Non-adherence in patients on peritoneal dialysis: a systematic review

Pica is associated with lower willingness to change negative habits of diet and exercise, inadequate lifestyle, and less healthful food consumption in dialysis

Background

In dialysis patients, on the one hand unwillingness to change negative lifestyle patterns is associated with worse nutritional status and unhealthy lifestyle, whereas on the other, pica may be highly prevalent. However, it is not known whether pica is associated with unwillingness to change negative lifestyle behaviors, as well as with consumption of different types of foods. This study aimed to investigate this issue.

Methods

This is a cross-sectional study in dialysis patients. Lifestyle was assessed using the self-administered Instrument to Measure Lifestyle Questionnaire (IMEVID). Pica diagnosis was established according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. A food frequency questionnaire was performed and self-reported willingness to change was determined by a trans-theoretical model staging inventory.

Results

Compared with patients without pica, those with pica (particularly hard pica) had lower willingness to change unhealthy behavior in the case of diet (22% vs. 46% in precontemplation/contemplation stages, respectively) and exercise (43% vs. 62% in precontemplation/contemplation stages, respectively). Patients with hard pica had significantly (p < 0.05) lower scores in almost all dimensions of the lifestyle questionnaire than those in the no pica group: diet (23.9 vs. 26.8, respectively), physical activity (5.5 vs. 7, respectively), knowledge of disease (5.7 vs. 6.4, respectively), emotion management (6.6 vs. 8, respectively) and adherence to treatment (13.4 vs. 14.7, respectively), but not in the consumption of tobacco and alcohol. Compared to patients with no pica, those with hard pica ate vegetables and fruits less frequently, and dairy products, fried foods and soda more frequently.

Conclusions

Pica was more frequently observed in patients with lower willingness to change negative habits of diet and exercise, in those who had more unhealthy behaviors in diet, exercise and emotion management dimensions and adherence to treatment, as well as in those who ate less frequently healthful foods and more frequently unhealthy foods.

Effect of a Management Algorithm for Wet Contamination of Peritoneal Dialysis System on the Prevention of Peritonitis: A Prospective Observational Study

Introduction

Wet contamination was a common problem of peritoneal dialysis (PD) system. We developed a management algorithm for wet contamination of PD system (wet contamination) on the basis of the related research literature and clinical practice experience. The purpose of this study was to observe clinical effect of the management algorithm on the prevention of peritonitis.

Methods

Patients treated wet contamination in a single PD center between October 2017 and September 2022 were included. A management algorithm was established to treat wet contamination. It comprised identification of the contamination type, addressing contaminated or aging catheters, prophylactic antibiotics, and retraining. Demographic data and clinical data about wet contamination were collected and compared.

Results

One hundred and forty-one cases of wet contamination were included in this study. The mean age was 51.7 ± 14.1 years, and 49.6% were female. The proportion of diabetic nephropathy was 9.9%. The median PD duration was 27.0 (1.7-79.7) months. Eighteen episodes (12.8%) of wet contamination-associated peritonitis developed after wet contamination. The main pathogenic bacteria of peritonitis were Gram-positive bacteria (33.3%) and Gram-negative bacteria (27.8%). The incidence of wet contamination-associated peritonitis in the compliance with the management algorithm group was significantly lower than that in the non-compliance with the management algorithm group (0.9 vs. 48.6%; p < 0.001). Non-compliance with management algorithm (OR = 185.861, p < 0.001) together with advance age (OR = 1.116, p < 0.001) and longer distance from home to hospital (OR = 1.007, p < 0.001) were independent risk factors for wet contamination-associated peritonitis.

Conclusion

The management algorithm for wet contamination of PD system could reduce the risk of peritonitis.

Perceptions of peritonitis risk, prevention, diagnosis and stigma: Findings from a mixed methods study with patients and relatives using peritoneal dialysis

BACKGROUND

Peritonitis is the main treatment-related complication of peritoneal dialysis and a primary concern for patients and their relatives. Therefore, understanding their perceptions of peritonitis is important.

OBJECTIVES

To explore patients' and relatives' perceptions of peritoneal dialysis-associated peritonitis risk, prevention measures and experiences of diagnosis, and experience of perceived stigma.

DESIGN

A sequential mixed methods study design was used, including a questionnaire and semi-structured interviews.

PARTICIPANTS

Patients using peritoneal dialysis and relatives (n = 75) from six National Health Service organisations from the United Kingdom.

MEASUREMENTS

A structured questionnaire was administered with patients and relatives (n = 75) using peritoneal dialysis; data were analysed using descriptive statistics. Thirty questionnaire respondents were then purposively sampled and interviewed in-depth; data were analysed thematically. Data were collected 2017-2018. Ethical and governance approvals were gained.

RESULTS

Qualitative and quantitative analyses were integrated and three themes presented: • Perceptions of risk: participants assessed their risk of developing peritonitis and possible implications on their health and relatives. Participants felt greatly responsible for preventing infection. • Preventing peritonitis: participants reported similar and some differing measures to minimise their risk of developing peritonitis. Participants wanted to be seen as "clean". • Diagnosis of peritonitis: peritonitis diagnosis was embarrassing and stigmatising for many individuals. This was influenced by the response of healthcare professionals and the cause of peritonitis.

CONCLUSIONS

It is important that healthcare professionals are aware of how responsible patients and relatives feel about preventing peritonitis, the emotional effect of this responsibility and crucially the impact this may have on seeking help.

Structural Equation Modelling to Identify Psychometric Determinants of Medication Adherence in a Survey of Kidney Dialysis Patients

Purpose

Medication non-adherence in dialysis patients is associated with increased mortality and higher healthcare costs. We assessed whether medication adherence is influenced by specific psychometric constructs measuring beliefs about the necessity for medication and concerns about them. We also tested whether medication knowledge, health literacy, and illness perceptions influenced this relationship.

Patients and Methods

This study is based on data from a cross-sectional in-person questionnaire, administered to a random sample of all adult dialysis patients at a teaching hospital. The main outcome was self-assessed medication adherence (8-Item Morisky Medication Adherence Scale). The predictors were: concerns about medications and necessity for medication (Beliefs About Medication Questionnaire); health literacy; medication knowledge (Medication Knowledge Evaluation Tool); cognitive, emotional, and comprehensibility Illness perceptions (Brief Illness Perception Questionnaire). Path analysis was performed using structural equations in both covariance and variance-based models.

Results

Necessity for medication increased (standardized path coefficient [β] 0.30 [95% CI 0.05, 0.54]) and concerns about medication decreased (standardized β -0.33 [-0.57, -0.09]) medication adherence, explaining most of the variance in outcome (r2=0.95). Medication knowledge and cognitive illness perceptions had no effects on medication adherence, either directly or indirectly. Higher health literacy, greater illness comprehension, and a more positive emotional view of their illness had medium-to-large sized effects in increasing medication adherence. These were indirect rather and direct effects mediated by decreases in concerns about medications (standardized β respectively -0.40 [-0.63,-0.16], -0.60 [-0.85, -0.34], -0.33 [-0.52, -0.13]).

Conclusion

Interventions that reduce patients' concerns about their medications are likely to improve adherence, rather than interventions that increase patients' perceived necessity for medication. Improving patients' general health literacy and facilitating a better understanding and more positive perception of the illness can probably achieve this. Our study is potentially limited by a lack of generalizability outside of the population and setting in which it was conducted.

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.

Factors Associated with Self-Management of Peritoneal Dialysis Patients in Urumqi of Xinjiang of China: A Cross-Sectional Survey

Purpose

To explore the factors associated with self-management of Peritoneal Dialysis (PD) patients and methods of acquiring PD knowledge.

Design

Cross-sectional survey design.

