Adherence to hemodialysis dietary sodium recommendations: influence of patient characteristics, self-efficacy, and perceived barriers

Predictors of excess fluid volume in hemodialysis patients: an observational study

OBJECTIVES

to assess risk factors for excess fluid volume in hemodialysis patients.

METHODS

a retrospective case-control study was conducted. A total of 392 patients (196 cases and 196 controls) from two hemodialysis centers were included. Sociodemographic data and 23 risk factors for excess fluid volume were assessed using a data collection form. Data were analyzed using a multivariate logistic regression model.

RESULTS

the insufficient knowledge (OR=2.06), excessive fluid intake (OR=2.33), inadequate fluid removal during hemodialysis (OR=2.62) and excessive sodium intake (OR=1.91) risk factors may increase the chance of occurrence of excess fluid volume in hemodialysis patients by approximately two times. Education level (OR=0.95) and age (OR=0.97) are protective factors for excessive fluid volume.

CONCLUSIONS

knowing these risk factors may help nurses with accurate and rapid diagnostic inference of the risk of excessive fluid volume.

Association between home meal preparers and salt intake in haemodialysis patients: a cross-sectional study

OBJECTIVES

This study aimed to examine the association between home meal preparer and salt intake among haemodialysis patients, including daily dietary status. We hypothesised that salt intake is higher among individuals who rely on meal preparation from others than those who prepare meals by themselves.

DESIGN

Cross-sectional study.

SETTING

Two medical facilities in Fukushima Prefecture, Japan.

PARTICIPANTS

237 haemodialysis outpatients who visited one of the medical facilities between February 2020 and August 2021 and were diagnosed with anuria, defined as urination of <100 mL/day, were the potential participants of the present study. Finally, 181 participants (131 male and 50 female) were included in the analysis.

OUTCOME MEASURE

Salt intake amount was calculated from the results of predialysis and postdialysis blood draws, using Watson's formula based on predialysis weight, predialysis serum sodium level, postdialysis weight and serum sodium level at the end of dialysis.

RESULTS

Salt intake was significantly higher in participants who relied on meal preparation from others ('relying on others') than those who prepared meals by themselves ('self-prepared') (B=1.359; 95% CI: 0.495 to 2.222). No statistical difference was found between individuals who ate out or ate takeout ('outsourcing') and those who prepared their own meals ('self-prepared'). These results were robust after adjustment for confounding factors.

CONCLUSIONS

The present study revealed an association between self-preparation of meals at home and reduced salt intake among dialysis patients. Our findings suggest that whoever is the home meal preparer is possibly a social determinant of salt intake. To improve the prognosis of haemodialysis patients, actively reaching out to the family and assessing their social environment, such as identifying the home meal preparer and, if the patient relies on others for meal preparation, conducting nutritional/dietary guidance for that person, are effective in enhancing salt reduction.

Digital Healthy Diet Literacy and Fear of COVID-19 as Associated with Treatment Adherence and Its Subscales among Hemodialysis Patients: A Multi-Hospital Study

Treatment adherence (TA) is a critical issue and is under-investigated in hemodialysis patients. A multi-center study was conducted from July 2020 to March 2021 on 972 hemodialysis patients in eight hospitals in Vietnam to explore the factors associated with TA during the COVID-19 pandemic. Data were collected, including socio-demographics, an End-Stage Renal Disease Adherence Questionnaire (ESRD-AQ), 12-item short-form health literacy questionnaire (HLS-SF12), 4-item digital healthy diet literacy scale (DDL), 10-item hemodialysis dietary knowledge scale (HDK), 7-item fear of COVID-19 scale (FCoV-19S), and suspected COVID-19 symptoms (S-COVID19-S). Bivariate and multivariate linear regression models were used to explore the associations. Higher DDL scores were associated with higher TA scores (regression coefficient, B, 1.35; 95% confidence interval, 95%CI, 0.59, 2.12; p = 0.001). Higher FCoV-19S scores were associated with lower TA scores (B, -1.78; 95%CI, -3.33, -0.24; p = 0.023). In addition, patients aged 60-85 (B, 24.85; 95%CI, 6.61, 43.11; p = 0.008) with "very or fairly easy" medication payment ability (B, 27.92; 95%CI, 5.89, 44.95; p = 0.013) had higher TA scores. Patients who underwent hemodialysis for ≥5 years had a lower TA score than those who received <5 years of hemodialysis (B, -52.87; 95%CI, -70.46, -35.28; p < 0.001). These findings suggested that DDL and FCoV-19S, among other factors, should be considered in future interventions to improve TA in hemodialysis patients.

Interventions for improving health literacy in people with chronic kidney disease

BACKGROUND

Low health literacy affects 25% of people with chronic kidney disease (CKD) and is associated with increased morbidity and death. Improving health literacy is a recognised priority, but effective interventions are not clear.

OBJECTIVES

This review looked the benefits and harms of interventions for improving health literacy in people with CKD.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 12 July 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. We also searched MEDLINE (OVID) and EMBASE (OVID) for non-randomised studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and non-randomised studies that assessed interventions aimed at improving health literacy in people with CKD.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for eligibility and performed risk of bias analysis. We classified studies as either interventions aimed at improving aspects of health literacy or interventions targeting a population of people with poor health literacy. The interventions were further sub-classified in terms of the type of intervention (educational, self-management training, or educational with self-management training). Results were expressed as mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals (CI) for continuous outcomes and risk ratios (RR) with 95% CI for dichotomous outcomes.

MAIN RESULTS

We identified 120 studies (21,149 participants) which aimed to improve health literacy. There were 107 RCTs and 13 non-randomised studies. No studies targeted low literacy populations. For the RCTs, selection bias was low or unclear in 94% of studies, performance bias was high in 86% of studies, detection bias was high in 86% of studies reporting subjective outcomes and low in 93% of studies reporting objective outcomes. Attrition and other biases were low or unclear in 86% and 78% of studies, respectively. Compared to usual care, low certainty evidence showed educational interventions may increase kidney-related knowledge (14 RCTs, 2632 participants: SMD 0.99, 95% CI 0.69 to 1.32; I² = 94%). Data for self-care, self-efficacy, quality of life (QoL), death, estimated glomerular filtration rate (eGFR) and hospitalisations could not be pooled or was not reported. Compared to usual care, low-certainty evidence showed self-management interventions may improve self-efficacy (5 RCTs, 417 participants: SMD 0.58, 95% CI 0.13 to 1.03; I² = 74%) and QoL physical component score (3 RCTs, 131 participants: MD 4.02, 95% CI 1.09 to 6.94; I² = 0%). There was moderate-certainty evidence that self-management interventions probably did not slow the decline in eGFR after one year (3 RCTs, 855 participants: MD 1.53 mL/min/1.73 m², 95% CI -1.41 to 4.46; I² = 33%). Data for knowledge, self-care behaviour, death and hospitalisations could not be pooled or was not reported. Compared to usual care, low-certainty evidence showed educational with self-management interventions may increase knowledge (15 RCTs, 2185 participants: SMD 0.65, 95% CI 0.36 to 0.93; I² = 90%), improve self-care behaviour scores (4 RCTs, 913 participants: SMD 0.91, 95% CI 0.00 to 1.82; I² =97%), self-efficacy (8 RCTs, 687 participants: SMD 0.50, 95% CI 0.10 to 0.89; I² = 82%), improve QoL physical component score (3 RCTs, 2771 participants: MD 2.56, 95% CI 1.73 to 3.38; I² = 0%) and may make little or no difference to slowing the decline of eGFR (4 RCTs, 618 participants: MD 4.28 mL/min/1.73 m², 95% CI -0.03 to 8.85; I² = 43%). Moderate-certainty evidence shows educational with self-management interventions probably decreases the risk of death (any cause) (4 RCTs, 2801 participants: RR 0.73, 95% CI 0.53 to 1.02; I² = 0%). Data for hospitalisation could not be pooled.

