Nonadherence to Medication Therapy in Haemodialysis Patients: A Systematic Review

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.

Barriers to kidney transplant evaluation in HIV-positive patients with advanced kidney disease: A single-center study

BACKGROUND

HIV-positive kidney transplant (KT) recipients have similar outcomes to HIV-negative recipients. However, HIV-positive patients with advanced kidney disease might face additional barriers to initiating the KT evaluation process. We sought to characterize comorbidities, viral control and management, viral resistance, and KT evaluation appointment rates in a cohort of KT evaluation-eligible HIV-positive patients.

METHODS

We included patients seen between January 1, 2008, and December 31, 2015, at a primary care HIV clinic who met KT evaluation eligibility by an estimated glomerular filtration rate ≤20 mL/min/1.73 meters² or dialysis dependence. The primary outcome was a documented appointment for KT evaluation.

RESULTS

Of 3735 patients evaluated at the HIV primary clinic during the study period, 42 (1.6%) were KT evaluation-eligible patients. The median age was 47 years, 77% were male, and 95%, black. Median CD4 count was 328 cells/mm³ (IQR 175-461). Among the 63% percent with antiretroviral therapy (ART) prescription, 40% had viral loads >200 copies. Among patients with HIV resistance profiles (50%, n = 21), 52% had resistance to at least one class of ART. A majority (60%, n = 25) were scheduled for KT evaluation appointment, but of those, only 8% (n = 2) had evidence of appointments before dialysis dependence. Those without appointments had more schizophrenia (29% vs 4%, P = .02), resistance (78% vs 33%, P = .04), ART prescription (76% vs 48%, P = .04), and more kidney disease of unknown etiology (53% vs 8%, P = .02).

CONCLUSION

Kidney transplant evaluation-eligible HIV-positive patients had a high rate of evaluation appointments, but a low rate of preemptive evaluation appointments. Schizophrenia and viral resistance disproportionally affected patients without evaluation appointments. These data precede the recommendation for universal ART for all HIV+ patients, regardless of CD4 count and viral load, and must be interpreted in the context of this limitation.

Brown Bag Simulation to Improve Medication Management in Older Adults

INTRODUCTION

Medical students must care for aging patients with growing medication lists and need training to address negative patient outcomes associated with polypharmacy. The literature shows that many trainees and practitioners are not confident in their abilities to care for this older population with complex medical conditions. We created an innovative simulation activity to teach safe, effective, and simplified medication management to second-year medical students.

METHODS

We developed the brown bag medication reconciliation simulation to improve self-efficacy and knowledge for trainees working with older adults. The case example was an older patient who presented with his brown bag of medications and prefilled pillbox for a medication reconciliation with his provider. Teams of medical students identified his medication-management errors and determined strategies for resolution. We assessed learner self-efficacy, knowledge, and satisfaction.

RESULTS

A class of 137 second-year medical students completed the simulation. The average number of learners confident about medication management in older adults increased overall by 41%, with a significant increase across all four self-efficacy domains (p < .001). The average percentage of correctly answered knowledge questions significantly increased from 85% on the presurvey to 92% on the delayed postsurvey (p = .009). Learner open-ended feedback indicated high satisfaction with the simulation.

DISCUSSION

The brown bag medication reconciliation simulation increased medical student self-efficacy and knowledge related to medication reconciliation and management for older adults. Interactive simulations like this one may be considered for inclusion in health science curricula to improve skills in medication reconciliation and management.

Patient-centered Pharmacist Care in the Hemodialysis Unit: a quasi-experimental interrupted time series study

BACKGROUND

Nonadherence to medications by patients requiring hemodialysis (HD) leads to unfavorable clinical outcomes. Limited data exist to demonstrate the effect of incorporating patient-centered interventions using concepts of medication therapy management and motivational interview by pharmacists on pharmacoadherence in patients requiring HD. Therefore, we assessed the impact of patient-centered pharmacist care on pharmacoadherence and its outcomes in patients requiring HD.

METHODS

Adult patients who had received outpatient HD for at least 3 months were enrolled. The study was conducted from October 2016 to April 2017. Pharmacists interviewed the patients at month 1, 2, 4 and 6, and the intervention (comprehensive review) occurred at months 3 and 5. The primary outcome was the change in pharmacoadherence as assessed by pre-HD serum phosphate levels and the differences in the number of medications between patient' self-report and medications records at the electronic healthcare records (EHRs). The secondary outcomes included changes in systolic blood pressure (SBP), glycosylated hemoglobin levels, serum low-density lipoprotein (LDL) levels, and the prevalence and types of medication-related problems (MRPs).

RESULTS

Seventy-two patients were enrolled. Their median age was 59 (interquartile range: 47-67.5) years, and 53% were men. Pre- and post-intervention pharmacoadherence, as indicated by serum phosphate levels and the differences in the number of medications between patient' self-report and the medication records at the EHRs, did not significantly differ (p = 0.682 and 0.348, respectively). Mean SBP and mean LDL did not significantly change post-intervention. The median number of MRPs declined between Months 3 and 5 (p = 0.002): the prevalence of MRPs at Month 3 was 44.9% (95 confidence interval [CI]: 40.4-49.3) and decreased to 29.8% (95 CI: 25.6-34.3) at Month 5. Drug use without indication was the most frequent MRP (23.9%).

CONCLUSIONS

Patient-centered pharmacist care did not result in significant changes in pharmacoadherence. However, its clinical utility as a tool to identify and mitigate MRPs in patients requiring HD is indisputable.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03576404 (retrospectively registered on July 3rd, 2018).

Electronic Health Self-Management Interventions for Patients With Chronic Kidney Disease: Systematic Review of Quantitative and Qualitative Evidence

BACKGROUND

Chronic kidney disease (CKD) poses a major challenge to public health. In CKD patients, adequate disease self-management has been shown to improve both proximal and distal outcomes. Currently, electronic health (eHealth) interventions are increasingly used to optimize patients' self-management skills.

OBJECTIVE

This study aimed to systematically review the existing evidence regarding the implementation and effectiveness of eHealth self-management interventions for patients with CKD.

METHODS

Following a search in 8 databases (up to November 2017), quantitative and qualitative data on process and effect outcomes were extracted from relevant studies. Quality was appraised using the Crowe Critical Appraisal Tool; narrative synthesis was performed to analyze the data extracted.

RESULTS

Of the 3307 articles retrieved, 24 (comprising 23 studies) were included in this review; of these, almost half were appraised to be of low to moderate quality. There was considerable heterogeneity in the types of interventions used and the outcomes measured. A total of 10 effect and 9 process outcome indicators were identified. The most frequently reported effect outcome indicators were specific laboratory tests and blood pressure (BP), whereas satisfaction was the most frequently reported process outcome indicator. Positive effects were found for proximal outcomes (eg, BP control and medication adherence), and mixed effects were found for more distal outcomes (eg, quality of life). High feasibility, usability, and acceptability of and satisfaction with eHealth self-management interventions were reported. The determinant ability of health care professionals to monitor and, if necessary, anticipate on patient measurements online was mostly cited to influence patients' adherence to interventions.