Setting

Urumqi, Xinjiang, China.

Patients

131 Chinese maintenance Peritoneal Dialysis (PD) patients.

Methods

This cross-sectional study was conducted from October 2019 to March 2020 in the First Affiliated Hospital of Xinjiang Medical University of China. 131 PD patients were recruited. Data were collected, including demographic characteristics, clinical dialysis data, self-management ability scale, and methods to obtain PD knowledge. A self-management questionnaire was used for the evaluation of self-management ability.

Results

The score of the self-management ability of PD patients in Xinjiang, China, was (57.6±13.7) points, which was at the middle level in China. There was no statistically significant difference in the self-management ability scores of patients with different ages, sex, ethnicity, marital status, pre-dialysis status, PD time, PD procedures, self-care ability, PD satisfaction, and 24-hour average urine output (P>0.05). There were significant differences in the self-management ability scores of patients with different education levels, occupations, and medical insurance forms (P<0.05). The self-management ability of PD patients was positively correlated with the disease course of uremia and attending lectures on PD knowledge (P<0.05). The main factor affecting self-management ability was education level. There 73.28% of patients considered that it was necessary to establish a WeChat group for PD patients, and 65.7% believed that establishing a WeChat group for PD patients could facilitate communication between patients and enhance treatment confidence.

Conclusion

The study surveyed PD patients who have certain self-management ability. For patients with different education levels, different health education methods should be adopted to promote the improvement of patients' self-management ability. Furthermore, WeChat is essential for Chinese PD patients to obtain disease-related information.

Impact of COVID-19 on Disease Self-management Among Patients With Advanced CKD: A Qualitative Study

Rationale & Objective

Patients with advanced chronic kidney disease (CKD) and their care partners experienced decreased access to care, and worse physical and emotional health during the Coronavirus Disease-19 (COVID-19) pandemic. Few studies have explored how COVID-19-related challenges affected disease self-management among those with advanced chronic kidney disease (CKD) and their care partners. Leventhal's self-regulation model offers a comprehensive framework for understanding disease self-management through the interplay of cognitive beliefs, emotional reactions and social influences. The study aims to examine the impact of COVID-19 on self-management activities among patients with CKD and care partners.

Study Design

Qualitative study.

Setting & Participants

Adults with advanced CKD, including dialysis and transplant recipients, and their carepartners.

Analytical Approach

Thematic Analysis.

Results

Among 42 participants, 12 had stage 4 CKD, 5 had stage 5 CKD, 6 were receiving in-center hemodialysis, 5 had a kidney transplant, and 14 were care partners. We identified 4 patient-related themes with corresponding subthemes related to the impact of COVID-19 on self-management: 1) cognitive understanding that COVID-19 is an additional health threat to existing kidney disease, 2) heightened anxiety and vulnerability driven by perceived risk, 3) coping with isolation through virtual interactions with healthcare services and social circles, 4) increased protective behaviors to maximize survival. Three care partner-related themes emerged: 1) hypervigilance in family care and protection, 2) interaction with health system and adaptations to self-management, and 3) increased intensity in caregiving role to facilitate patient self-management.

Limitations

The qualitative study design limits the ability to generate generalizable data. Grouping patients with Stage 3 and 4 CKD, in-center hemodialysis, and kidney transplants together limited our ability to examine self-management challenges specific to each treatment requirement.

Conclusions

When faced with the COVID-19 pandemic, patients with CKD and their care partners experienced heightened vulnerability and thus increased cautionary activities to maximize survival. Our study provides the groundwork for future interventions to help patients and care partners live with kidney disease during future crises.

Patients and nursing-related factors associated with switching from peritoneal dialysis to hemodialysis: A cross-sectional survey

The study aimed at analyzing patients and nursing-related factors associated with switching from peritoneal dialysis to hemodialysis. A telephone survey with 574 patients receiving care at six peritoneal dialysis centers of the Mexican Institute of Social Security was conducted: 64.3% were on peritoneal dialysis, and 35.7% had transitioned from peritoneal dialysis to hemodialysis. Data were collected on participants' sociodemographic and clinical characteristics, peritoneal dialysis center size, and nursing workload. Descriptive, bivariate, and multiple Poisson regression analyses were performed. Factors associated with an increased probability of switching from peritoneal dialysis to hemodialysis were a history of catheter dysfunction, peritonitis, and being treated in a large peritoneal dialysis center with a low (<50 patients per nurse per month) or high nursing workload (>70 patients per nurse per month) located in the State of Mexico, compared to a medium-size peritoneal dialysis center with a moderate workload (50-70 patients per nurse per month). To decrease the odds of switching from peritoneal dialysis to hemodialysis, improvement programs should aim to limit nurses' workload to 50-70 patients per nurse per month and implement evidence-based nursing interventions to prevent, detect, and manage peritonitis and peritoneal catheter dysfunction.

Evaluation of the Claria sharesource system from the perspectives of patient/caregiver, physician, and nurse in children undergoing automated peritoneal dialysis

BACKGROUND

Automated peritoneal dialysis (APD) is increasingly preferred worldwide. By using a software application (Homechoice with Claria sharesource system (CSS)) with a mod-M added to the APD device, details of the home dialysis treatment become visible for PD nurses and physicians, allowing for close supervision. We aimed to evaluate the perceptions of patients/caregivers, PD nurses, and physicians about the advantages and disadvantages of CSS.

METHODS

Three different web-based questionnaires for patients/caregivers, nurses, and physicians were sent to 15 pediatric nephrology centers with more than 1 year of experience with CSS.

RESULTS

Respective questionnaires were answered by 30 patients/caregivers, 22 pediatric nephrologists, and 15 PD nurses. Most of the nurses and physicians (87% and 73%) reported that CSS improved patient monitoring. A total of 73% of nurses suggested that CCS is not well known by physicians, while half of them reported reviewing CSS data for all patients every morning. Sixty-eight percent of physicians thought that CSS helps save time for both patients/caregivers and healthcare providers by reducing visits. However, only 20% of patients/caregivers reported reduced hospital visits. A total of 90% of patients/caregivers reported that being under constant monitoring made them feel safe, and 83% stated that the patient's sleep quality improved.

CONCLUSIONS

A remote monitoring APD system, CSS, can be successfully applied with children for increased adherence to dialysis prescription by giving shared responsibility and may help increase the patient's quality of life. This platform is more commonly used by nurses than physicians. Its potential benefits should be evaluated in further well-designed clinical studies with larger patient groups. A higher resolution version of the Graphical abstract is available as Supplementary information.

Comparison of CT acquired cardiac valvular calcification scores in hemodialysis and peritoneal dialysis patients undergoing open heart surgery

Study objective

Data is scarce regarding which dialysis modality portends more severe cardiac valvular calcification (CVC). Our aim was to compare the degree of CVC in hemodialysis (HD) and peritoneal dialysis (PD) patient cohorts prior to open heart surgery (OHS) using a CT calcium score.

Design setting and participants

Dialysis patients who underwent OHS at our institution from 2009 to 2019 and who had pre-surgical cardiac CT were included in our study. We obtained duration of dialysis modality prior to their surgical date. There were two study cohorts to evaluate outcomes of interest: mitral and aortic calcification. CVC was assessed using the Agatston score. Logistic regression was performed to test for the association of PD and HD cumulative dialysis duration with presence of CVC.

Results

A total of 214 and 166 patients met inclusion for the mitral and aortic strata, respectively. Age, female sex, and BMI were associated with higher odds of presence of mitral calcification. Age and BMI were associated with higher odds of presence of aortic calcification, while female sex was associated with lower odds in the aortic strata. Cumulative years on PD and cumulative years on HD were not significantly associated with presence of CVC in either cohort.