AUTHORS' CONCLUSIONS

Interventions to improve aspects of health literacy are a very broad category, including educational interventions, self-management interventions and educational with self-management interventions. Overall, this type of health literacy intervention is probably beneficial in this cohort however, due to methodological limitations and high heterogeneity in interventions and outcomes, the evidence is of low certainty.

The Effect of Roy Adaptation Model Guided Education on Fluid Adherence and Disease Acceptance of Hemodialysis Patients: A Nonrandomized Interventional Study

Background and Purpose: Difficulty in acceptance of illness and adherence to fluid control are common in patients receiving haemodialysis treatment, and they are associated with higher morbidity and mortality. This study aims to identify the effects of the training based on the Roy Adaptation Model, which is given to patients receiving haemodialysis treatment on the acceptance of illness, and adherence to fluid control. Methods: The study was designed as a nonrandomised interventional study. This study was conducted with 81 patients, who received haemodialysis treatment. The experimental group was given training according to the Roy Adaptation Model for six months. Data were collected through the Patient Identification Form, Acceptance of Illness Scale, and Fluid Control Scale in Haemodialysis Patients. Results: While the difference between the experimental and control groups’ second interview Acceptance of Illness Scale mean score was not statistically significant, the difference between the score of Fluid Control Scale in Haemodialysis Patients were statistically significant. Conclusions: The training based on the Roy Adaptation Model given to the experimental group caused an increase in adherence to fluid control but had no effects on the acceptance of illness levels.

Self-care Adherence in Hemodialysis Patients: A Structural Equation Modeling

BACKGROUND: Management of health problems in patients undergoing hemodialysis is quite complicated, fluid restriction, diet, following treatment recommendations, and managing physical activity are problems that are often difficult to manage. Self-regulation of HD patients is needed to maintain adherence regarding fluid restriction, diet, medication, and physical activity management. AIM: We aimed to investigate self-care adherence in hemodialysis patients with a structural equation modeling. METHODS: One hundred and thirty patients with the hemodialysis-dependent end-stage renal disease took part in a quantitative cross-sectional study. RESULTS: The researchers investigated personality traits, information factors, emotional factors, disease representation, motivation, appraisal, coping, and self-care adherence. CONCLUSION: Except for motivation, which has no direct effect on coping (T-statistic = 1.666), almost every construct in this model significantly affects coping.

Benchmarking Diet Quality to Assess Nutritional Risk in Hemodialysis Patients: Applying Adequacy and Moderation Metrics of the Hemodialysis-Healthy Eating Index

OBJECTIVES

This study modified Healthy Eating Index (HEI) based on hemodialysis (HD) specific guidelines and investigated associations between the diet quality (DQ) and nutritional risk in HD patients.

METHODS

The HD-HEI tool adapted the XXX Dietary Guidelines 2010 framework according to HD-specific nutrition guidelines. This HD-HEI was applied to 3-day dietary records of 382 HD patients. Relationships between HD-HEI scores and nutritional parameters were tested by partial correlations. Binary logistic regression models adjusted with confounders were used to determine adjusted odds ratio (_adjOR) with 95% confidence interval (CI) for nutritional risk based on HD-HEI scores categorization.

RESULTS

The total HD-HEI score (51.3 ± 10.2) for this study population was affected by ethnicity (P_trend<0.001) and sex (P=0.003). No patient achieved "good" DQ (score: 81-100), while DQ of 54.5% patients were classified as "needs improvement" (score: 51-80) and remaining as "poor" (score: 0-51). Total HD-HEI scores were positively associated with dietary energy intake (DEI) and dietary protein intakes (DPI), dry weight and handgrip strength, but inversely associated with Dietary Monotony Index (DMI) (all P<0.05). Individually, scores for refined grain, total protein, and animal protein were positively associated with DEI (all P< 0.05), whilst total, animal, fish and vegetable proteins indicated positive associations with DPI (all P< 0.05). Moderating metrics for convenience meals, saturated fats, sodium, and fluid negatively correlated towards DEI with similar trends for DPI excepting convenience meals and fluids. "Poor" DQ was associated with DMI ≥ 29.2 (_adjOR: 18.83, 95% CI: 9.36-37.86, P<0.001), Malnutrition Inflammation Score (MIS) ≥ 5 (_adjOR: 1.78, 95% CI: 1.01-3.15, P=0.045), and Protein Energy Wasting (PEW) (_adjOR: 1.96, 95% CI: 1.14-3.34, P=0.031), but became nullified with covariate adjustments. "Poor" DQ was also associated with low lean tissue mass (< 32.6 kg) in men (_adjOR: 2.38, 95% CI: 1.01-5.58, P=0.046) but not women.

CONCLUSIONS

"Poor" DQ was associated with poor nutritional status in XXX HD patients, who should be targeted for nutritional counselling.

Applying A Biopsychosocial Framework to Achieve Durable Behavior Change in Kidney Disease

Chronic disease self-management is the establishment and maintenance of behaviors needed to be an active participant in one's health care and experience the best health outcomes. Kidney disease self-management behaviors to slow disease progression include engaging in exercise or physical activity; adhering to a diet low in sodium, potassium, and phosphorus; monitoring laboratory parameters; managing complex medication regimens; coping with disease-related emotional distress; and communicating effectively with providers. Durable behavior change has been difficult to achieve in kidney disease, in part because of an incomplete understanding of the multilevel factors determining chronic disease self-management in this patient group. The biopsychosocial model of chronic illness care posits that an individual's health outcomes result from biological, psychological, social, and environmental factors as part of a multilevel systems hierarchy. Although this theoretical model has been used to comprehensively identify factors driving self-management in other chronic conditions, it has been applied infrequently to behavioral interventions in kidney disease. In this scoping review, we apply the biopsychosocial model of health to identify individual, interpersonal, and systems-level drivers of kidney disease self-management behaviors. We further highlight factors that may serve as novel, impactful targets of theory-based behavioral interventions to understand and sustain behavior change in kidney disease.