CONCLUSIONS

eHealth self-management interventions have the potential to improve disease management and health outcomes. To broaden the evidence base and facilitate intervention upscaling, more detailed descriptions and thorough analysis of the intervention components used are required. In addition, our review reveals that outcomes closely related to the scope and duration of the intervention implemented are most likely to be impacted. For instance, if a 4-week Web-based training to optimize disease management skills is implemented, the outcome perceived control would more likely be affected than kidney function. Although this seems obvious, most studies evaluate only distal outcomes and thereby fail to capture intervention effects that might contribute to long-term health improvement. We advise future researchers to carefully consider their choice of outcomes based on their sensitivity for change. In this way, we ensure that relevant effects are captured and legitimate conclusions are drawn.

Is polypharmacy an increasing burden in chronic kidney disease? The German experience

This is a commentary article describing the key findings of the German chronic kidney disease (GCKD) study and how these relate to current practice. With the GCKD study showing high levels of polypharmacy, this article discusses ways to ensure that polypharmacy is appropriate and the difficulties faced within a chronic kidney disease population. Suggestions of ways to minimize medication burden in renal patients provide some practical advice for clinicians.

A Qualitative Study on Factors Affecting Adherence Among Indian Haemodialysis Patients at a Tertiary Teaching Hospital of Southern India

Non-adherence to treatment regimen can have a detrimental effect on the heath of dialysis patients, increase mortality, morbidity and increase in healthcare service utilization and cost of hospitalization. This qualitative study explores the factors affecting adherence among the dialysis population visiting a tertiary care teaching hospital in southern India by conducting one-to-one in-depth interviews with the patients as well as key informant interview with the caregivers at the outpatient dialysis facility of a tertiary care teaching hospital. Interview transcripts were thematically analyzed using ATLAS.ti. Patient factors, health financing, cultural beliefs, caregivers’ burden and health systems factors were identified. Understanding the factors affecting adherence can help the healthcare providers and the government to devise strategies to promote adherence and improved well-being among dialysis patients. Universal health coverage for dialysis, regulations to safeguard employment, creating awareness about opting for critical illness policies through private insurance companies when the disease is not pre-existing can reduce the out-of-pocket expenditure; these are some of the important areas for consideration to promote adherence.

Modifying Phosphate Toxicity in Chronic Kidney Disease

Phosphate toxicity is a well-established phenomenon, especially in chronic kidney disease (CKD), where hyperphosphatemia is a frequent occurrence when CKD is advanced. Many therapeutic efforts are targeted at phosphate, and comprise dietary intervention, modifying dialysis schemes, treating uncontrolled hyperparathyroidism and importantly, phosphate binder therapy. Despite all these interventions, hyperphosphatemia persists in many, and its pathological influence is ongoing. In nephrological care, a somewhat neglected aspect of treatment-when attempts fail to lower exposure to a toxin like phosphate-is to explore the possibility of "anti-dotes". Indeed, quite a long list of factors modify, or are mediators of phosphate toxicity. Addressing these, especially when phosphate itself cannot be sufficiently controlled, may provide additional protection. In this narrative overview, several factors are discussed that may qualify as either such a modifier or mediator, that can be influenced by other means than simply lowering phosphate exposure. A wider scope when targeting phosphate-induced comorbidity in CKD, in particular cardiovascular disease, may alleviate the burden of disease that is the consequence of this potentially toxic mineral in CKD.

Dietary Patterns of Patients with Chronic Kidney Disease: The Influence of Treatment Modality

BACKGROUND

We analyzed the dietary patterns of Brazilian individuals with a self-declared diagnosis of chronic kidney disease (CKD) and explored associations with treatment modality.

METHODS

Weekly consumption of 14 food intake markers was analyzed in 839 individuals from the 2013 Brazil National Health Survey with a self-declared diagnosis of CKD undergoing nondialysis (n = 480), dialysis (n = 48), or renal transplant (n = 17) treatment or no CKD treatment (n = 294). Dietary patterns were derived by exploratory factor analysis of food intake groups. Multiple linear regression models, adjusted by sociodemographic and geographical variables, were used to evaluate possible differences in dietary pattern scores between different CKD treatment groups.

RESULTS

Two food patterns were identified: an "Unhealthy" pattern (red meat, sweet sugar beverages, alcoholic beverages, and sweets and a negative loading of chicken, excessive salt, and fish) and a "Healthy" pattern (raw and cooked vegetables, fruits, fresh fruit juice, and milk). The Unhealthy pattern was inversely associated with nondialysis and dialysis treatment (β: -0.20 (95% CI: -0.33; -0.06) and β: -0.80 (-1.16; -0.45), respectively) and the Healthy pattern was positively associated with renal transplant treatment (β: 0.32 (0.03; 0.62)).

CONCLUSIONS

Two dietary patterns were identified in Brazilian CKD individuals and these patterns were linked to CKD treatment modality.

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.

Pharmacotherapy related quality of life in Thai patients with chronic diseases

Background Little was known about patient's pharmacotherapy related quality of life (PTRQoL) and its differences between disease groups. Objective First, to assess PTRQoL in Thai patients with chronic diseases using the Patient-Reported Outcomes Measure of Pharmaceutical Therapy for Quality of Life (PROMPT-QoL). Second, to determine the differences in PROMPT-QoL domain scores and total scores between disease groups. Setting Three public university hospitals in Bangkok, Thailand. Method Eleven hundred and fifty-six adult outpatients continuously taking medicines to treat their diseases for at least 3 months were conveniently sampled. Bonferroni post hoc tests were used to determine the differences in eight PROMPT-QoL domain scores and total scores between 14 disease groups. Main outcome measure The descriptive statistics of PROMPT-QoL domains and the total score. Results Approximately two-thirds of all patients preferred to use only medicines for treating their diseases. Impacts of Medicines and Side-Effects and Medicine and Disease Information yielded the highest (87.3) and lowest (55.4) mean domain scores, respectively. The other domains and the total score provided the average scores between 65 and 75, which were interpreted as moderate-to-good. Bonferroni post hoc tests showed that there were five domains providing significantly different scores between disease groups. They included Medicine and Disease Information, Satisfaction with Medicine Effectiveness, Impacts of Medicines and Side-effects, Convenience, and Therapeutic Relationships with Healthcare Providers domains. Conclusion Pharmacotherapy related quality of life in Thai patients is moderate-to-good. Five of eight pharmacotherapy related quality of life domain scores differed by disease groups.

Interventional study to improve adherence to phosphate binder treatment in dialysis patients

Background

Adherence to phosphate binder treatment is important to prevent high serum phosphate level in chronic dialysis patients. We therefore wanted to investigate patient knowledge, beliefs about and adherence to phosphate binders among these patients and assess whether one-to-one pharmacist-led education and counselling enhance adherence and lead to changes in serum phosphate levels.

Methods

A descriptive, interventional, single arm, pre-post study was performed at a hospital in Norway, including chronic dialysis patients aged 18 years or more using phosphate binders. The primary end-point was change in the proportion of patients with serum phosphate below 1.80 mmol/L and the secondary end-points included change in the patient’s knowledge, beliefs and adherence after the intervention measured by completion of questionnaires ‘Patient Knowledge’, Medication Adherence Report Scale (MARS− 5) and Beliefs about Medicines Questionnaire (BMQ). Data was collected both prior to and after one-to-one pharmacist-led education and counselling about their phosphate binders. Other medicines used by the patient was also registered.