Conclusion

Presence of mitral and aortic calcification for patients undergoing OHS was not significantly associated with cumulative length of PD or HD after adjusting for age, gender, and BMI suggesting that there may be more factors at play in the progression of CVC in end stage renal disease patients than what was previously established.

Outcomes and perception of cloud-based remote patient monitoring in children receiving automated peritoneal dialysis: a prospective study

BACKGROUND

Remote patient monitoring (RPM) for automated peritoneal dialysis (APD) may improve clinical outcomes. Paediatric data, however, remain extremely scarce.

METHODS

We conducted a prospective observational study of children (0-18 years) receiving APD with cloud-based RPM over two 24-week periods (pre- and post-RPM). Primary outcomes were unplanned hospitalizations and fluid management. Children receiving APD without RPM (non-RPM) were included as control.

RESULTS

Seven patients (6 females) receiving APD were enrolled in the RPM programme at 11.3 years (IQR 2.6-17.1). Main indications for RPM included history of fluid overload (n = 3) and non-adherence (n = 2). Ten children were included in the non-RPM group (6 females; 16.9 years, IQR 12.8-17.6). Four patients (57.1%, 95% CI 22.5-100%) experienced fewer unplanned hospitalizations and 5 patients (71.4%, 95% CI 34.1-100%) had shorter hospital stays during the post-RPM period. The hospitalization rates and length of stay were reduced by 45% and 42%, respectively. The higher hospitalization rates among the RPM group, compared to the non-RPM group, were no longer observed following implementation of RPM. There was a significant increase in ultrafiltration (565.6 ± 248.7 vs. 501.7 ± 286.6 ml/day, p = 0.03) and reduction in systolic blood pressure (114.1 ± 12.6 vs. 119.9 ± 11.19 mmHg, p = 0.02) during the post-RPM period. All patients demonstrated satisfactory adherence. Although quality of life (PedsQL 3.0 ESRD module) was not different pre- and post-RPM, all patients agreed in the questionnaires that the use of RPM improved their quality of life and sense of security.

CONCLUSIONS

In conclusion, RPM in children receiving APD is associated with fewer and shorter unplanned hospitalizations, improved fluid management and favourable adherence to PD. A higher resolution version of the Graphical abstract is available as Supplementary information.

Peritoneal dialysis in the modern era

The practice and clinical outcomes of peritoneal dialysis (PD) have demonstrated significant improvement over the past 20 years. The aim of this review is to increase awareness and update healthcare professionals on current PD practice, especially with respect to patient and technique survival, patient modality selection, pathways onto PD, understanding patient experience of care and use prior to kidney transplantation. These improvements have been impacted, at least in part, by greater emphasis on shared decision-making in dialysis modality selection, the use of advanced laparoscopic techniques for PD catheter implantation, developments in PD connecting systems, glucose-sparing strategies, and modernising technology in managing automated PD patients remotely. Evidence-based clinical guidelines such as those prepared by national and international societies such as the International Society of PD have contributed to improved PD practice underpinned by a recognition of the place of continuous quality improvement processes.

Prevalence of Non-adherence to Prescribed Medications among Hemodialysis Patients in Makkah City

Patients with end-stage kidney disease (ESKD) are required to take multiple medications. Adherence to a complex regimen of medications is challenging and might lead to non-adherence. This study aimed to assess nonadherence to prescribed medications among patients with ESKD in Makkah City and determine the factors associated with a such behavior. A cross-sectional study was conducted at three governmental hospitals in Makkah City, Saudi Arabia. Descriptive statistics were performed to characterize participants, and a multivariable logistic regression analysis was used to determine factors associated with nonadherence to prescribed medications among patients with ESKD. In total, 358 patients have submitted completed surveys and were included in this study. A considerable number (45.25%) of participating patients were found to be nonadherent to prescribed medications. The factors: age, belief that taking medications as scheduled is important, adherence to dialysis sessions, and the number of comorbid diseases had significant and negative associations with nonadherence to prescribed medications. On the other hand, the factors: forgetfulness and having depression were significantly and positively associated with non-adherence to prescribed medications. Non-adherence to medications among patients on hemodialysis is a significant issue that leads to life-threatening complications. The factors identified as being significantly associated with nonadherence should be considered in designing future interventions to improve adherence to medications.

Polypharmacy Predicts Onset and Transition of Frailty, Malnutrition, and Adverse Outcomes in Peritoneal Dialysis Patient

BACKGROUND

Polypharmacy, frailty and malnutrition are known predictors of adverse outcomes in dialysis patients. Little has reported about their interaction and composite prognostic values. We aimed to describe the interaction between polypharmacy, frailty, nutrition, hospitalization, and survival in peritoneal dialysis patients.

METHODS

In this prospective cohort study, we recruited 573 peritoneal dialysis patients. Drug burden was measured by medication number and daily pill load. Frailty and nutrition were assessed by the validated Frailty Score (FQ) and Subjective Global Assessment (SGA) respectively. All patients were followed for two years. Primary outcome was all-cause mortality. Secondary outcomes were fall and fracture episodes, hospitalization, change in FQ and SGA.

RESULTS

At baseline, each patient took 7.5 ± 2.6 medications with 15.5 ± 8.5 tablets per day. Medication number, but not daily pill load predicted baseline FQ (p = 0.004) and SGA (p = 0.03). Over 2 years, there were 69 fall and 1,606 hospitalization episodes. In addition, 148 (25.8%) patients died, while FQ and SGA changed by 0.73 ± 4.23 and -0.07 ± 1.06 respectively in survivors. Medication number (hospitalization: p = 0.02, survival: p = 0.005), FQ (hospitalization: p < 0.001; survival: p = 0.01) predicted hospitalization and survival. Medication number also predicted fall episodes (p = 0.02) and frailty progression (p = 0.002). Daily pill load did not predict any of these outcomes.

CONCLUSIONS

Drug burden is high in peritoneal dialysis patients, and it carries important prognostic implication. Medication number but not pill load significantly predicted onset and progression of frailty, malnutrition, fall, hospitalization, and mortality.

The utility of remote patient management in peritoneal dialysis

Remote patient management (RPM) programs are one of the most crucial innovations in the peritoneal dialysis (PD) field that have been developed in the last decade. RPM programs are associated with favourable clinical outcomes by increasing the adherence of the patients to PD prescription. The literature supports that RPM is associated with increased blood pressure control and technique survival, and decreased hospitalization rate, length of hospital stay and health costs. RPM programs also facilitate patient follow-up during the coronavirus disease 2019 pandemic, increase treatment adherence and lead to better clinical outcomes. However, published data remain scarce and mainly consist of observational or retrospective studies with relatively low numbers of patients. Therefore, randomized controlled trial results will be more informative to demonstrate the effect of RPM programs on clinical outcomes.

Seeking help for peritoneal dialysis-associated peritonitis: Patients' and families' intentions and actions. A mixed methods study

AIMS

To examine patients' and families' help-seeking intentions and actions when suspecting peritoneal dialysis-associated peritonitis.

DESIGN

A sequential explanatory mixed methods design was used, comprising a questionnaire and semi-structured interviews.

METHODS

A questionnaire was designed, piloted and used with patients and family members (n=75) using peritoneal dialysis from six hospital sites in Wales and England. Questionnaire data were analysed using descriptive statistics. A purposive sample of questionnaire participants (n=30) then took part in telephone or face-to-face semi-structured interviews. Interview data were analysed thematically. Data were collected between September 2017 and August 2018. Ethical and governance approvals were obtained; the study was reported on national research portfolios.