OUP accepted manuscript

Patients on chronic hemodialysis are counseled to reduce dietary sodium intake to limit their thirst and consequent interdialytic weight gain (IDWG), chronic volume overload and hypertension. Low-sodium dietary trials in hemodialysis are sparse and mostly indicate that dietary education and behavioral counseling are ineffective in reducing sodium intake and IDWG. Additional nutritional restrictions and numerous barriers further complicate dietary adherence. A low-sodium diet may also reduce tissue sodium, which is positively associated with hypertension and left ventricular hypertrophy. A potential alternative or complementary approach to dietary counseling is home delivery of low-sodium meals. Low-sodium meal delivery has demonstrated benefits in patients with hypertension and congestive heart failure but has not been explored or implemented in patients undergoing hemodialysis. The objective of this review is to summarize current strategies to improve volume overload and provide a rationale for low-sodium meal delivery as a novel method to reduce volume-dependent hypertension and tissue sodium accumulation while improving quality of life and other clinical outcomes in patients undergoing hemodialysis.

Experiences of New Zealand Haemodialysis Patients in Relation to Food and Nutrition Management: A Qualitative Study

People receiving haemodialysis have considerable and complex dietary and healthcare needs, including co-morbidities. A recent New Zealand study has shown that few patients on haemodialysis are able to meet nutritional requirements for haemodialysis. This study aims to describe the perspectives and experiences of dietary management among patients on haemodialysis in New Zealand. This exploratory qualitative study used in-depth semi-structured interviews. Purposive sampling was used to recruit participants from different ethnic groups. Forty interviews were conducted, audio-recorded and transcribed verbatim. An inductive approach was taken using thematic analysis. Forty participants were interviewed. Participants spoke of major disruption to their lives as a result of their chronic kidney disease and being on haemodialysis, including loss of employment, financial challenges, loss of independence, social isolation and increased reliance on extended family. Most had received adequate dietary information, although some felt that more culturally appropriate support would have enabled a healthier diet. These findings show that further support to make the recommended dietary changes while on haemodialysis should focus on socio-cultural factors, in addition to the information already provided.

Altered dietary salt intake for people with chronic kidney disease

BACKGROUND

Evidence indicates that reducing dietary salt may reduce the incidence of heart disease and delay decline in kidney function in people with chronic kidney disease (CKD). This is an update of a review first published in 2015.

OBJECTIVES

To evaluate the benefits and harms of altering dietary salt for adults with CKD.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 6 October 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials comparing two or more levels of salt intake in adults with any stage of CKD.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for eligibility, conducted risk of bias evaluation and evaluated confidence in the evidence using GRADE. Results were summarised using random effects models as risk ratios (RR) for dichotomous outcomes or mean differences (MD) for continuous outcomes, with 95% confidence intervals (CI).

MAIN RESULTS

We included 21 studies (1197 randomised participants), 12 in the earlier stages of CKD (779 randomised participants), seven in dialysis (363 randomised participants) and two in post-transplant (55 randomised participants). Selection bias was low in seven studies, high in one and unclear in 13. Performance and detection biases were low in four studies, high in two, and unclear in 15. Attrition and reporting biases were low in 10 studies, high in three and unclear in eight. Because duration of the included studies was too short (1 to 36 weeks) to test the effect of salt restriction on endpoints such as death, cardiovascular events or CKD progression, changes in salt intake on blood pressure and other secondary risk factors were examined. Reducing salt by mean -73.51 mmol/day (95% CI -92.76 to -54.27), equivalent to 4.2 g or 1690 mg sodium/day, reduced systolic/diastolic blood pressure by -6.91/-3.91 mm Hg (95% CI -8.82 to -4.99/-4.80 to -3.02; 19 studies, 1405 participants; high certainty evidence). Albuminuria was reduced by 36% (95% CI 26 to 44) in six studies, five of which were carried out in people in the earlier stages of CKD (MD -0.44, 95% CI -0.58 to -0.30; 501 participants; high certainty evidence). The evidence is very uncertain about the effect of lower salt intake on weight, as the weight change observed (-1.32 kg, 95% CI -1.94 to -0.70; 12 studies, 759 participants) may have been due to fluid volume, lean tissue, or body fat. Lower salt intake may reduce extracellular fluid volume in the earlier stages of CKD (-0.87 L, 95% CI -1.17 to -0.58; 3 studies; 187 participants; low certainty evidence). The evidence is very uncertain about the effect of lower salt intake on reduction in antihypertensive dose (RR 2.45, 95% CI 0.98 to 6.08; 8 studies; 754 participants). Lower salt intake may lead to  symptomatic hypotension (RR 6.70, 95% CI 2.40 to 18.69; 6 studies; 678 participants; moderate certainty evidence). Data were sparse for other types of adverse events.

AUTHORS' CONCLUSIONS

We found high certainty evidence that salt reduction reduced blood pressure in people with CKD, and albuminuria in people with earlier stage CKD in the short-term. If such reductions could be maintained long-term, this effect may translate to clinically significant reductions in CKD progression and cardiovascular events. Research into the long-term effects of sodium-restricted diet for people with CKD is warranted.

Adequate Management of Phosphorus in Patients Undergoing Hemodialysis Using a Dietary Smartphone App: Prospective Pilot Study

Background

The renal diet is complex and requires alterations of the diet and careful monitoring of various nutrients. Elevated serum phosphorus is common among patients undergoing hemodialysis, and it is associated with many complications. Smartphone technology could be used to support both dietitians and patients by providing a source of accessible and reliable information.

Objective

The aim of this pilot is to assess the potential efficacy of an intervention using the educational and self-monitoring mobile app KELA.AE on the phosphorous management in hemodialysis patients. Results will be used to improve both the app and a planned, rigorous large-scale trial intended to assess app efficacy.

Methods

This is a prospective pilot study performed at the hemodialysis unit of Al Qassimi Hospital (Emirate of Sharjah, United Arab Emirates). All patients were assessed for eligibility and, based on inclusion criteria, considered for enrollment. Participants met with a dietitian once a week and used the mobile app regularly for 2 weeks. Outcomes (knowledge, self-reported nonadherence, dietary intake, anthropometry, and biochemical data) were measured. This pilot is reported as per guidelines for nonrandomized pilot and feasibility studies and in line with the CONSORT (Consolidated Standards of Reporting Trials) 2010 checklist for reporting pilot or feasibility trials.

Results

Of 26 subjects, 23 successfully completed the pilot. Patient dietary knowledge about phosphorous management improved from 51.4% (SD 13.9) to 68.1% (SD 13.3) after intervention with a large effect size (d=1.22, 95% CI 0.59 to 1.85). Dietary protein intake increased from a mean of 0.9 g/kg (SD 0.3) per day to a mean of 1.3 g/kg (SD 0.5) per day with a large effect size (d=1.07, 95% CI 0.45 to 1.69). Phosphorus to protein ratio dropped from a mean of 18.4 mg/g protein to 13.5 mg/g protein with a large effect size (d=0.83, 95% CI 0.22 to 1.43). There was no evidence of change in phosphorous intake, self-reported nonadherence, and serum phosphorus.