Results

A total of 69 patients were enrolled in the study. After intervention, the probability of serum phosphate being below the target threshold 1.80 mmol/L (5.58 mg/dL) increased, although no significant change in mean serum phosphate levels was seen. On the other hand, the knowledge regarding phosphate binder treatment and the patients’ beliefs about the necessity of the treatment increased, while the concerns decreased (BMQ). This effect did not lead to increase in self-reported adherence measured by MARS-5. However the scores were high before the intervention.

Conclusions

Short term one-to-one individualized pharmacist-led education and counselling about phosphate binders increased the probability of serum phosphate concentrations being below the target threshold level 1.80 mmol/L (5.58 mg/dL), although not statistically significant. However, it did not decrease the mean serum phosphate level or increase the patients’ self-reported adherence. The patients increased their knowledge about the phosphate binder and their understanding of adherence, and were less concerned about the side effects of the medication.

Trial registration

ISRCTN52852596, registered 11 April 2019. The trial was registered retrospectively.

Predictors of cinacalcet discontinuation and reinitiation in hemodialysis patients: results from 7 European countries

Background

The putative benefits of cinacalcet therapy for management of secondary hyperparathyroidism (SHPT) are thought to be most manifested when patients are taking it consistently and as prescribed. Real-world descriptions of cinacalcet prescription discontinuation and reinitiation in European hemodialysis patients are lacking. To address this knowledge gap, we used Dialysis Outcomes and Practice Patterns Study (DOPPS) data, based on dialysis facility medical records, from seven European countries to estimate rates and predictors of cinacalcet prescription discontinuation and reinitiation in hemodialysis patients and to describe the trajectories of CKD-MBD laboratory values after discontinuation.

Methods

Cox regression analyses were used to predict (1) cinacalcet discontinuation among 613 patients with ≥3 consecutive months without cinacalcet prescription immediately prior to a new cinacalcet prescription and (2) cinacalcet reinitiation among 415 patients with a newly discontinued cinacalcet prescription immediately after ≥3 consecutive months of prescribed use.

Results

Cinacalcet was discontinued in 21 and 35% of new users after 6 and 12 months, respectively. Cinacalcet was reinitiated in 38 and 49% of newly-discontinued users after 6 and 12 months, respectively. Predictors of discontinuation included lower parathyroid hormone (PTH) in the previous month (< 150 pg/ml vs. 150–299, HR = 2.57 [95% CI: 1.52–4.33]) and lower serum calcium in the previous month (< 8.4 mg/dl vs. 8.4–10.19, HR = 1.67 [95% CI: 1.08–2.59]). Predictors of reinitiation included higher PTH in the previous month (300–599 pg/ml vs. 150–299, HR = 1.88 [95% CI = 1.19–2.97]; 600+ pg/ml, HR = 3.02 [95% CI = 1.92–4.76]). After cinacalcet discontinuation, mean serum PTH increased from 408 to 510 pg/ml, mean serum calcium briefly rose from 9.12 to 9.22 mg/dl before declining to 9.06 mg/dl, and mean serum phosphorus showed little change.

Conclusions

Nephrologist discontinuation of cinacalcet therapy is common in European countries. Additional research is needed to identify optimal cinacalcet treatment strategies for SHPT management, including comparisons of intermittent cinacalcet therapy versus sustained treatment with reduced dose or frequency.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1355-5) contains supplementary material, which is available to authorized users.

Psychosocial Mediators between Socioeconomic Status and Dietary Restrictions among Patients Receiving Hemodialysis in Japan

The generalizability of differences in dietary restrictions (DRs) as function of socioeconomic status (SES) and the pathways of the associations between SES and DRs remain unclear. Therefore, we aimed to explore SES differences in DRs and psychosocial mediators between SES and DRs in Japanese patients receiving hemodialysis. This study was a cross-sectional survey of 6,644 outpatients (average age = 66.5 years; 65% males) of hemodialysis facilities across Japan. DRs were assessed by self-reported and objective measures, and SES was assessed based on education and income. Three psychosocial mediators were used: self-efficacy, control expectancy, and social support. Indirect influences of SES through the mediators were evaluated with a multiple mediator model. Although higher education was significantly associated with higher self-reported DRs, higher income was significantly associated with lower self-reported DRs. Significant SES differences in objective DRs were not observed. The relationships between education and self-reported DRs and objective DRs were significantly mediated by self-efficacy and/or control expectancy. The influences of income were mediated by social support. It becomes possible to design interventions targeting modifiable psychosocial factors including self-efficacy, control expectancy, and social support in order to reduce SES inequalities in DRs.

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.

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.

Strategies to improve dietary, fluid, dialysis or medication adherence in patients with end stage kidney disease on dialysis: A systematic review and meta-analysis of randomized intervention trials

Background

In patients with end stage kidney disease (ESKD) on dialysis, treatment non-adherence is common and results in poor health outcomes. However, the clinical benefits of interventions to improve adherence in dialysis patients are difficult to evaluate since trialled interventions and reported outcomes are highly diverse/ heterogeneous. This review summarizes existing literature on randomized controlled trials (RCTs) evaluating adherence interventions in ESKD patients focusing on the intervention category, outcome efficacy and persistence of benefit beyond the intervention.

Methods

We performed electronic database searches in Medline, Embase & Cochrane CENTRAL upto 1^st July 2018 for RCTs evaluating interventions to improve diet, fluid, medication or dialysis adherence in ESKD patients. Study characteristics including category of interventions, outcomes, efficacy and follow-up were assessed. Meta-analysis was used to compute pooled estimates of the effects on the commonest reported outcome measures.

Results

From 1311 citations, we included 36 RCTs (13 cluster-randomized trials), recruiting a total of 3510 dialysis patients (mean age 55.1 ± 5.8 years, males 58.1%). Overall risk of bias was ‘high’ for 24 and of ‘some concern’ for 12 studies. Most interventions (33 trials, 92%) addressed patient related factors, and included educational/cognitive (N = 11), behavioural / counselling (N = 4), psychological/affective (N = 4) interventions or a combination (N = 14) of the above. A majority of (28/36) RCTs showed improvement in some reported outcomes. Surrogate measures like changes in phosphate (N = 19) and inter-dialytic weight gain (N = 15) were the most common reported outcomes and both showed significant improvement in the meta-analysis. Sixteen trials reported follow-up (1–12 months) beyond intervention and the benefits waned or were absent in nine trials within 12 months post-intervention.

Conclusions

Interventions to improve treatment adherence result in modest short-term benefits in surrogate outcome measures in dialysis patients, but significant improvements in trial design and outcome reporting are warranted to identify strategies that would achieve meaningful and sustainable clinical benefits.

Limitations

Poor methodological quality of trials. Frequent use of surrogate outcomes measures. Low certainly of evidence.