RESULTS

The quantitative data highlighted differences between participants' knowledge of when they should seek help for suspected peritonitis and their actions when they subsequently experienced peritonitis. The interview data revealed the complexities involved with recognizing peritonitis, making the decision to seek help and accessing healthcare. Some participants struggled to recognize peritonitis when signs/symptoms started, leading to delays in deciding to seek help. Furthermore, some participants reported that they accessed help from renal or generic out-of-hours and were misadvised or misdiagnosed, delaying diagnosis and treatment. The data were integrated using conceptual analyses of help-seeking behaviour and access to healthcare, which informs understanding of the complexity of seeking help in this context.

CONCLUSIONS

This study revealed differences between participants' help-seeking intentions and actions. Using the conceptual analyses of help-seeking behaviour and access to healthcare informs understanding of the complexity of the help-seeking process in this context. To safely use a home therapy, it is imperative that individuals recognize signs/symptoms of peritonitis, seek help promptly and are appropriately supported when they access healthcare. Further work is needed to examine how these individual and system changes can be enacted.

Three week compared to seven week run-in period length and the assessment of pre-randomization adherence: A study within a trial

BACKGROUND/AIMS

To examine how measuring adherence at 3 weeks by self-report and pill counts compares to measurements at 7 weeks in a pre-randomization run-in period.

METHODS

Study within a trial of an international parallel group randomized controlled trial (RCT) that compares spironolactone to placebo. Adults receiving dialysis enter an 8-week active run-in period with spironolactone. Adherence was assessed by both self-report and pill counts in a subgroup of participants at both 3 weeks and 7 weeks.

RESULTS

332 participants entered the run-in period of which 166 had complete data. By self-report, 146/166 (94.0%) and 153/166 (92.2%) had at least 80% adherence at 3 and 7 weeks respectively (kappa = 0.27 (95% C.I. 0.16 to 0.38). By pill counts, the mean (SD) adherence was 96.5% (16.1%) and 92.4% (18.2%) at 3 and 7 weeks respectively (r = 0.32) with a mean (SD) difference of 3.1% (17.8%) and a 95% limit of agreement from -31.7% to +37.9%. The proportion of adherent participants by self-report and pill counts at 3 weeks agreed in 87.4% of participants (McNemar's p-value 0.58, kappa 0.11, p = 0.02) and at 7 weeks agreed in 92.2% (McNemar's p-value 0.82, kappa 0.47, p < 0.001).

CONCLUSIONS

Three and seven-week run-in periods and both self-reported and pill count assessments performed similarly.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03020303.

Ethical Duties of Nephrologists: When Patients Are Nonadherent to Treatment

When providing care, nephrologists are subject to various ethical duties. Beyond the Hippocratic notion of doing no harm, nephrologists also have duties to respect their patients' autonomy and dignity, to meet their patients' care goals in the least invasive way, to act impartially, and, ultimately, to do what is (clinically) beneficial for their patients. Juggling these often-conflicting duties can be challenging at the best of times, but can prove especially difficult when patients are not fully adherent to treatment. When a patient's nonadherence begins to cause harm to themselves and/or others, it may be questioned whether discontinuation of care is appropriate. We discuss how nephrologists can meet their ethical duties when faced with nonadherence in patients undergoing hemodialysis, including episodic extreme agitation, poor renal diet, missed hemodialysis sessions, and emergency presentations brought on by nonadherence. Furthermore, we consider the impact of cognitive impairment and provider-family conflict when making care decisions in a nonadherence context, as well as how the coronavirus disease 2019 pandemic might affect responses to nonadherence. Suggestions are provided for ethically informed responses, prioritizing a patient-narrative approach that is attentive to patients' values and preferences, multidisciplinarity, and the use of behavioral contracts and/or technology where appropriate.

Considering the Role of Adherence in New and Emerging Sleep Treatments

There are several novel and emerging treatments for obstructive sleep apnea (OSA), including new devices and pharmacotherapies. Long-term efficacy and adherence data for these interventions in the sleep context are lacking. Future studies exploring the long-term adherence and efficacy in novel and emerging treatments of OSA are required to fully understand the place of these treatments in treatment hierarchies. Such research also should aim to evaluate the use of these novel therapies in real-world clinical settings, because many of the studies performed to date have been done under closely monitored research populations and relatively small sample sizes.

Dietary Adherence, Self-Regulatory Fatigue and Trait Self-Control Among Chinese Patients with Peritoneal Dialysis: A Cross-Sectional Study

PURPOSE

Little is known about factors that predict dietary adherence among Chinese patients undergoing peritoneal dialysis. We investigated whether self-regulatory fatigue and trait self-control influence dietary adherence among Chinese patients with peritoneal dialysis.

METHODS

A total of 192 Chinese patients undergoing peritoneal dialysis were recruited at two peritoneal dialysis centers. The dietary adherence, trait self-control and self-regulatory fatigue of these patients were assessed using self-administered questionnaires. Clinical data were extracted from the hospital medical records. The significance of several social demographic factors on dietary adherence was analyzed using One-way ANOVA was used to analyze, whereas the association between dietary adherence and self-regulatory fatigue as well as trait self-control were analyzed using Pearson correlation. The independence association between dietary adherence and other influencing factors was assessed using Multivariable linear regression analyses.

RESULTS

We found that peritoneal dialysis patients only moderately adhere to dietary prescriptions. The top three least adherences were observed for salt intake (1.89±0.36), face of difficulty (2.86±0.26) and fluid restriction adherence intake (2.97±0.30). Multivariable linear regression analysis revealed that education level (β=0.339, P<0.001), residence (β=-0.151, P=0.015), self-regulatory fatigue (β= -0.648, P<0.001), and trait self-control (β=0.118, P=0.022) were independent predictors of dietary adherence.

CONCLUSION

Education level and residence strongly influence dietary adherence among Chinese peritoneal dialysis patients. On the other hand, Self-regulatory fatigue and trait self-control are independent predictors of dietary adherence among peritoneal dialysis patients. These findings can guide the enhancement of dietary adherence of peritoneal dialysis patients.

Multidisciplinary Team versus a "Phosphate-Counting" App for Serum Phosphate Control: A Randomized Controlled Trial

Background

Hyperphosphatemia is almost universal in well-nourished patients with ESKD treated with dialysis due to an imbalance between dietary intake and phosphate removal via residual kidney function and dialysis. Although food phosphate content can vary dramatically between meals, the current standard is to prescribe a fixed dose of phosphate binder that may not match meal phosphate intake. The primary objective of our study was to determine if the use of an app that matches phosphate binder dose with food phosphate content would be associated with an improvement in serum phosphate and a reduction in calcium carbonate intake compared with the multidisciplinary renal team.

Methods

Eighty patients with ESKD treated with peritoneal dialysis at a tertiary care hospital in Canada were randomized to the standard of care for serum phosphate management (multidisciplinary renal team) versus the OkKidney app. Serum phosphate was measured at baseline and then monthly for 3 months with adjustments to phosphate management as deemed necessary by the multidisciplinary team (control) or the phosphate binder multiplier in the OkKidney app (intervention) on the basis of the laboratory values. The primary analysis was an unpaired t test of the serum phosphate at study completion.

Results

The participants were 56 (±14) years old, and 54% were men; the most common cause of ESKD was diabetes mellitus. The serum phosphate values were 1.96 (0.41) and 1.85 (0.44) mmol/L in the control and intervention groups, respectively, at the end of 3 months (P=0.30). The median elemental daily dose of calcium carbonate did not differ between the groups at study completion (587 mg [309-928] versus 799 mg [567-1183], P=0.29).

Conclusions

The OkKidney app was associated with similar but not superior serum phosphate control to the standard of care, which included renal dietician support.

Clinical Trial registry name and registration number

US National Library Medicine ClinicalTrials.gov, NCT01643486.