Conclusions

The findings of this prospective pilot reveal the potential efficacy of a smartphone app as a supportive nutrition education tool for phosphorus management in patients undergoing hemodialysis. This pilot study showed that the KELA.AE app has the potential to improve knowledge and dietary choices. A rigorous randomized controlled trial should be performed to evaluate the efficacy, assessing app use of a long-term intervention.

Assessment of Factors Related to Diminished Appetite in Hemodialysis Patients with a New Adapted and Validated Questionnaire

Appetite loss is a common phenomenon in end-stage renal disease (ESRD) patients undergoing maintenance hemodialysis (HD). We aimed to (i) adapt and validate a Spanish language version of the Council on Nutrition Appetite Questionnaire (CNAQ) and (ii) to identify psychological and biological factors associated with diminished appetite. We recruited 242 patients undergoing HD from four hemodialysis centers to validate the Spanish-translated version of the CNAQ. In another set of 182 patients from three HD centers, the Appetite and Diet Assessment Tool (ADAT) was used as the gold standard to identify a cut-off value for diminished appetite in our adapted questionnaire. The Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Distorted Thoughts Scale (DTS), Dialysis Malnutrition Score (DMS), anthropometric, values and laboratory values were also measured. Seven items were preserved in the adapted appetite questionnaire, with two factors associated with flavor and gastric fullness (Cronbach’s alpha = 0.758). Diminished appetite was identified with a cut-off value ≤25 points (sensitivity 73%, specificity 77%). Patients with diminished appetite had a higher proportion of females and DMS punctuation, lower plasmatic level of creatinine, blood urea nitrogen, and phosphorus. Appetite score correlated with BDI score, BAI score and DTS. Conclusions: This simple but robust appetite score adequately discriminates against patients with diminished appetite. Screening and treatment of psychological conditions may be useful to increase appetite and the nutritional status of these patients.

Classification tree for the inference of the nursing diagnosis Fluid Volume Excess (00026)

OBJECTIVE

To generate a Classification Tree for the correct inference of the Nursing Diagnosis Fluid Volume Excess (00026) in chronic renal patients on hemodialysis.

METHOD

Methodological, cross-sectional study with patients undergoing renal treatment. The data were collected through interviews and physical evaluation, using an instrument with socio-demographic variables, related factors, associated conditions and defining characteristics of the studied diagnosis. The classification trees were generated by the Chi-Square Automation Interaction Detection method, which was based on the Chi-square test.

RESULTS

A total of 127 patients participated, of which 79.5% (101) presented the diagnosis studied. The trees included the elements "Excessive sodium intake" and "Input exceeds output", which were significant for the occurrence of the event, as the probability of occurrence of the diagnosis in the presence of these was 0.87 and 0.94, respectively. The prediction accuracy of the trees was 63% and 74%, respectively.

CONCLUSION

The construction of the trees allowed to quantify the probability of the occurrence of Fluid Volume Excess (00026) in the studied population and the elements "Excessive sodium intake" and "Input exceeds output" were considered predictors of this diagnosis in the sample.

The Cross-Cultural Adaptation and the Reliability Test for the Chinese-Version Dietary Behavior and Psychological Series Scales in Maintenance Hemodialysis Patients

PURPOSE

To translate three novel measures of psychological mechanisms associated with dietary behavior, including the Dietary Goal-Desire Incongruence scale (DG-DI), the Motivation for Dietary Self-control scale (MDSC), the Satisfaction with Dietary Behavior scale (SWDB), to cross-culturally adapt the measures into Chinese and verify their reliability and validity in maintenance hemodialysis patients.

METHOD

After the forward translation and the back-translation, the perspective of a panel of experts and cognitive interviews with maintenance hemodialysis patients were used to ensure cultural relevance of the three scales. Subsequently, 420 maintenance hemodialysis patients from three hemodialysis centers in Zhengzhou were recruited for the item analysis and the internal consistency, content validity, construct validity and reliability tests.

RESULTS

The moderate associations between items and domains (r>0.50) and the significant differences between the high and low groups were measured by an independent sample t test (P<0.001). The Cronbach's α coefficient of the DG-DI reached 0.884. The Cronbach's α of the MDSC was 0.831, with Cronbach's α values (0.865,0.800 and 0.797 for "Internal", "External" and "Amotivation", respectively). In addition, the Cronbach's alpha of the SWDB was 0. 914. The scale-level content validity index (S-CVI) reached 0.96, 0.98 and 1.00 for the DG-DI, the MDSC and the SWDB, respectively. The exploratory factor analysis verified the scale structures of five factors, and the cumulative variance contribution rate of the respective factor was 65.507%. The confirmatory factor analysis was conducted to test the original structure of the scale.

CONCLUSION

The DG-DI, the MDSC and the SWDB showed satisfactory psychometric characteristics. They could effectively assess the eating behavior of hemodialysis patients. Subsequent studies should recruit other different population samples in China to verify the applicability of the scale.

Pilot study to reduce interdialytic weight gain by provision of low-sodium, home-delivered meals in hemodialysis patients

INTRODUCTION

Patients with kidney failure undergoing maintenance hemodialysis (HD) therapy are routinely counseled to reduce dietary sodium intake to ameliorate sodium retention, volume overload, and hypertension. However, low-sodium diet trials in HD are sparse and indicate that dietary education and behavioral counseling are ineffective in reducing sodium intake. This study aimed to determine whether 4 weeks of low-sodium, home-delivered meals in HD patients reduces interdialytic weight gain (IDWG). Secondary outcomes included changes in dietary sodium intake, thirst, xerostomia, blood pressure, volume overload, and muscle sodium concentration.

METHODS

Twenty HD patients (55 ± 12 years, body mass index [BMI] 40.7 ± 16.6 kg/m² ) were enrolled in this study. Participants followed a usual (control) diet for the first 4 weeks followed by 4 weeks of three low-sodium, home-delivered meals per day. We measured IDWG, hydration status (bioimpedance), standardized blood pressure (BP), food intake (3-day dietary recall), and muscle sodium (magnetic resonance imaging) at baseline (0 M), after the 4-week period of usual diet (1 M), and after the meal intervention (2 M).

FINDINGS

The low-sodium meal intervention significantly reduced IDWG when compared to the control period (-0.82 ± 0.14 kg; 95% confidence interval, -0.55 to -1.08 kg; P < 0.001). There were also 1 month (1 M) to 2 month (2 M) reductions in dietary sodium intake (-1687 ± 297 mg; P < 0.001); thirst score (-4.4 ± 1.3; P = 0.003), xerostomia score (-6.7 ± 1.9; P = 0.002), SBP (-18.0 ± 3.6 mmHg; P < 0.001), DBP (-5.9 ± 2.0 mmHg; P = 0.008), and plasma phosphorus -1.55 ± 0.21 mg/dL; P = 0.005), as well as a 0 M to 2 M reduction in absolute volume overload (-1.08 ± 0.33 L; P = 0.025). However, there were no significant changes in serum or tissue sodium (all P > 0.05).

DISCUSSION

Low-sodium, home-meal delivery appears to be an effective method for improving volume control and blood pressure in HD patients. Future studies with larger sample sizes are needed to examine the long-term effects of home-delivered meals on these outcomes and to assess cost-effectiveness.