The Role of Deprescribing in Older Adults with Chronic Kidney Disease

Older adults with chronic kidney disease (CKD) often experience polypharmacy, a recognized predictor of prescribing problems including inappropriately dosed medications, drug-drug and drug-disease interactions, morbidity and mortality. Polypharmacy is also associated with nonadherence, which leads to recurrent hospitalizations and poorer hemodialysis outcomes in CKD patients. Further complicating medication management in this vulnerable population are the physiologic changes that occur with both age and CKD. This guide for pharmacists and prescribers offers considerations in medication evaluation and management among older adults with CKD. Careful prescribing with the aid of tools such as the American Geriatrics Society Beers Criteria can support safe medication use and appropriate prescribing. Polypharmacy may be systematically addressed through 'deprescribing,' an evidence-based process that enables identification and elimination of unnecessary or inappropriate medications. Detailed guidance for deprescribing in older adults with CKD has not been published previously. We highlight three specific targets for medication optimization and deprescribing in older adults with CKD: (1) proton pump inhibitors, (2) oral hypoglycemic agents, including newer classes of agents, and (3) statins. These medication classes have been chosen as they represent three of the most commonly prescribed classes of medications in the United States. For each area, we review considerations for medication use in older adults with CKD and provide strategies to avoid, modify, or discontinue these medications when clinically indicated. By utilizing deprescribing techniques, pharmacists are well positioned to help decrease the medication burden in older adults with CKD, thereby potentially reducing the risk of morbidity and mortality associated with polypharmacy.

Improving Patient Experience and Treatment Adherence in the Adult, Outpatient Hemodialysis Population

BACKGROUND

The commonly employed medication reconciliation process leaves room for mismanagement of medications in the complex end-stage renal disease patient population.

PURPOSE

The purpose of this quality improvement project was to implement and evaluate a multidisciplinary education and feedback intervention designed to improve self-management for adults with end-stage renal disease.

METHODS

A pre-post, same subject repeated measures design was used to evaluate the intervention. Laboratory values, vital signs, interdialytic weight gains, dialysis attendance, and questionnaires were used to assess regimen adherence.

RESULTS

We observed improvements in patient outcomes including laboratory values, vital signs, and interdialytic weight gains. Significant improvements in process outcomes were also seen, including accuracy of medication lists, dialysis attendance, and use of remote pharmacy services.

CONCLUSIONS

A comprehensive medication review, with concurrent pharmacist access, represents a time-effective approach to improved self-management and end-stage renal disease outcomes.

Abacavir/lamivudine/dolutegravir single tablet regimen in patients with human immunodeficiency virus and end-stage renal disease on hemodialysis

No single-tablet antiretroviral (ARV) regimens (STRs) are approved for patients with human immunodeficiency virus (HIV) and end-stage renal disease (ESRD) on hemodialysis (HD). Based on known pharmacokinetic (PK) properties, abacavir (ABC)/lamivudine (3TC)/dolutegravir (DTG) STR may represent a promising option. This case series presents the safety and efficacy of ABC/3TC/DTG STR in patients with HIV and ESRD on HD. Patients were included if they were HIV-positive, maintained on intermittent HD for ESRD, switched to an ARV regimen containing ABC/3TC/DTG, and had at least one set of virologic data before and after the switch. Average age (±standard deviation) was 59 (±8) years. The majority of patients were cis-gender male and non-Hispanic Black. Only one demonstrated clinically significant resistance at baseline. All were on multiple-tablet regimens prior to the switch. Five patients (83%) achieved undetectable HIV-RNA after the switch while only four patients (46%) were undetectable immediately prior. No decline in immune function was noted. ABC/3TC/DTG STR was well tolerated. Only one patient self-reported an adverse event (nausea), which resolved without drug discontinuation. Based on these data, it appears that ABC/3TC/DTG may be a safe and effective ARV-STR option for patients with HIV and ESRD on HD. A larger trial including a PK analysis is needed to confirm these findings.

Rationale and design of technology assisted stepped collaborative care intervention to improve patient-centered outcomes in hemodialysis patients (TĀCcare trial)

Most hemodialysis (HD) patients experience symptoms of depression, pain and fatigue that impair their health-related quality of life (HRQOL) significantly. These symptoms are associated with increased hospitalization and mortality, mediated by behavioral factors (e.g. non-adherence to medication and dialysis) and biological factors (e.g. inflammatory cytokines). Prior interventions to alleviate symptoms and improve HRQOL showed limited effectiveness in HD patients and their effect on bio-behavioral mediators is lacking evidence. It is imperative to improve patient-centered dialysis care and to address call from Kidney Disease Improving Global Outcomes (KDIGO) guidelines for integration of symptom assessment and management in routine HD-care. Technology-Assisted stepped Collaborative Care (TĀCcare) is a multi-center randomized controlled trial (RCT) of 150 diverse HD patients from Pennsylvania and New Mexico, designed to compare the effectiveness of a 12-week stepped collaborative care intervention (cognitive behavioral therapy, CBT) with an attention control arm of technology-delivered health education. Collaborative care provides an integrated multi-disciplinary structured management plan. Furthermore, a stepped approach to pharmacotherapy and/or CBT allows for individualization of treatment according to patients' clinical status, preferences and treatment response. To simplify the delivery of CBT and to minimize patient and provider burden, we will use live video-conferencing with patients in dialysis units. We will examine the effect of these interventions on patient symptoms, HRQOL, treatment adherence and inflammatory biomarkers. This RCT tests a readily implementable intervention that can be integrated in routine HD-care and will generate novel and meaningful insights on strategies to alleviate common symptoms and improve HRQOL in HD.

PREVALÊNCIA E FATORES ASSOCIADOS PARA A OCORRÊNCIA DE EVENTOS ADVERSOS NO SERVIÇO DE HEMODIÁLISE

RESUMO Objetivo: analisar a prevalência e os fatores associados para a ocorrência de eventos adversos no serviço de hemodiálise. Método: estudo descritivo longitudinal com abordagem quantitativa, cuja amostra foi composta de 51 pacientes atendidos na unidade de hemodiálise entre maio e julho de 2016. Os dados foram obtidos por meio do registro diário de eventos adversos em um checklist e submetidos análise e, para as variáveis categóricas, foi realizada a análise bivariada, por meio do teste Qui-Quadrado de independência de Pearson. Resultados: foram registrados 1110 eventos adversos com prevalência em 98,03% dos pacientes, sendo os mais frequentes: erro de medicação (45,2%) e fluxo sanguíneo inadequado (42,9%). Quanto ao grau de dano, a maioria dos eventos foi de grau leve (93,8%), seguido do moderado (5,9%). A ocorrência do evento adverso esteve associada ao sexo feminino, idade menor que 40 anos, ausência de comorbidades, tempo de tratamento menor que um ano e uso de cateter venoso central de longa permanência. Conclusão: a prevalência de eventos adversos foi considerada alta, com predominância do grau leve. O estudo reforça a necessidade de estratégias de gestão e assistência para implantação de medidas de controle da ocorrência dos eventos adversos em hemodiálise, resultando em benefícios econômicos e sociais para a instituição e sua clientela.

A perspective on nonadherence to drug therapy: psychological barriers and strategies to overcome nonadherence

Medication adherence represents an inefficiency and ongoing challenge within medical care. The problem has been long-recognized - indeed, the research literature contains thousands of articles on the topic. Nonetheless, because of the complex nature of the problem, it still cannot be considered to be solved. Reasons for nonadherence are myriad but psychological barriers to adherence are most difficult to mitigate and, thus, are the focus of this paper. The present narrative review sketches a summary of theoretical models commonly utilized to understand and help address medication nonadherence; uses a patient-centered care approach to contextualize the problem of nonadherence to drug therapies; and then outlines a set of best-practice recommendations based on the extant data and framed from the perspective of the Information-Motivation-Strategy model.