The reliability and success of peritoneal dialysis during the COVID-19 pandemic

We evaluated the symptoms, changes in laboratory findings during the novel coronavirus disease (COVID-19) pandemic, and the effect of depression in patients with peritoneal dialysis (PD). This is an observational and cross-sectional study. All patients were asked to fill the clinical assessment form and Beck depression and anxiety inventory. Also, the last two laboratory evaluations during this period were examined. A total of 123 patients performing PD were included. None of the patients were diagnosed with COVID-19. In the total study population, parathyroid hormone (PTH), serum albumin, phosphorus and ferritin levels significantly elevated at the end of 97 ± 31 days. PTH and phosphorus levels remained stable in remote monitoring automated PD (RM-APD) group (p = 0.4 and p = 0.5), they tended to increase in continuous ambulatory PD group and significantly increased in automated PD group (p = 0.09 and p = 0.01 for PTH and p = 0.06 and p = 0.001 for phosphorus, respectively). Moderate to severe depression was associated with dyspnoea, weight gain more than 5 kg, fatigue, palpitation and increased anxiety. PD is a reliable and successful form of dialysis and can be safely administered even if hospital access is restricted. Also, RM-APD may be a better choice because of providing more stable bone-mineral metabolism. Moreover, evaluating depression and anxiety is essential for the accurate clinical assessment.

Patients’ and caregivers’ expectations and experiences of remote monitoring for peritoneal dialysis: A qualitative interview study

Background:

Peritoneal dialysis (PD) can offer more flexibility and independence compared with hemodialysis, yet uptake of PD remains low. Barriers to PD include the fear of dialyzing without medical assistance and uncertainty about recognizing and managing complications. There is increasing use of remote monitoring in automated peritoneal dialysis (APD), but little is known about its acceptability by patients and caregivers. We aimed to describe patients’ and caregivers’ expectations and experiences of remote monitoring for APD.

Methods:

Qualitative study design, using semi-structured face-to-face interviews of patients who either receiving PD or were considered eligible for PD, and their caregivers. Transcripts were analyzed using thematic analysis.

Results:

Of the 34 participants, 27 were patients and the remainder caregivers. Four themes (with subthemes) were identified reducing patient burden (seeking reassurance and shared responsibility, convenience and accuracy); strengthening partnerships in care (empowering knowledge and understanding, increased accountability to dialysis team); improving access to treatment (saving time and money, providing timely care and avoiding hospital); and preserving quality patient–provider interactions (enhancing face-to-face contact, clarifying expectations of access and use of data).

Conclusions:

Remote monitoring may increase patient knowledge about their kidney disease and its treatment, encourage accountability to the clinical team, enhance partnerships with clinicians, and improve access to treatment and timely care. It is also important to ensure that remote monitoring does not replace face-to-face clinical contact with clinicians.

Effect of remote patient management in peritoneal dialysis on haemodynamic and volume control

AIM

Reduced treatment compliance in patients with peritoneal dialysis facilitates the development of fluid overload and as a result increased blood pressure and vascular stiffness in the long term. We aimed to evaluate blood pressure change and anti-hypertensive needs of patients within 1 year after the changeover to remote monitoring automated peritoneal dialysis (RM-APD) and compare the effect of RM-APD and continuous ambulatory peritoneal dialysis (CAPD) on peripheral and central haemodynamic parameters, volume status of patients and anti-hypertensive drug needs.

METHODS

This was an observational and cross-sectional study. We enrolled 15 patients performing CAPD, 20 patients performing RM-APD, and 38 age, and gender-matched healthy control. We measured pulse wave velocity to assess arterial stiffness, peripheral and central haemodynamic parameters. We measured the volume status of participants via bioimpedance spectroscopy.

RESULTS

The mean excess hydration of patients who underwent CAPD were higher than those who performed RM-APD and healthy control (P = .02). We found that mean diastolic blood pressure, heart rate, central systolic and diastolic blood pressure, and central pulse pressure were significantly different between the RM-APD, CAPD and healthy control (P = .02, P = .05, P = .007, P = .05 and P = .005, respectively). Post hoc analysis of these results showed that the differences between the groups were caused by the healthy control group and the patients with underwent CAPD. Daily anti-hypertensive drug count in patients with performing RM-APD was reduced over time (P < .001).

CONCLUSION

The RM-APD provides better control of peripheral blood pressure and decrease of central haemodynamic parameters via controlling the excess body water.

Evaluating Factors Contributing to Dropout in a Large Peritoneal Dialysis Program

BACKGROUND

The low prevalence of peritoneal dialysis (PD) (9%) vs. hemodialysis (HD) (88.2%) is partly due to patient dropout from therapy.

METHODS

This retrospective study identified patients who withdrew from PD between 2016 and 2018 in our program. We evaluated all other factors as controllable losses. Analysis included time on therapy at dropout (very early, early or late) and method of initiation (HD to PD conversion, unplanned PD, or planned start).

RESULTS

Eighty-three patients enrolled into our PD program. 27 dropped out; 24 were due to controllable factors, 3 due to death, with a median age at dropout of 52 years old. We determined psychosocial factors (PF) to be the largest controllable factor influencing dropout; contributing a 63% rate among all controllable factors. When considering time until dropout, 100% of very early dropout patients and 50% of late dropout patients did so due to PF. Among early dropout patients 67% dropped out due to other medical reasons. The mean time to dropout for PF, other, and infection (INF) were 13, 26, and 33 months, respectively. When considering type of initiation, we found PF to be the largest attributable factor with 50% of unplanned, 100% of planned, and 50% of conversions stopping therapy.

CONCLUSIONS

Our study indicates that the primary reason for controllable loss from therapy was secondary to PF regardless of the time on therapy or the method of initiation to therapy.

Risk of Serious Falls Between Hemodialysis and Peritoneal Dialysis Patients: A Nationwide Population-based Cohort Study

The association between serious falls and dialysis modality [hemodialysis (HD) and peritoneal dialysis (PD)] is unclear. A nationwide population-based retrospective cohort study with 127,823 end-stage renal disease patients aged over 18 years was conducted with the unmatched cohort of 101,304 HD and 7,584 PD patients retrieved from Taiwan's National Health Insurance Research Database during 2000-2013. A total of 7,584 HD and 7,584 PD patients matched at 1:1 ratio by propensity score were enrolled to the study. Serious falls were defined by the diagnostic codes, E code, and image studies. Cox regression model and competing-risk model were used for statistical analysis. HD patients were older and had more comorbidities at baseline than PD patients. After matching and adjustment, HD patients had a higher risk of serious falls than PD patients [sHR 1.27 (95% CI 1.06-1.52)]. Females, elders, a history of falls before dialysis, comorbidity with stroke or visual problems, using diuretics, α-blockers, and mydriatics were associated with higher risks of serious falls among dialysis patients. The risk of serious falls was higher in HD patients than PD patients. Health professionals should create age-friendly environments, reduce unnecessary medications, and raise patients' awareness of falls in daily life.

eHealth interventions to support patients in delivering and managing peritoneal dialysis at home: A systematic review

Peritoneal dialysis (PD) requires patients to develop a variety of self-management skills in order to effectively deliver and manage their dialysis at home. eHealth interventions may provide patients with accessible information to develop the skills and knowledge they require to manage their treatment. This review aims to identify and evaluate 'active' eHealth interventions in supporting patients on PD. Six databases were included within the review using the terms Peritoneal Dialysis, eHealth, telemedicine and remote consultation. Studies which explored patients who were delivering PD, an intervention where the main component involved a digital device and required active engagement from patients were included. The primary outcomes examined were identified using the core outcomes recommended by the Standardised Outcomes in Nephrology in Peritoneal Dialysis initiative (PD infection, cardiovascular disease, mortality, PD failure and life participation). Hospitalisation rates were also considered as a primary outcome. Secondary outcomes included quality of life, patient skills, patient knowledge and satisfaction. Using the inclusion criteria, 15 studies (1334 participants) were included in the study. The effectiveness of eHealth interventions was mixed. Due to high heterogeneity, a meta-analysis was not possible, and quality of evidence was low. Risk of bias across the randomised studies was unclear but bias across non-randomised studies was identified as critical. There were no reported adverse effects of eHealth interventions within the included studies. Despite the high interest of eHealth interventions in PD, good quality evidence is needed to explore their effectiveness before a wider application of eHealth interventions.