Poor Sleep Quality, Depression and Social Support Are Determinants of Serum Phosphate Level among Hemodialysis Patients in Malaysia

Despite optimal control of serum phosphate level being imperative to avoid undesirable health outcomes, hyperphosphataemia is a highly prevalent mineral abnormality among the dialysis population. This study aimed to determine factors associated with hyperphosphatemia among hemodialysis patients in Malaysia. Multiple linear regression analysis was used to ascertain the possible factors that influence serum phosphate levels. A total of 217 hemodialysis patients were recruited. Hyperphosphatemia was prevalent. Only approximately 25% of the patients were aware that optimal control of hyperphosphatemia requires the combined effort of phosphate binder medication therapy, dietary restriction, and dialysis prescription. The presence of diabetes mellitus may affect serum phosphate levels, complicating dietary phosphorus management. Patients who were less depressive portrayed higher serum phosphate levels, implying intentional non-compliance. Better compliance on phosphate binder, longer sleep duration, and higher social support was associated with a lower level of serum phosphate. Despite sleep disturbance being one of the most prevalent and intense symptom burdens identified by hemodialysis patients, relatively few studies have addressed this issue. It is time to formulate sleep therapeutic interventions besides the encouragement of strong social support, hoping which many clinical outcomes including hyperphosphatemia can be better controlled among hemodialysis patients.

Dietary Daily Sodium Intake Lower than 1500 mg Is Associated with Inadequately Low Intake of Calorie, Protein, Iron, Zinc and Vitamin B1 in Patients on Chronic Hemodialysis

Background: To measure daily sodium intake in patients on chronic hemodialysis and to compare the intake of nutrients, minerals, trace elements, and vitamins in patients who had a daily sodium intake below or above the value of 1500 mg recommended by the American Heart Association. Methods: Dietary intake was recorded for 3 days by means of 3-day diet diaries in prevalent patients on chronic hemodialysis. Each patient was instructed by a dietitian on how to fill the diary, which was subsequently signed by a next of kin. Results: We studied 127 patients. Mean sodium intake (mg) was 1295.9 ± 812.3. Eighty-seven (68.5%) patients had a daily sodium intake <1500 mg (group 1) and 40 (31.5%) ≥ 1500 mg (group 2). Correlation between daily sodium intake and daily calorie intake was significant (r = 0.474 [0.327 to 0.599]; p < 0.0001). Daily calorie intake (kcal/kg/day) was lower in group 1 (21.1 ± 6.6; p = 0.0001) than in group 2 (27.1 ± 10.4). Correlation between daily sodium intake and daily protein intake was significant (r = 0.530 [0.392 to 0.644]; p < 0.0001). The daily protein intake (grams/kg/day) was lower in group 1 (0.823 ± 0.275; p = 0.0003) than in group 2 (1.061 ± 0.419). Daily intake of magnesium, copper, iron, zinc, and selenium was significantly lower in group 1 than in group 2. Daily intake of vitamin A, B2, B3, and C did not differ significantly between group 1 and group 2. Daily intake of vitamin B1 was significantly lower in group 1 than in group 2. Significantly lower was, in group 1 than in group 2, the percentage of patients within the target value with regard to intake of calories (11.5% vs. 37.5%; p = 0.001) and proteins (9.2% vs. 27.5%; p = 0.015) as well as of iron (23% vs. 45%; p = 0.020), zinc (13.8% vs. 53.8%; p = 0.008) and vitamin B1 (8.1% vs. 50%; p < 0.001). Conclusion: A low daily intake of sodium is associated with an inadequately low intake of calorie, proteins, minerals, trace elements, and vitamin B1. Nutritional counselling aimed to reduce the intake of sodium in patients on chronic hemodialysis should not disregard an adequate intake of macro- and micronutrients, otherwise the risk of malnutrition is high.

Information Technology-based Interventions for Health Care Support in Patients with Chronic Kidney Disease: A Systematic Review

Background: Self-management and support in managing therapeutic regimens is very important for patients with CKD. Information technology-based interventions are increasingly being used to support the self-management of patients with CKD. This study aimed to conduct a systematic review to evaluate information technology-based interventions in relation to the support of the health management of patients with CKD.Method: We conducted a systematic review using electronic databases (Scopus, Science Direct, ProQuest) limited to the last 8 years from 2010 to 2018 with the relevant keywords. The studies included used RCT, pilot and case-control methods focusing on patients with CKD stage 1-5 and that reported on at least one outcome from the health management of patients with CKD.Result: Out of the 7.852 studies taken, 13 studies fulfilled the inclusion criteria. The interventions in this systematic review are multifaceted, including smartphone/PDA (6/13), telematics devices (2/13), internet/web (3/13) and a combination of several interventions (2 studies). In total, 12 (92%) out of the 13 studies showed a positive outcome from the intervention, 7 studies showed improved outcomes in the clinical points, 3 studies had improved adherence and 2 studies improved knowledge.Conclusion: This evidence indicates the potential of IT-based interventions (i.e. smartphone/PDA, computer, internet/web, telematic device) to support the health management of patients with CKD. The variety of interventions in this systematic review requires further research on which interventions are best applied.

Feasibility of Assessing Sodium-Associated Body Fluid Composition in End-Stage Renal Disease

BACKGROUND

Cardiovascular disease accounts for more than half of all deaths in the hemodialysis (HD) population. Although much of this mortality is associated with fluid overload (FO), FO is difficult to measure, and many HD patients have significant pulmonary congestion despite the absence of clinical presentation. Cohort studies have observed that FO, as measured by bioimpedance spectroscopy (BIS), correlates with mortality. Other studies have observed that lower sodium intake is associated with less fluid-related weight gain, improved hypertension, and survival. Whether sodium intake influences FO in HD patients as measured by BIS is not known.

OBJECTIVE

The aims of the study were to determine the feasibility of assessing the impact of sodium restriction on body fluid composition as measured by BIS among patients with three levels of sodium intake and to determine if there are statistical and/or clinical differences in BIS measures across sodium intake groups.

METHODS

We used a double-blinded randomized controlled trial design with three levels of sodium restriction, 2,400 mg per day, 1,500 mg per day, and unrestricted (control group), to test our aims. Forty-two HD patients from a tertiary acute care academic institution associated with three urban DaVita dialysis centers were enrolled. Participants remained in the inpatient center for 5 days and 4 nights and were randomly assigned to sodium intake groups. Body fluid composition was measured with BIS.

RESULTS

Recruitment, enrollment, and retention statistics supported the feasibility of the study design. Regression analyses showed that there were no statistically significant differences among sodium intake groups on any of the outcomes.

DISCUSSION

Our data suggest the need for additional research into the effects of sodium restriction on body fluid composition.

The relationship of volume overload and its control to hypertension in hemodialysis patients

Hypertension is highly prevalent and associated with poor clinical outcomes among individuals receiving maintenance hemodialysis (HD). Volume overload is a key modifiable contributor to hypertension and cardiovascular disease in the HD population. Despite their importance, assessment and treatment of volume overload and hypertension remain major clinical challenges and have substantial implications for both clinical outcomes and patient experiences of care. This review will summarize current data on the diagnosis, epidemiology, pathophysiology, and clinical consequences of hypertension and volume overload in HD patients. We will also identify priorities for future research studies.