Management Practice, and Adherence and Its Contributing Factors among Patients with Chronic Kidney Disease at Tikur Anbessa Specialized Hospital: A Hospital Based Cross-Sectional Study

The objective of this study was to assess the management practice, medication adherence, and factors affecting medication adherence in CKD patients at Tikur Anbessa Specialized Hospital (TASH). Methods. A cross-sectional study was conducted at the nephrology clinic of TASH. A total of 256 CKD (stages 1 and 2=50, stage 3=88, stage 4=55, and stage 5=63) patients were recruited through systematic random sampling. Data were collected from medical records and interviewing patients. The rate of adherence was determined using 8-item Morisky medication adherence scale. The data were analyzed using SPSS version 20.0 statistical software. Univariate and multivariate binary logistic regression were used to investigate the potential predictors of medication nonadherence. Results. About 57.3% of diabetes mellitus with hypertension were treated with combination of insulin and ACEI based regimens. Other cardiovascular comorbidities were predominantly treated with Acetyl Salicylic Acid in combination with β-blocker. Only 61.3% (stages 1 and 2=70%, stage 3=73.9%, stage 4=54.5%, and stage 5=43%) of the study population were adherent to their treatment regimens. Forgetfulness (79.8%) was the major reason for medication nonadherence. Patients who had an average and high monthly income were 4.14 (AOR=4.14, 95% CI: 1.45-11.84, p=0.008) and 6.17 times (AOR=6.17, 95% CI: 1.02-37.46, p=0.048) more likely to adhere as compared to those who had very low income. Patients who were prescribed with ≥5 drugs were 0.46 times (AOR= 0.54, 95% CI: 0.27-1.10, p=0.049) less likely to adhere compared to their counterpart. Patients who were students, drivers, or teachers working in private school were about 7.46 times (AOR=7.46, 95% CI: 1.49-37.26, p=0.014) more likely to adhere compared with patients who were farmers. Conclusion. Insulin and ACEIs based regimens were the most frequently used regimens in the treatment of diabetes mellitus and hypertension comorbidities. Very low income, increased number of prescribed medications, and being a farmer were the predictors of medication nonadherence.

Management practice, and adherence and its contributing factors among patients with chronic kidney disease at Tikur Anbessa Specialized Hospital: A hospital-based cross-sectional study

INTRODUCTION

Chronic kidney disease (CKD) has a complicated interrelationship with other diseases and major risk factor for cardiovascular disease. Therapeutic management for CKD patients is complicated due to co-morbidities and dominant risk factors of CKD. Non-adherence to treatment is an increasing problem for patients with CKD and it has not been extensively studied in patients with CKD. Hence, the present study was carried out to assess the management practice, medication adherence and factors affecting medication adherence in CKD patients at Tikur Anbessa Specialized Hospital (TASH).

METHODS

A hospital-based cross-sectional study was conducted at the nephrology clinic of TASH. A total of 256 patients were recruited through systematic random sampling. Data were collected from medical records and interviewing patients. The degree of adherence was determined using eight-item Morisky Medication Adherence Scale. The data were entered into Epi Info 7.2.2.2 and analyzed using SPSS version 20.0 statistical software. Descriptive statistics such as frequency, percent, mean and standard deviation were used to summarize patients' baseline characteristics. Univariable and multivariable binary logistic regression were used to investigate the potential predictors of medication non-adherence.

RESULTS

About 55% patients with hypertension only were treated with non-angiotensin converting enzyme inhibition based regimens; 57.3% of diabetes mellitus with hypertension treated with combination of insulin and ACEI based regimens. About three-fourth of patients with anemia and osteodystrophy complications were treated with iron preparations and calcium based phosphate binder. Only 61.3% of the study population were adherent to their treatment regimens. Forgetfulness (79.8%) was the major reason for medication non-adherence. Patients who had an average and high monthly income were 4.14 (AOR = 4.14, 95% CI: 1.45-11.84, p = 0.008) and 6.17 times (AOR = 6.17, 95% CI: 1.02-37.46, p = 0.048) more likely to adhere as compared to those who had very low income. Patients who were prescribed with ≥5 drugs were 0.46 times (AOR = 0.54, 95% CI: 0.27-1.10, p = 0.049) less likely to adhere compared to their counterpart. Patients who were students, drivers, teachers working in private school were about 7.46 times (AOR = 7.46, 95% CI: 1.49-37.26, p = 0.014) more likely to adhere compared with patients who were farmers.

CONCLUSION

Insulin and ACEIs based regimens were the most frequently used regimens in the treatment of diabetes mellitus and hypertension co-morbidities. Very low income, increased number of prescribed medications and being a farmer were the predictors of medication non-adherence.

Phosphate-control adherence in hemodialysis patients: current perspectives

OBJECTIVES

This review summarizes factors relevant for adherence to phosphate-control strategies in dialysis patients, and discusses interventions to overcome related challenges.

METHODS

A literature search including the terms "phosphorus", "phosphorus control", "hemo-dialysis", "phosphate binder medications", "phosphorus diet", "adherence", and "nonadherence" was undertaken using PubMed, PsycInfo, CINAHL, and Embase.

RESULTS

Hyperphosphatemia is associated with cardiovascular and all-cause mortality in dialysis patients. Management of hyperphosphatemia depends on phosphate binder medication therapy, a low-phosphorus diet, and dialysis. Phosphate binder therapy is associated with a survival benefit. Dietary restriction is complex because of the need to maintain adequate protein intake and, alone, is insufficient for phosphorus control. Similarly, conventional hemodialysis alone is insufficient for phosphorus control due to the kinetics of dialytic phosphorus removal. Thus, all three treatment approaches are important contributors, with dietary restriction and dialysis as adjuncts to the requisite phosphate binder therapy. Phosphate-control adherence rates are suboptimal and are influenced directly by patient, provider, and phosphorus-control strategy-related factors. Psychosocial factors have been implicated as influential "drivers" of adherence behaviors in dialysis patients, and factors based on self-motivation associate directly with adherence behavior. Higher-risk subgroups of nonadherent patients include younger dialysis patients and non-whites. Provider attitudes may be important - yet unaddressed - determinants of adherence behaviors of dialysis patients.

CONCLUSION

Adherence to phosphate binders, low-phosphorus diet, and dialysis prescription is suboptimal. Multicomponent strategies that concurrently address therapy-related factors such as side effects, patient factors targeting self-motivation, and provider factors to improve attitudes and delivery of culturally sensitive care show the most promise for long-term control of phosphorus levels. Moreover, it will be important to identify patients at highest risk for lack of control, and for programs to be ready to deliver flexible person-centered strategies through training and dedicated resources to align with the needs of all patients.