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.

A Study of Executive Function in Patients with Chronic Kidney Disease before and after a Single Session of Hemodialysis

Background  Executive functions (EFs) are critical to daily life and sensitive to our physiological functioning and emotional states. The number of people living with chronic kidney disease (CKD) on hemodialysis (HD) globally is increasing steadily. We aimed to determine the impact of a single session of HD on EFs in patients with CKD receiving maintenance HD (MHD). Methods  This was a quasi-experimental study conducted at the department of psychiatry and dialysis unit of a tertiary hospital. Patients undergoing MHD underwent screening to rule out delirium, using the Confusion Assessment Method prior to EF testing. The tests of EF used were the Trail-Making Test-Part B (TMT-B) and Frontal Assessment Battery (FAB), both of which were administered before and after a session of HD. Statistical tests used were Wilcoxon matched pairs signed ranks test, paired t -test, single sample t -test, and correlation analyses. Results  The mean time taken on TMT-B before HD was 195.36 seconds and after HD, 171.1 seconds; difference is significant ( p = 0.0001). The mean FAB score was 13.19 before HD and 14.83 after HD; the difference is significant ( p < 0.0001). Significant differences were observed on similarities (p = 0.003), lexical fluency (p = 0.02), and go-no go ( p = 0.003) subtests of FAB. Mean TMT-B scores before and after HD differed significantly from that of a reference study (reference TMT-B 150.69 seconds), p = 0.0002 and 0.04, respectively. Conclusion  We conclude that patients with CKD on MHD, in general, have worse executive cognitive functioning compared with healthy populations. A session of HD results in significant improvement in these functions.

Factors affecting medication adherence among pre-dialysis chronic kidney disease patients: a systematic review and meta-analysis of literature

BACKGROUND

Medication adherence plays an essential role in slowing the progression of chronic kidney disease (CKD). This review aims to summarise factors affecting medication adherence among these pre-dialysis CKD patients.

METHODS

A systematic review of the literature was performed in Medline®, Embase®, SCOPUS® and CINAHL®. Peer-reviewed, English language articles which evaluated factors associated with medication adherence among pre-dialysis CKD patients were included. Meta-analysis was performed to assess the pooled medication adherence rates across studies. Factors identified were categorised using the World Health Organization's five dimensions of medication adherence (condition, patient, therapy, health-system, and socio-economic domains).

RESULTS

Of the 3727 articles reviewed, 18 articles were included. The pooled adherence rate across studies was 67.4% (95% CI 61.4-73.3%). The most studied medication class was anti-hypertensives (55.6%). A total of 19 factors and 95 sub-factors related to medication adherence were identified. Among condition-related factors, advanced CKD was associated with poorer medication adherence. Patient-related factors that were associated with lower medication adherence included misconceptions about medication and lack of perceived self-efficacy in medication use. Therapy-related factors which were associated with poorer medication adherence included polypharmacy while health system-based factors included loss of confidence in the physician. Socioeconomic factors such as poor social support and lower education levels were associated with poorer medication adherence.

CONCLUSION

Factors associated with poor medication adherence among pre-dialysis CKD patients were highlighted in this review. This will aid clinicians in designing interventions to optimise medication adherence among pre-dialysis CKD patients.

Evaluating a remote patient monitoring program for automated peritoneal dialysis

BACKGROUND

The benefits of automated peritoneal dialysis (APD) have been established, but patient adherence to treatment remains a concern. Remote patient monitoring (RPM) programs are a potential solution; however, the cost implications are not well established. This study modeled, from the payer perspective, expected net costs and clinical consequences of a novel RPM program in Colombia.

METHODS

Amarkov model was used to project costs and clinical outcomes for APD patients with and without RPM. Clinical inputs were directly estimated from Renal Care Services data or taken from the literature. Dialysis costs were estimated from national fees. Inpatient costs were obtained from a recent Colombian study. The model projected overall direct costs and several clinical outcomes. Deterministic and probabilistic sensitivity analyses (DSA and PSA) were also conducted to characterize uncertainty in the results.

RESULTS

The model projected that the implementation of an RPM program costing US$35 per month in a cohort of 100 APD patients over 1 year would save US$121,233. The model also projected 31 additional months free of complications, 27 fewer hospitalizations, 518 fewer hospitalization days, and 6 fewer peritonitis episodes. In the DSA, results were most sensitive to hospitalization rates and days of hospitalization, but cost savings were robust. The PSA found there was a 91% chance for the RPM program to be cost saving.

CONCLUSION

The results of the model suggest that RPM is cost-effective in APD patients which should be verified by a rigorous prospective cost analysis.

Effectiveness of using STOPP/START criteria to identify potentially inappropriate medication in people aged ≥ 65 years with chronic kidney disease: a randomized clinical trial

PURPOSE

Polypharmacy and inappropriate prescribing are common in elderly with chronic kidney disease (CKD). This study identified potentially inappropriate prescriptions (PIPs) and potential prescribing omissions (PPOs) using the Screening Tool of Older Persons' Prescriptions (STOPP) and the Screening Tool to Alert doctors to the Right Treatment (START) criteria in elderly with advanced CKD and determined the effect of a medication review on medication adherence and health-related quality of life (HRQoL).

METHODS

The intervention consisted of a medication review using STOPP/START criteria with a recommendation to a nephrologist or similar review without a recommendation. End points were prevalence of PIP and PPO, medication adherence, and HRQoL. Group differences in outcomes were assessed using a generalized linear mixed model. The trial was registered under www.clinicaltrial.gov (ID: NCT02424786).

RESULTS

We randomized 180 patients with advanced CKD (mean age 77 years, 23% female). The prevalence of PIPs and PPOs in the intervention group was 54% and 50%, respectively. The odds of PPOs were lower in the intervention than the control group (OR 0.42, 95% CI 0.19-0.92, p = 0.032), while there was no intergroup difference in the number of PIPs (OR 0.57, CI 0.27-1.20, p = 0.14). There was no difference in changes in medication adherence or HRQoL from baseline to 6 months between the groups.

CONCLUSIONS

The intervention with the STOPP/START criteria identified a high prevalence of inappropriate medications in the elderly with advanced CKD and reduced the number of PPOs. However, there was no detectable impact of the intervention on medication adherence or HRQoL.

Medication regimen complexity and medication adherence in elderly patients with chronic kidney disease

INTRODUCTION

Elderly patients with chronic kidney disease (CKD) stage 5 with or without dialysis treatment usually have concomitant comorbidities, which often result in multiple pharmacological therapies. This study aimed to identify factors associated with medication complexity and medication adherence, as well as the association between medication complexity and medication adherence, in elderly patients with CKD.

METHODS

This prospective study involved elderly patients with CKD stage 5 (estimated glomerular filtration rate < 15 ml/min/1.73m² ) recruited from three Norwegian hospitals. Most of the patients were receiving either hemodialysis or peritoneal dialysis. We used the Medication Regimen Complexity Index (MRCI) to assess the complexity of medication regimens, and the eight-item Morisky Medication Adherence Scale (MMAS-8) to assess medication adherence. Factors associated with the MRCI and MMAS-8 score were determined using either multivariable linear or ordinal logistic regression analysis.