Factors associated with adherence to dietary prescription among adult patients with chronic kidney disease on hemodialysis in national referral hospitals in Kenya: a mixed-methods survey

Introduction

Adherence to dietary prescriptions among patients with chronic kidney disease is known to prevent deterioration of kidney functions and slow down the risk for morbidity and mortality. This study determined factors associated with adherence to dietary prescription among adult patients with chronic kidney disease on hemodialysis.

Methods

A mixed-methods study, using parallel mixed design, was conducted at the renal clinics and dialysis units at the national teaching and referral hospitals in Kenya from September 2018 to January 2019. The study followed a QUAN + qual paradigm, with quantitative survey as the primary method. Adult patients with chronic kidney disease on hemodialysis without kidney transplant were purposively sampled for the quantitative survey. A sub-sample of adult patients and their caregivers were purposively sampled for the qualitative survey. Numeric data were collected using a structured, self-reported questionnaire using Open Data Kit “Collect software” while qualitative data were collected using in-depth interview guides and voice recording. Analysis on STATA software for quantitative and NVIV0 12 for qualitative data was conducted. The dependent variable, “adherence to diet prescription” was analyzed as a binary variable. P values < 0.1 and < 0.05 were considered as statistically significant in univariate and multivariate logistic regression models respectively. Qualitative data were thematically analyzed.

Results

Only 36.3% of the study population adhered to their dietary prescriptions. Factors that were independently associated with adherence to diet prescriptions were “flexibility in the diets” (AOR 2.65, 95% CI 1.11–6.30, P 0.028), “difficulties in following diet recommendations” (AOR 0.24, 95% CI 0.13–0.46, P < 001), and “adherence to limiting fluid intake” (AOR 9.74, 95% CI 4.90–19.38, P < 0.001).

Conclusions

For patients with chronic kidney disease on hemodialysis, diet prescriptions with less restrictions and requiring minimal extra efforts and resources are more likely to be adhered to than the restrictive ones. Patients who adhere to their fluid intake restrictions easily follow their diet prescriptions. Prescribed diets should be based on the individual patient’s usual dietary habits and assessed levels of challenges in using such diets. Additionally, diet adherence messages should be integrated with fluid limitation messages. Further research on understanding patients’ adherence to fluid restriction is also suggested.

eHealth interventions for people with chronic kidney disease

BACKGROUND

Chronic kidney disease (CKD) is associated with high morbidity and death, which increases as CKD progresses to end-stage kidney disease (ESKD). There has been increasing interest in developing innovative, effective and cost-efficient methods to engage with patient populations and improve health behaviours and outcomes. Worldwide there has been a tremendous increase in the use of technologies, with increasing interest in using eHealth interventions to improve patient access to relevant health information, enhance the quality of healthcare and encourage the adoption of healthy behaviours.

OBJECTIVES

This review aims to evaluate the benefits and harms of using eHealth interventions to change health behaviours in people with CKD.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 14 January 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs using an eHealth intervention to promote behaviour change in people with CKD were included. There were no restrictions on outcomes, language or publication type.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility, extracted data and assessed the risk of bias. The certainty of the evidence was assessed using GRADE.

MAIN RESULTS

We included 43 studies with 6617 participants that evaluated the impact of an eHealth intervention in people with CKD. Included studies were heterogeneous in terms of eHealth modalities employed, type of intervention, CKD population studied and outcomes assessed. The majority of studies (39 studies) were conducted in an adult population, with 16 studies (37%) conducted in those on dialysis, 11 studies (26%) in the pre-dialysis population, 15 studies (35%) in transplant recipients and 1 studies (2%) in transplant candidates We identified six different eHealth modalities including: Telehealth; mobile or tablet application; text or email messages; electronic monitors; internet/websites; and video or DVD. Three studies used a combination of eHealth interventions. Interventions were categorised into six types: educational; reminder systems; self-monitoring; behavioural counselling; clinical decision-aid; and mixed intervention types. We identified 98 outcomes, which were categorised into nine domains: blood pressure (9 studies); biochemical parameters (6 studies); clinical end-points (16 studies); dietary intake (3 studies); quality of life (9 studies); medication adherence (10 studies); behaviour (7 studies); physical activity (1 study); and cost-effectiveness (7 studies).Only three outcomes could be meta-analysed as there was substantial heterogeneity with respect to study population and eHealth modalities utilised. There was found to be a reduction in interdialytic weight gain of 0.13kg (4 studies, 335 participants: MD -0.13, 95% CI -0.28 to 0.01; I² = 0%) and a reduction in dietary sodium intake of 197 mg/day (2 studies, 181 participants: MD -197, 95% CI -540.7 to 146.8; I² = 0%). Both dietary sodium and fluid management outcomes were graded as being of low evidence due to high or unclear risk of bias and indirectness (interdialytic weight gain) and high or unclear risk of bias and imprecision (dietary sodium intake). Three studies reported death (2799 participants, 146 events), with 45 deaths/1000 cases compared to standard care of 61 deaths/1000 cases (RR 0.74, CI 0.53 to 1.03; P = 0.08). We are uncertain whether using eHealth interventions, in addition to usual care, impact on the number of deaths as the certainty of this evidence was graded as low due to high or unclear risk of bias, indirectness and imprecision.

AUTHORS' CONCLUSIONS

eHealth interventions may improve the management of dietary sodium intake and fluid management. However, overall these data suggest that current evidence for the use of eHealth interventions in the CKD population is of low quality, with uncertain effects due to methodological limitations and heterogeneity of eHealth modalities and intervention types. Our review has highlighted the need for robust, high quality research that reports a core (minimum) data set to enable meaningful evaluation of the literature.

Envolvimento da pessoa com doença renal crônica em seus cuidados: revisão integrativa

Resumo A doença renal crônica (DRC) acarreta ao indivíduo uma sobrecarga de cuidados indispensáveis ao alcance das metas terapêuticas e qualidade de vida. O controle nutricional, o regime medicamentoso e as terapias de substituição renal são exemplos que requerem participação ativa. Assim, foi realizada revisão integrativa de artigos científicos para identificar os que versam sobre envolvimento e participação do paciente em seus cuidados na DRC. Os descritores “Chronic kidney disease”; “Self-Care” and “Patient Participation” foram aplicados nas bases CINHAL, Bireme e Medline. Selecionamos 21 publicações entre 2012 e 2016. A entrevista semiestruturada destacou-se como método de coleta de dados, com a aplicação da análise temática fenomenológica. Conforme a predominância do assunto tratado, os manuscritos foram alocados em quatro eixos temáticos: Manejo da doença renal e seu tratamento; Envolvimento na tomada de decisão; Plano avançado de cuidados; e, Diálise peritoneal domiciliar. Verificamos que abordagens envolvendo pessoas transplantadas ou nos primeiros estágios da doença são pouco explorados com a aplicação do método qualitativo e, ainda, consideramos que pessoas com DRC devem ser instigadas no envolvimento ativo de seus próprios cuidados, necessitando de conhecimento, motivação e suporte dos profissionais de saúde.