The Effect of Quality of Life on Medication Compliance Among Dialysis Patients

Dialysis treatment is known to lead to reduced quality of life (QOL) among patients. This decreased QOL is believed to influence medication compliance, although this effect has not yet been clarified. In this study, we investigated whether decreased QOL due to dialysis treatment does in fact influence medication compliance. Participants were 92 patients who self-managed their medication and were receiving dialysis treatment at Secomedic Hospital or Chiba Central Medical Center. We surveyed their age, sex, dialysis period, and medication management situation, and administered the EQ-5D and Kidney Disease Quality of Life Instrument-Short Form. A multiple logistic regression analysis with medication compliance as the dependent variable and QOL as the independent variable was conducted. The recovery rate and effective response rate were both 100%. The results indicated that patients with good sleep QOL (mean or above) had higher odds of medication compliance (odds ratio, 3.36; 95% confidence interval, 1.26-8.96; P = 0.016). Therefore, improving the quality of sleep of dialysis patients might help to improve their medication compliance.

Role of etelcalcetide in the management of secondary hyperparathyroidism in hemodialysis patients: a review on current data and place in therapy

Secondary hyperparathyroidism (sHPT) is a frequently occurring severe complication of advanced kidney disease. Its clinical consequences include extraskeletal vascular and valvular calcifications, changes in bone metabolism resulting in renal osteodystrophy, and an increased risk of cardiovascular morbidity and mortality. Calcimimetics are a cornerstone of parathyroid hormone (PTH)-lowering therapy, as confirmed by the recently updated 2017 Kidney Disease: Improving Global Outcomes chronic kidney disease – mineral and bone disorder clinical practice guidelines. Contrary to calcitriol or other vitamin D-receptor activators, calcimimetics reduce PTH without increasing serum-calcium, phosphorus, or FGF23 levels. Etelcalcetide is a new second-generation calcimimetic that has been approved for the treatment of sHPT in adult hemodialysis patients. Whereas the first-generation calcimimetic cinacalcet is taken orally once daily, etelcalcetide is given intravenously thrice weekly at the end of the hemodialysis session. Apart from improving drug adherence, etelcalcetide has proven to be more effective in lowering PTH when compared to cinacalcet, with an acceptable and comparable safety profile. The hope for better gastrointestinal tolerance with intravenous administration did not come true, as etelcalcetide did not significantly mitigate the adverse gastrointestinal effects associated with cinacalcet. Enhanced adherence and strong reductions in PTH, phosphorus, and FGF23 could set the stage for a future large randomized controlled trial to demonstrate that improved biochemical control of mineral metabolism with etelcalcetide in hemodialysis patients translates into cardiovascular and survival benefits and better health-related quality of life.

Influence of Major Coping Strategies on Treatment Non-adherence and Severity of Comorbid Conditions in Hemodialysis Patients

BACKGROUND

Non-adherence and comorbidities are prevalent among hemodialysis patients and are associated with increased mortality and financial burden. We aimed to investigate the influence of major coping strategies (CSs) on non-adherence and comorbidities in hemodialysis patients.

METHODS

A total of 49 patients were enrolled. We collected participant data including CS measured by a Korean version of the ways of coping questionnaire (K-WCQ), comorbidities measured by age-adjusted Charlson comorbidity index (CCI), and adherence measured by the 8-item Morisky medication adherence scale (MMAS-8).

RESULTS

Regarding major CS, 61.2% of participants reported use of support-seeking CS (SUP group), 14.3% reported use of problem-focused CS (PRO group), and 24.5% reported use of hopeful-thinking CS (HOP group). The mean MMAS-8 score was higher in the PRO group than in the HOP group (P = 0.024). The mean CCI score was lower in the PRO group than in the HOP group (P = 0.017). In the HOP group, the severity of somatic symptoms was positively correlated with the scores for the emotion-focused CS subscale (r = 0.39, P = 0.029) and the hopeful-thinking CS subscale (r = 0.38, P = 0.036) of the K-WCQ. The level of life satisfaction positively correlated with the score for the problem-focused CS subscale in the HOP group (r = 0.40, P = 0.027).

CONCLUSION

We should pay more attention to the CSs of hemodialysis patients and provide interventions that promote problem-focused CSs, especially for nonadherent patients with high comorbidity rates who mainly use a hopeful-thinking CS.

Is quality of life associated with compliance to pharmacoterapy in patients with chronic kidney disease undergoing maintenance hemodialysis?

Objective

To analyzed the association of quality of life and compliance to drug treatment in chronic kidney disease patients.

Methods

The Short Form Health Survey was used to evaluate the quality of life of these patients, and the therapeutic complexity index was verified. The Morisky-Green test and the Brief Medication Questionnaire were applied to check compliance to drug therapy.

Results

A total of 197 patients were included. The Morisky-Green test and Brief Medication Questionnaire showed that most patients had low compliance to treatment (50.3% and 80.6%, respectively). Compliance was highly associated with gender (male) and slightly associated with complexity of therapy, mental health, and social aspects.

Conclusion

We observed a slight association between compliance to pharmacotherapy and quality of life and complexity of therapy, and a strong association with gender.

Influence of pH and phosphate concentration on the phosphate binding capacity of five contemporary binders. An in vitro study

AIM

Hyperphosphataemia is associated with increased mortality and morbidity in end stage renal disease. Despite phosphate binder therapy, a large proportion of patients do not reach the treatment target. In five contemporary binders we explored the influence of pH and phosphate concentration on phosphate binding. This interaction could be of relevance in clinical practice.

METHODS

Phosphate binding was quantified in vitro in 25 mL of purified water containing phosphate concentrations of 10, 15 and 20 mM and baseline pH values of 3.0 or 6.0, with a binder over 6 h. Lanthanum carbonate, calcium acetate/magnesium carbonate, sevelamer carbonate, calcium carbonate and sucroferric oxyhydroxide, 67 mg of each, were used. The experiments were performed in duplicate. The primary outcome was the difference in the amount of bound phosphate for each binder after 6 h in solutions at two different pH values. Secondary outcomes were the influence of phosphate concentration on phosphate binding, next to binding patterns and phosphate binder saturation.

RESULTS AND CONCLUSION

In this specific in vitro setting, lanthanum carbonate, sevelamer carbonate, calcium carbonate and sucroferric oxyhydroxide bound more phosphate in the solution with baseline pH of 3.0. Differences however were small except for lanthanum carbonate. Calcium acetate/magnesium carbonate was most effective in a solution with baseline pH of 6.0. All phosphate binders bound more phosphate in solutions with higher concentrations of phosphate. Sevelamer carbonate, calcium acetate/magnesium carbonate and sucroferric oxyhydroxide bound most phosphate in the first hour and reached maximum binding capacity in less than 6 h.

Prevention and treatment of hyperphosphatemia in chronic kidney disease

Hyperphosphatemia has consistently been shown to be associated with dismal outcome in a wide variety of populations, particularly in chronic kidney disease (CKD). Compelling evidence from basic and animal studies elucidated a range of mechanisms by which phosphate may exert its pathological effects and motivated interventions to treat hyperphosphatemia. These interventions consisted of dietary modifications and phosphate binders. However, the beneficial effects of these treatment methods on hard clinical outcomes have not been convincingly demonstrated in prospective clinical trials. In addition, exposure to high amounts of dietary phosphate may exert untoward actions even in the absence of overt hyperphosphatemia. Based on this concept, it has been proposed that the same interventions used in CKD patients with normal phosphate concentrations be used in the presence of hyperphosphatemia to prevent rise of phosphate concentration and as an early intervention for cardiovascular risk. This review describes conceptual models of phosphate toxicity, summarizes the evidence base for treatment and prevention of hyperphosphatemia, and identifies important knowledge gaps in the field.