FINDINGS

In total, 157 patients aged 76 ± 7.2 years (mean ± SD) were included in the analysis. Their overall MRCI score was 22.8 ± 7.7. In multivariable linear regression analyses, female sex (P = 0.044), Charlson Comorbidity Index of 4 or 5 (P = 0.029) and using several categories of phosphate binders (P < 0.001 to 0.04) were associated with the MRCI. Moderate or high adherence (MMAS-8 score ≥ 6) was demonstrated by 83% of the patients. The multivariable logistic regression analyses found no association of medication complexity, age or other variables with medication adherence as assessed using the MMAS-8.

DISCUSSION

Female sex, comorbidity and use of phosphate binders were associated with more-complex medication regimens in this population. No association was found between medication regimen complexity, phosphate binders or age and medication adherence. These findings are based on a homogeneous elderly group, and so future studies should test if they can be generalized to patients of all ages with CKD.

Remote Patient Management in Automated Peritoneal Dialysis: A Promising New Tool

Remote patient management (RPM) has the potential to help clinicians detect early issues, allowing intervention prior to development of more significant problems. A 23-year-old end-stage kidney disease patient required urgent start of renal replacement therapy. A newly available automated peritoneal dialysis (APD) RPM system with cloud-based connectivity was implemented in her care. Pre-defined RPM threshold parameters were set to identify clinically relevant issues. Red flag dashboard alerts heralded prolonged drain times leading to clinical evaluation with subsequent diagnosis of and surgical repositioning for catheter displacement, although it took several days for newly-RPM-exposed staff to recognize this issue. Post-PD catheter repositioning, drain times were again normal as indicated by disappearance of flag alerts and unremarkable cycle volume profiles. Identification of < 90% adherence to prescribed PD therapy was then documented with the RPM system, alerting the clinical staff to address this important issue given its association with significant negative clinical outcomes. Healthcare providers face a "learning curve" to effect optimal utilization of the RPM tool. Larger scale observational studies will determine the impact of RPM on APD technique survival and resource utilization.

Peritoneal dialysis in older adults: Evaluation of clinical, nutritional, metabolic outcomes, and quality of life

The number of older adults requiring dialysis is increasing worldwide, whereas the use of peritoneal dialysis (PD) in this population is lower with respect to younger patients, despite the theoretical advantages of PD respect to hemodialysis. This is most likely due to the concern that older patients may not be able to correctly and safely manage PD.We aimed to prospectively compare clinical, nutritional and metabolic outcomes and measures of quality of life between younger (<65 years old) and older (≥65 years old) patients on PD.PD patients were enrolled and divided into 2 groups according to age (Group A < 65 years, Group B ≥ 65 years). Clinical and instrumental parameters, and quality of life were evaluated at baseline (start of PD) (T0) and at 24 months (T1). Technique survival, mortality, total number of hospitalizations, and the index of peritonitis (episodes of peritonitis/month) were also evaluated.Fifty-one patients starting PD were enrolled. Group A included 22 patients (48.7 ± 8.3 years), and Group B consisted of 29 patients (74.1 ± 6.4 years). At baseline, the 2 groups showed no differences in cognitive status, whereas Group A showed higher total cholesterol (P = .03), LDL (P = .03), and triglycerides (P = .03) levels and lower body mass index (P = .02) and carotid intima media thickness (P < .0001) with respect to Group B. At T1 Group B showed, compared to baseline, a significant reduction in albumin (P < .0001) and phosphorus (P = .045) levels, while no significant differences on body composition, technique survival, total number of hospitalizations, index of peritonitis, and quality of life indices were observed.Our data do not show clinically relevant barriers to use PD in older adult patients, supporting its use in this population. Nutritional and metabolic parameters should be carefully monitored in older PD patients.

Remote Monitoring of Automated Peritoneal Dialysis Improves Personalization of Dialytic Prescription and Patient's Independence

BACKGROUND

Remote monitoring (RM) supports a healthcare model that enhances patients' self-management. We evaluated the utility of RM in patients undergoing automated peritoneal dialysis (APD).

METHODS

We observed 37 -RM-APD patients, 16 incidents, and 21 prevalents switched from traditional APD (T-APD). We observed the number of changes for APD prescription, the frequency of visits, and PD adequacy parameters during 1 year of RM utilization in APD.

RESULTS

The APD prescriptions were modified more frequently in RM-APD vs. T-APD in incident (p = 0.002) and prevalent patients (p = 0.045). Visits were significant less in -RM-APD than in T-APD for incident patient (p = 0.008). No significant difference was found between prevalent populations. PD adequacy was similar in both groups.

CONCLUSIONS

Our results demonstrate that RM allows an efficient use of healthcare resources, helping to improve personalization of APD prescription and to intervene early with "trouble shooting", thereby reducing the frequency of in-person visits for emergency problems.

Structural and functional differences in gut microbiome composition in patients undergoing haemodialysis or peritoneal dialysis

Complications of end-stage renal disease (ESRD) are critically related to inflammation. The gut microbiome is a key driver of inflammation. Since dialysis modalities may differently influence the gut microbiome, we aimed to compare the effects of haemodialysis (HD) and peritoneal dialysis (PD) on patients' gut microbiome composition and function. We therefore studied faecal microbiome composition and function as well as inflammation and gut permeability in 30 patients with ESRD (15 HD, 15 PD) and compared to 21 healthy controls. We found an increase in potentially pathogenic species and a decrease in beneficial species in patients on HD and to a lesser extend in patients on PD when compared to controls. These changes in taxonomic composition also resulted in differences in predicted metagenome functions of the faecal microbiome. In HD but not in PD, changes in microbiome composition were associated with an increase in c-reactive protein (CRP) but not with intestinal inflammation or gut permeability. In conclusion microbiome composition in ESRD differs from healthy controls but also between modes of dialysis. These differences are associated with systemic inflammation and cannot completely be explained by dialysis vintage. The mode of renal replacement therapy seems to be an important driver of dysbiosis in ESRD.

A Pilot Study of Okkidney, A Phosphate Counting Application in Patients on Peritoneal Dialysis

Background

Hyperphosphatemia is associated with adverse outcomes in patients treated with peritoneal dialysis (PD). We have shown that a fixed meal phosphate binder dosing schedule is not appropriate. The purpose of this study was to evaluate the beta version of OkKidney, a phosphate counting app that matches meal phosphate content with binder dose.

Methods

A convenience sample of adult patients treated with PD completed a pre-survey that included the technology readiness index (TRI 2.0). After a short information session, patients used OkKidney for 30 days. Pre- and post-intervention serum calcium, serum phosphate, and calcium carbonate binder intake were collected and compared using a paired t-test. A post-intervention survey using a 5-point Likert scale was used to gather patient feedback.

Results

Ten patients (5M, 5F) completed the study protocol. Participants were 55 ± 17 years old, predominately Caucasian, retired (60%), and owned a smartphone (70%). The median TRI score was 3.66 (max 5), indicating a moderate level of readiness. The post-survey results indicated a favorable rating for ease of use (μ = 4.4 ± 0.84) and usefulness (μ = 4.3 ± 0.68) of OkKidney. The average serum phosphate ( p = 0.99) and calcium ( p = 0.68) were not different pre-/post-intervention, but calcium carbonate intake tended to decrease ( p = 0.12).

Conclusion

Patients reported a positive experience with OkKidney. Further patient-specific adjustments of the binder dose to meal phosphate content may be required to demonstrate a statistically significant decrease in phosphate levels. We believe a larger trial is warranted to investigate the clinical implications of this app.