Effect of educational intervention on promoting self-care in hemodialysis patients: Applying the self-efficacy theory

BACKGROUND

Hemodialysis patients experience many issues in self-care behavior. Patients require to control of manage the issue to improve the self-care. Educational intervention to behavior change can be effective on self-care behavior. This study was conducted to investigate the effect of an educational intervention, based on the self-Efficacy theory on promoting self-care in hemodialysis patients.

MATERIALS AND METHODS

Seventy hemodialysis patients recruited in this study and divided randomly into intervention group (n = 35) and control group (n = 35) with convenience sampling in 2016 from Qom city, Iran. Data were collected before and 3 months after education using demographic questionnaire, self-efficacy, a valid researcher-made questionnaire regarding to awareness and self-care. The educational intervention was performed for the intervention group in 4 1-h sessions over 2 months. The data were analyzed through Paired t-test, Independent t-test, Chi-square, and Mann-Whitney at the significant level of 0.05.

RESULTS

While variables in two groups did not show significant difference before education (P > 0.05), a significant increase was observed in variables of self-efficacy (P < 0.001), awareness (P < 0.001), and self-care dimensions (P < 0.05) between two groups after 3 months education.

CONCLUSION

The results of this research suggested that employing educational programs based on the self-efficacy theory can lead to the improvement of the self-care behaviors in hemodialysis patients.

Determinants and the Role of Self-Efficacy in a Sodium-Reduction Trial in Hemodialysis Patients

OBJECTIVE

This study was to assess the impact of baseline dietary self-efficacy on the effect of a dietary intervention to reduce sodium intake in patients undergoing hemodialysis (HD) and to identify determinants of low dietary self-efficacy.

METHODS

This is a post hoc analysis of the BalanceWise study, a randomized controlled trial that aimed to reduce dietary sodium intake in HD patients recruited from 17 dialysis centers in Pennsylvania. The main outcome measures include dietary self-efficacy and reported dietary sodium density. Analysis of variance with post hoc group-wise comparison was used to examine the effect of baseline dietary self-efficacy on changes in reported sodium density in the intervention and control groups at 8 and 16 weeks. Chi-square test, independent t tests, or Wilcoxon rank-sum tests were used to identify determinants of low dietary self-efficacy.

RESULTS

The interaction between dietary self-efficacy and the impact of the intervention on changes in reported dietary sodium density approached significance at 8 and 16 weeks (P interaction = 0.051 and 0.06, respectively). Younger age and perceived income inadequacy were significantly associated with low self-efficacy in patients undergoing HD.

CONCLUSION

The benefits of dietary interventions designed to improve self-efficacy may differ by the baseline self-efficacy status. This may be particularly important for HD patients who are younger and report inadequate income as they had lower dietary self-efficacy.

Perceived Sodium Reduction Barriers Among Patients with Chronic Kidney Disease: Which Barriers Are Important and Which Patients Experience Barriers?

PURPOSE

The purposes of this study were to assess the importance of perceived sodium reduction barriers among patients with chronic kidney disease (CKD) and identify associated sociodemographic, clinical, and psychosocial factors.

METHOD

A total of 156 patients with CKD completed a questionnaire assessing sodium reduction barriers (18 self-formulated items), depressive symptoms (Beck Depression Inventory), perceived autonomy support (Modified Health Care Climate Questionnaire), and self-efficacy (Partners in Health Questionnaire). Factor analysis was used to identify barrier domains. Correlation coefficients were computed to examine relationships between barrier domains and patient characteristics.

RESULTS

Nine barrier domains were identified. Barriers perceived as important were as follows: high sodium content in products, lack of sodium feedback, lack of goal setting and discussing strategies for sodium reduction, and not experiencing CKD-related symptoms (mean scores > 3.0 on 5-point scales, ranging from 1 'no barrier' to 5 'very important barrier'). Other barriers (knowledge, attitude, coping skills when eating out, and professional support) were rated as moderately important (rated around midpoint), and the barrier 'intrinsic motivation' was rated as somewhat important (mean score = 1.9). Sodium reduction barrier domains were not associated with gender and kidney function, but were associated with age, level of education, number of comorbidities, perceived autonomy support, depressive symptoms, and self-efficacy (range r = 0.17-0.35). Patients with lower self-efficacy and perceived autonomy support scores experienced most sodium reduction barriers.

CONCLUSION

Patients with CKD experience multiple important sodium reduction barriers and could benefit from support strategies that target various sodium reduction barriers and strengthen beliefs regarding self-efficacy and autonomy support. Additionally, environmental interventions should be implemented to reduce sodium levels in processed foods.

Validation of the shortened Perceived Medical Condition Self-Management Scale in patients with chronic disease

Self-efficacy, or perceived competence, has been identified as an important factor in self-management behaviors and health outcomes in patients with chronic disease. Measures of self-management self-efficacy are currently available for multiple forms of chronic disease. One established measure is the 8-item Perceived Medical Condition Self-Management Scale (PMCSMS). This study investigated the use of the PMCSMS in samples of patients with a chronic disease to develop an abbreviated version of the scale that could be more readily used in clinical contexts or in large population health cohort studies. The PMCSMS was administered as either a generic scale or as a disease-specific scale. The results of analyses using item response theory and classical test theory methods indicated that using 4 items of the scale resulted in similar internal consistency (α = .70-0.90) and temporal stability (test-retest r = .75 after 2 to 4 weeks) to the 8-item PMCSMS (r = .81 after 2 to 4 weeks). The 4 items selected had the greatest discriminability among participants (α parameters = 2.49-3.47). Scores from both versions also demonstrated similar correlations with related constructs such as health literacy (r = .13-0.29 vs. 0.14-0.27), self-rated health (r = .17-0.48 vs. 0.26-0.50), social support (r = .21-0.32 vs. 0.25-0.34), and medication adherence (r = .20-0.24 vs. 0.20-0.25). The results of this study indicate that 4-item PMCSMS scores are equally valid but more efficient, and have the potential to be beneficial for both research and clinical applications. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

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.

Dietary Sodium and Other Nutrient Intakes among Patients Undergoing Hemodialysis in New Zealand

This study describes baseline intakes of sodium and other nutrients in a multi-ethnic sample of hemodialysis patients in New Zealand participating in the SoLID Trial between May/2013 to May/2016. Baseline 3-day weighed food record collections were analyzed using Foodworks 8 Professional food composition database, supplemented by other sources of nutrient information. Intakes of dietary sodium and other nutrients were compared with relevant guidelines and clinical recommendations. Eighty-five participants completed a 3-day weighed food record. The mean (SD) sodium intake was 2502 (957) mg/day at and more than half of the participants exceeded recommended intake levels. Sodium intake was positively associated with energy intake. Only 5% of participants met the recommended calorie density; nine percent of participants ate the recommended minimum of 1.2 g/kg of protein per day; 68% of participants were consuming inadequate fiber at baseline. A high proportion of dialysis patients in SoLID Trial did not meet current renal-specific dietary recommendations. The data show excess sodium intake. It is also evident that there was poor adherence to dietary guidelines for a range of other nutrients. A total diet approach is needed to lower sodium intake and improve total diet quality among hemodialysis patients in New Zealand.

