adherence were identified at organisational, professional and patient levels, there is a need to address barriers from each level in order to improve adherence assessment practices in haemodialysis settings.

RELEVANCE TO CLINICAL PRACTICE

This qualitative study highlights the challenges and practical ways by which adherence assessment practices could be improved in haemodialysis settings. This would encourage renal clinicians to actively participate in adherence assessment and promotion activities to ensure patients benefit from their therapies.