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.

Psychosocial Factors Predict Nonadherence to PD Treatment: A Hong Kong Survey

Background

Nonadherence to hand hygiene and aseptic regimen, dialysis environment guidelines, and catheter and exit-site care guidelines are risk factors of peritonitis. However, little is known about the psychosocial factors that account for the nonadherent behavior of patients undergoing peritoneal dialysis (PD). Applying the health belief model, this study seeks to enhance the understanding of psychosocial influences on patients’ nonadherent behavior to the 3 regimen components.

Methods

Through referrals by 7 Hong Kong renal patient support groups, we surveyed patients undergoing PD treatment.

Results

A total of 244 Hong Kong PD patients completed the questionnaires. About 90% of the patients reported no deviation from catheter and exit-site care guidelines. However, the nonadherence rates of hand hygiene and aseptic regimen and of dialysis environment guidelines were 30.3% and 23%, respectively. Longer time on PD treatment and lower family monthly income were associated with nonadherence to dialysis environment guidelines. Employed patients tended toward nonadherence to catheter and exit-site care guidelines twice as much as unemployed patients. Of the 5 health beliefs, perceived benefits, perceived barriers, and efficacy belief were significant predictors of nonadherence to the 3 regimen components.

Conclusions

The findings of this study inform the design of intervention to change patients’ behavior in regimen nonadherence for preventing peritonitis. To identify the target audience for adherence intervention based on the 3 regimen components, the results suggest dividing patients into subgroups according to their sociodemographic background. To foster behavioral change, health communicators should address patients’ health beliefs when formulating intervention strategies.

Changes of perceived control after kidney transplantation: a prospective study

AIMS

The aim of this study was to determine if kidney transplantation is associated with increases of perceived control and how changes of perceived control affect the course of psychological distress until 1 year after transplantation.

BACKGROUND

Low levels of perceived control are associated with reduced well-being among dialysis patients.

DESIGN

Prospective longitudinal cohort study.

METHODS

Perceived control (Mastery Scale) and psychological distress (GHQ-12) were prospectively assessed before (T0; n = 470) and three (T1; n = 197), six (T2; n = 210) and twelve (T3; n = 183) months after transplantation. Differences between T1 and T0 perceived control were used to stratify the sample into three groups (control gain, stable control and control loss). Socio-demographic and clinical variables, including complications, were examined as potential correlates and the course of psychological was distress compared across groups. Data were collected between July 2008 - July 2013.

RESULTS

Perceived control showed a small increase overall, with 35·1%, 50·0% and 14·9% reporting gain, stable level and loss respectively. Patients with secondary schooling were overrepresented in the control loss group. The course of psychological distress varied across perceived control change groups, with patients in the control gain group experiencing a significant reduction in psychological distress.

CONCLUSION

A considerable number of patients report increased levels of perceived control after transplantation that are associated with a subsequent decrease in psychological distress. Results emphasize the importance of perceived control and could inform interventions to facilitate well-being after kidney transplantation.

Differences in Knowledge, Stress, Sensation Seeking, and Locus of Control Linked to Dietary Adherence in Hemodialysis Patients

Patients with chronic kidney disease (CKD) often require regular hemodialysis (HD) to prolong life. However, between HD sessions, patients have to restrict their diets carefully to avoid excess accumulation of potassium, phosphate, sodium, and fluid, which their diseased kidneys can no longer regulate. Failure to adhere to their renal dietary regimes can be fatal; nevertheless, non-adherence is common, and yet little is known about the psychological variables that might predict this dietary behavior. Thus, this study aimed to assess whether dietary adherence might be affected by a variety of psychological factors including stress, personality, and health locus of control, as well as dietary knowledge, in chronic HD patients. Fifty-one patients (30 men; age range 25-85) who had undergone HD for at least 3 months and had been asked to restrict at least one of potassium, phosphate or fluid, were recruited from a hospital renal unit. Measures of adherence to each of potassium, phosphate, and fluid were derived from standard criteria for these physiological indices in renal patients. Knowledge of food/drink sources of these dietary factors, and their medical implications in relation to HD and CKD were assessed by a bespoke questionnaire. Psychological factors including stress, personality and health locus of control beliefs were measured by standardized questionnaires. Having to restrict a particular nutrient was associated with better knowledge of both food sources and medical complications for that nutrient; however, greater dietary knowledge was not linked to adherence, and knowledge of medical complications tended to be associated with poorer adherence to potassium and phosphate levels. Adherence to these two nutrient requirements was also associated with lower reported stress in the past week. Adherence was associated with differences in locus of control: these differences varied across indices although there was a tendency to believe in external loci. For potassium, phosphate, and fluid restriction, adherers were less likely to be sensation seekers but did not differ from non-adherers on impulsivity, anxiety sensitivity, or hopelessness. In conclusion, the links between dietary adherence and stress, locus of control and personality suggests that screening for such psychological factors may assist in managing adherence in HD patients.

Emotional management and biological markers of dietetic regimen in chronic kidney disease patients

The aim of the study was to investigate the association between psychological characteristics and biological markers of adherence in chronic kidney disease patients receiving conservative therapy, hemodialysis, peritoneal dialysis (PD), or kidney transplantation.

Seventy-nine adult patients were asked to complete the following questionnaires: Toronto Alexithymia scale, Snaith–Hamilton Pleasure Scale, and Short Form Health Survey. Biological markers of adherence to treatment were measured.

Peritoneal dialysis patients showed a lower capacity to feel pleasure from sensorial experience (p = .011) and a higher values of phosphorus compared to the other patients’ groups (p = .0001).

The inability to communicate emotions was negatively correlated with hemoglobin levels (r = −(0).69; p = .001) and positively correlated with phosphorus values in the PD patients (r = .45; p = .050).

Findings showed higher psychological impairments and a lower adherence to the treatment in PD patients and suggest the implication of emotional competence in adherence to treatment.

Psychosocial predictors of nonadherence to medical management among patients on maintenance dialysis

BACKGROUND

A number of reports suggest a link between depression and nonadherence to recommended management for end-stage renal disease (ESRD) patients on maintenance dialysis. However, the relationship between nonadherence and other psychosocial factors have been inadequately examined.

OBJECTIVES

To examine the prevalence of psychosocial factors including depression, anxiety, insecure attachment style, as well as cognitive impairment and their associations with adherence to recommended management of ESRD.

METHODS

A cross-sectional observational study was carried out from 2014 to 2015. Chronic dialysis patients were recruited conveniently from four major dialysis units in Riyadh, Saudi Arabia. Nonadherence was defined as decreased attendance in dialysis sessions, failure to take prescribed medications, and/or follow food/fluid restrictions and exercise recommendations.

RESULTS

A total of 234 patients (147 males and 87 females) were included in this analysis, with 45 patients (19.2%) considered as nonadherent (visual analog scale < 8). Approximately 17.9% of the patients had depression (Patient Health Questionnaire score ≥10), 13.2% had anxiety (Hospital Anxiety and Depression scale-anxiety >7), while 77.4% had cognitive impairment (Montreal Cognitive Assessment score <26). Nonadherence was significantly associated with depression and anxiety (p<0.001 for both) but not cognitive impairment (p=0.266). The Experiences in Close Relationships - Modified 16 (ECR-M16) scale score was 27.99±10.87 for insecure anxiety and 21.71±9.06 for insecure avoidance relationship, with nonadherence significantly associated with anxiety (p=0.001) but not avoidance (p=0.400).

CONCLUSION

Nonadherence to different aspects of ESRD continues to be a serious problem among dialysis patients, and it is closely linked to depression and anxiety. The findings from this study reemphasize the importance of early detection and management of psychosocial ailments in these patients.