Changes in retina and choroid after haemodialysis assessed using optical coherence tomography angiography

BACKGROUND

Reports of choroidal and retinal changes before and after haemodialysis are few and have been controversial. Traditional imaging modalities are insufficient for quantitative assessment. This study aims to use optical coherence tomography angiography to monitor the short-term vascular density and thickness changes in retina and choroid before and after haemodialysis.

METHODS

Seventy-seven eyes of 77 patients with end-stage kidney disease undergoing haemodialysis were included. Ophthalmologic examinations including optical coherence tomography angiography were performed one hour before and after haemodialysis. The vascular density of retina and choroid were measured and calculated by optical coherence tomography angiography. The retinal thickness and subfoveal choroidal thickness were measured manually using Image J software. The relationships between the changes in ocular and systemic parameters after haemodialysis were evaluated.

RESULTS

The systolic blood pressure decreased from 123.7 ± 19.7 to 116.9 ± 24.6 mmHg (p < 0.05) in all patients. The mean ocular perfusion pressure decreased significantly after haemodialysis in both diabetic and non-diabetic groups (p < 0.05). Mean retinal thickness decreased from 204.7 ± 22.4 μm to 200.8 ± 22.8 μm (p < 0.05) after haemodialysis in all patients. The vascular density of outer retina was decreased from 38.8 ± 5.5 per cent to 37.5 ± 3.4 per cent (p < 0.05) after haemodialysis in all patients. The changes in diastolic blood pressure, intraocular pressure, subfoveal choroidal thickness, vascular density of the superficial capillary plexus, deep capillary plexus and choriocapillaris were insignificant. There was no significant correlation between systolic blood pressure and the vascular density of the outer retina.

CONCLUSION

In optical coherence tomography angiography, the retinal thickness became thinner and the vascular density in the outer retina decreased after haemodialysis in patients with end-stage kidney disease. The change of subfoveal choroidal thickness showed no significance after haemodialysis. The decreased volume in the retinal vascular bed and deficient choroidal autoregulatory control of ocular blood flow might be involved in the mechanism of these changes.

Hemodialysis Self-management Intervention Randomized Trial (HED-SMART): A Practical Low-Intensity Intervention to Improve Adherence and Clinical Markers in Patients Receiving Hemodialysis

BACKGROUND

Poor adherence to treatment is common in hemodialysis patients. However, effective interventions for adherence in this population are lacking. Small studies of behavioral interventions have yielded improvements, but clinical effectiveness and long-term effects are unclear.

STUDY DESIGN

Multicenter parallel (1:1) design, blinded cluster-randomized controlled trial.

SETTING & PARTICIPANTS

Patients undergoing maintenance hemodialysis enrolled in 14 dialysis centers.

INTERVENTION

Dialysis shifts of eligible patients were randomly assigned to either an interactive and targeted self-management training program (HED-SMART; intervention; n=134) or usual care (control; n=101). HED-SMART, developed using the principles of problem solving and social learning theory, was delivered in a group format by health care professionals over 4 sessions.

OUTCOMES & MEASUREMENTS

Serum potassium and phosphate concentrations, interdialytic weight gains (IDWGs), self-reported adherence, and self-management skills at 1 week, 3 months, and 9 months postintervention.

RESULTS

235 participants were enrolled in the study (response rate, 44.2%), and 82.1% completed the protocol. IDWG was significantly lowered across all 3 assessments relative to baseline (P<0.001) among patients randomly assigned to HED-SMART. In contrast, IDWG in controls showed no change except at 3 months, when it worsened significantly. Improvements in mineral markers were noted in the HED-SMART arm at 3 months (P<0.001) and in potassium concentrations (P<0.001) at 9 months. Phosphate concentrations improved in HED-SMART at 3 months (P=0.03), but these effects were not maintained at 9 months postintervention. Significant differences between the arms were found for the secondary outcomes of self-reported adherence, self-management skills, and self-efficacy at all time points.

LIMITATIONS

Low proportion of patients with diabetes.

CONCLUSIONS

HED-SMART provides an effective and practical model for improving health in hemodialysis patients. The observed improvements in clinical markers and self-report adherence, if maintained at the longer follow-up, could significantly reduce end-stage renal disease-related complications. Given the feasibility of this kind of program, it has strong potential for supplementing usual care.

TRIAL REGISTRATION

Registered at ISRCTN with study number ISRCTN31434033.

Selective Nanoparticle Targeting of the Renal Tubules

Direct targeting to the kidneys is a promising strategy to improve drug therapeutic index for the treatment of kidney diseases. We sought to investigate the renal selectivity and safety of kidney-targeted mesoscale nanoparticle technology. We found that direct intravenous administration of these particles resulted in 26-fold renal selectivity and localized negligibly in the liver or other organs. The nanoparticles targeted the renal proximal tubular epithelial cells, as evidenced by intravital microscopy and ex vivo imaging. Mice treated with the nanoparticles exhibited no negative systemic consequences, immune reaction, liver impairment, or renal impairment. The localization of material selectively to the renal tubules is uncommon, and this work portends the development of renal-targeted drugs for the treatment of kidney diseases.

Hemodialysis Patients' Information and Associated Characteristics

Introduction

of this study was to explore characteristics associated with hemodialysis patients' degree of information.

Material and Methods

The sample of the study included 650 patients undergoing hemodialysis. For data collection a questionnaire specially designed for the needs of the research was used. More specifically, socio-demographic, clinical and other patients' characteristics were associated with the degree of information as it was reported by patients.

Results

of the 650 participants, 55.4% was men while 58.6% of the sample was aged over 60 years. Regarding information level, results showed that only 9.8% was "little" or "not all" informed about their health problem, 61,7% was "enough" informed whereas 28.5% were "very" informed. Statistically significant association was observed between degree of information and age (p=<0.001), family status (p=0.005), education (p=0.001), job (p=0.005) and number of children (p=0.019). In terms of clinical characteristics, statistically significant association was observed between the degree of information and whether patients had other disease or not (p=0.037), whether patients reported adherence to treatment guidelines (p=<0.001). Finally, statistically significant association was observed between the degree of information and relations with nursing staff (p=<0.001), doctors (p=0.007) and other patients (p=0.003), and whether patients faced difficulties in social (p=0.001) and family environment (p=0.002).

Conclusion

Health professionals when planning information interventions for orienting hemodialysis patients is increasingly important to evaluate socio-demographic, clinical and other patients ' characteristics and incorporate them in their project.

Features and Effects of Information Technology-Based Interventions to Improve Self-Management in Chronic Kidney Disease Patients: a Systematic Review of the Literature

Slowing down the progression of chronic kidney disease (CKD) and its adverse health outcomes requires the patient's self-management and attention to treatment recommendations. Information technology (IT)-based interventions are increasingly being used to support self-management in patients with chronic diseases such as CKD. We conducted a systematic review of randomized controlled trials (RCTs) to assess the features and effects of IT-based interventions on self-management outcomes of CKD patients. A comprehensive search was conducted in Medline, Scopus, and the Cochrane Library to identify relevant papers that were published until May 2016. RCT Studies that assessed at least one automated IT tool in patients with CKD stages 1 to 5, and reported at least one self-management outcome were included. Studies were appraised for quality using the Cochrane Risk of Bias assessment tool. Out of 12,215 papers retrieved, eight study met the inclusion criteria. Interventions were delivered via smartphones/personal digital assistants (PDAs) (three studies), wearable devices (three studies), computerized systems (one study), and multiple component (one study). The studies assessed 15 outcomes, including eight clinical outcomes and seven process of care outcomes. In 12 (80%) of the 15 outcomes, the studies had revealed the effects of the interventions as statistically significant positive. These positive effects were observed in 75% of the clinical outcomes and 86% of the process of care outcomes. The evidence indicates the potential of IT-based interventions (i.e. smartphones/PDAs, wearable devices, and computerized systems) in self-management outcomes (clinical and process of care outcomes) of CKD patients.

Earthquake Preparedness Among Japanese Hemodialysis Patients in Prefectures Heavily Damaged by the 2011 Great East Japan Earthquake

The purpose of this study was to explore the factors related to earthquake preparedness in Japanese hemodialysis patients. We focused on three aspects of the related factors: health condition factors, social factors, and the experience of disasters. A mail survey of all the members of the Japan Association of Kidney Disease Patients in three Japanese prefectures (N = 4085) was conducted in March, 2013. We obtained 1841 valid responses for analysis. The health factors covered were: activities of daily living (ADL), mental distress, primary renal diseases, and the duration of dialysis. The social factors were: socioeconomic status, family structure, informational social support, and the provision of information regarding earthquake preparedness from dialysis facilities. The results show that the average percentage of participants that had met each criterion of earthquake preparedness in 2013 was 53%. Hemodialysis patients without disabled ADL, without mental distress, and requiring longer periods of dialysis, were likely to meet more of the earthquake preparedness criteria. Hemodialysis patients who had received informational social support from family or friends, had lived with spouse and children in comparison to living alone, and had obtained information regarding earthquake preparedness from dialysis facilities, were also likely to meet more of the earthquake preparedness criteria.

Medication adherence perspectives in haemodialysis patients: a qualitative study

Background

End-stage kidney disease patients undergoing haemodialysis are prescribed with multiple complex regimens and are predisposed to high risk of medication nonadherence. The aims of this study were to explore factors associated with medication adherence, and, to examine the differential perspectives on medication-taking behaviour shown by adherent and nonadherent haemodialysis patients.

Methods

A qualitative exploratory design was used. One-on-one semi-structured interviews were conducted with 30 haemodialysis patients at the outpatient dialysis facility in Hobart, Australia. Patient self-reported adherence was measured using 4-item Morisky Green Levine scale. Interview transcripts were thematically analysed and mapped against the World Health Organization (WHO) determinants of medication adherence.

Results

Participants were 44–84 years old, and were prescribed with 4–19 medications daily. More than half of the participants were nonadherent to their medications based on self-reported measure (56.7%, n = 17). Themes mapped against WHO adherence model comprised of patient-related (knowledge, awareness, attitude, self-efficacy, action control, and facilitation); health system/ healthcare team related (quality of interaction, and mistrust and collateral arrangements); therapy-related (physical characteristics of medicines, packaging, and side effects); condition-related (symptom severity); and social/ economic factors (access to medicines, and relative affordability).

Conclusions

Patients expressed a number of concerns that led to nonadherence behaviour. Many of the issues identified were patient-related and potentially modifiable by using psycho-educational or cognitive-behavioural interventions. Healthcare professionals should be more vigilant towards identifying these concerns to address adherence issues. Future research should be aimed at understanding healthcare professionals’ perceptions and practices of assessing medication adherence in dialysis patients that may guide intervention to resolve this significant issue of medication nonadherence.

Electronic supplementary material

The online version of this article (doi:10.1186/s12882-017-0583-9) contains supplementary material, which is available to authorized users.

A Modified Version of the Greek Simplified Medication Adherence Questionnaire for Hemodialysis Patients

Non-adherence to the therapeutic regimen is an increasingly growing problem especially among patients undergoing hemodialysis. The aim of this study was to modify the Greek version of Simplified Medication Adherence Questionnaire (GR-SMAQ) for patients undergoing hemodialysis (GR-SMAQ-HD) and explore its validity and reliability. Between June 2016 and November 2016 a group of patients undergoing hemodialysis (N=107) completed the Greek version of SMAQ. The study was carried out in three Dialysis Units of Hospitals of Athens and Peloponnese region, Greece. The form of GR-SMAQ was modified specifically for renal patients while four additional items were added so as the tool study all aspects of adherence to hemodialysis regimen. Construct validity was checked through exploratory factor analysis with principal Component Analysis with the Equamax method. Test-retest reliability and internal consistency were tested. Statistical analysis was performed using the IBM SPSS Statistics version 21. The significance level was set up at 5%. The Greek version of SMAQ for patients undergoing hemodialysis includes eight questions. Three factors emerged from factor analysis. Cronbach’s a coefficient was 0.742 for the whole scale and for each subscale was for Medication Adherence 0.75, for Attendance at hemodialysis session 0.856 and for Diet/Fluid restriction was 0.717. The total mean score was 6.29 (±1.82). GR-SMAQ-HD is a reliable and valuable tool that can be used by hemodialysis nurses and students of nursing for detection of adherence levels in clinical practice.

Coping with kidney disease - qualitative findings from the Empowering Patients on Choices for Renal Replacement Therapy (EPOCH-RRT) study

Background

The highly burdensome effects of kidney failure and its management impose many life-altering changes on patients. Better understanding of successful coping strategies will inform patients and help health care providers support patients’ needs as they navigate these changes together.

Methods

A qualitative, cross-sectional study involving semi-structured telephone interviews including open- and closed-ended questions, with 179 U.S. patients with advanced chronic kidney disease (CKD), either not yet on dialysis ([CKD-ND], n = 65), or on dialysis (hemodialysis [HD], n = 76; or peritoneal dialysis [PD], n = 38) recruited through social media and in-person contacts from June to December 2013. Themes identified through content analysis of interview transcripts were classified based on the Coping Strategies Index (CSI) and compared across groups by demographics, treatment modality, and health status.

Results

Overall, more engagement than disengagement strategies were observed. “Take care of myself and follow doctors’ orders,” “accept it,” and “rely on family and friends” were the common coping themes. Participants often used multiple coping strategies. Various factors such as treatment modality, time since diagnosis, presence of other chronic comorbidities, and self-perceived limitations contributed to types of coping strategies used by CKD patients.

Conclusions

The simultaneous use of coping strategies that span different categories within each of the CSI subscales by CKD patients reflects the complex and reactive response to the variable demands of the disease and its treatment options on their lives. Learning from the lived experience of others could empower patients to more frequently use positive coping strategies depending on their personal context as well as the stage of the disease and associated stressors. Moreover, this understanding can improve the support provided by health care systems and providers to patients to better deal with the many challenges they face in living with kidney disease.