Adesão de portadores de doença renal crônica em hemodiálise ao tratamento estabelecido

Resumo Objetivo: Identificar o comportamento de adesão do paciente renal crônico ao regime terapêutico nas suas quatro dimensões: hemodiálise uso de medicamentos, dieta e restrição hídrica. Métodos: Estudo descritivo, transversal com abordagem quantitativa, desenvolvido em dois centros de hemodiálise no Estado do Rio de Janeiro. Para coleta de dados, foi utilizado um questionário de avaliação sobre a adesão do portador de doença renal crônica em hemodiálise. Os dados foram analisados por meio de estatística descritiva simples. Resultados: O domínio que apresentou maior percentual de pacientes não aderentes foi a hemodiálise, com 32%. Já a medicação foi o domínio com maior percentual de pacientes aderentes, 93,6%. Conclusão: A adesão à terapêutica é um comportamento dinâmico e, como tal, merece monitorização constante.

The Myth of Water and Salt: From Aquaretics to Tenapanor

The impact of water intake has been studied in several renal diseases. For example, increasing water intake is useful to prevent primary and secondary nephrolithiasis. In autosomal dominant polycystic kidney disease, arginine vasopressin (AVP) is involved in the progression of the disease, and water intake could play a therapeutic role by inhibiting the synthesis of AVP, but its efficacy is still controversial. Conversely, the use of aquaretics, which are antagonists of AVP V2 receptors, results in the reduction of the increase rate of total kidney volume with a slower decline of glomerular filtration rate. In chronic kidney disease, AVP contributes to glomerular hyperfiltration, arterial hypertension, and synthesis of renin, resulting in renal sclerosis. Increased water intake could reduce AVP activation determining a potential protective effect on the kidney, but its efficacy has not yet been clearly demonstrated. On the other side, sodium and potassium play an important role in the control of arterial blood pressure and are involved in the development and progression of chronic kidney disease. Reduction of sodium intake and increase of potassium intake determine a decrease of arterial blood pressure with a beneficial effect on the kidney; however, adherence to sodium restriction is very poor. Regarding this, sodium-hydrogen exchanger isoform 3 inhibitors may reduce sodium absorption in the gut. The most recent sodium-hydrogen exchanger isoform 3 inhibitor, known as tenapanor, reduces extracellular fluid volume, left ventricular hypertrophy, albuminuria, and blood pressure in experimental studies and increases fecal loss of sodium in humans.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Perceived Medical Condition Self-Management Scale can be applied to patients with chronic kidney disease

Chronic Kidney Disease (CKD) is a major burden on patients and the health care system. Treatment of CKD requires dedicated involvement from both caretakers and patients. Self-efficacy, also known as perceived competence, contributes to successful maintenance of patient's CKD self-management behaviors such as medication adherence and dietary regulations. Despite a clear association between self-efficacy and improved CKD outcomes, there remains a lack of validated self-report measures of CKD self-efficacy. To address this gap, the Perceived Kidney/Dialysis Self-Management Scale (PKDSMS) was adapted from the previously validated Perceived Medical Condition Self-Management Scale. We then sought to validate this using data from two separate cohorts: a cross-sectional investigation of 146 patients with end-stage renal disease receiving maintenance hemodialysis and a longitudinal study of 237 patients with CKD not receiving dialysis. The PKDSMS was found to be positively and significantly correlated with self-management behaviors and medication adherence in both patient cohorts. The PKDSMS had acceptable reliability, was internally consistent, and exhibited predictive validity between baseline PKDSMS scores and self-management behaviors across multiple time points. Thus, the PKDSMS is a valid and reliable measure of CKD patient self-efficacy and supports the development of interventions enhancing perceived competence to improve CKD self-management.

Ineffective Protection in Hemodialysis Patients: Sociodemographic and Clinical Context

PURPOSE

To analyze the association between components of the nursing diagnosis ineffective protection (00043) and sociodemographic and clinical data of hemodialysis patients.

METHOD

Cross-sectional study was conducted during the first half of 2015 with a sample of 200 patients from a reference clinic of nephrology. A structured instrument containing operational definitions was used to collect data.

FINDINGS

Hemodialysis patients presented defining characteristics of ineffective protection (00043) associated with sociodemographic and clinical context variables.

CONCLUSION

Components of this diagnosis may be influenced by sociodemographic and clinical context of hemodialysis patients.

Validation of the adherence questionnaire for Brazilian chronic kidney disease patients under hemodialysis

ABSTRACT Objective: To validate the evaluation questionnaire on adherence of chronic kidney disease (CKD) patients under hemodialysis. Method: We verified the following psychometric properties of the instrument: reliability (stability and internal consistency) and validity (face, content, and construct). Results: The intraclass correlation coefficient reached a value of 0.98 for the adherence questions and 0.91 for the perception questions. Regarding the kappa of the 14 questions examined, 12 had a value > 0.8, whereas the Cronbach's alpha had a value of 0.57. Experts ensured the face and content validity of the instrument, giving it an overall content validity index of 0.96. Construct validity, analyzed by Mann-Whitney test, was achieved as all domains showed a significant association with p<0.01. Conclusion: We verified, by the presented results, that the instrument has been validated for use in Brazil.

Estimated dietary sodium intake in haemodialysis patients using food frequency questionnaires

BACKGROUND

In clinical practice, dietary sodium assessment requires reliable and rapid screening tools. We wished to evaluate the usefulness of food frequency questionnaires (FFQ) in estimating dietary sodium intakes in haemodialysis patients.

METHODS

We used the Derby Salt Questionnaire (DSQ), and Scored Sodium Questionnaire (SSQ) to estimate sodium intake. Body composition was determined by bioimpedance.

RESULTS

In total, 139 haemodialysis patients (95 men) completed the FFQs, with mean ± standard deviation age 67 ± 15 years. The mean FFQ scores were DSQ 3.5 ± 2.0 and SSQ 68.4 ± 24.5. Men had higher estimated dietary sodium intakes [DSQ median (range) 3.6 (0.6-10.1) versus female 2.2 (0.5-9.1), P = 0.007)]. Younger patients and those aged >75 years had the higher SSQ dietary sodium scores; 70.7 ± 27.8 and 76.8 ± 24.6 versus those aged 55-75 years, 61.8 ± 22.3, P = 0.04. Patients with greater estimated sodium intake had higher extracellular water (ECW) to intracellular water (ICW) ratios pre-dialysis [75.1 ±12.5 versus 67.7 ± 4.8, P < 0.001] and ECW excess pre-dialysis [1.8 (1.5-2.6) versus 1.3 (0.8-2.0) L, P < 0.05]. Mean arterial pressure (MAP) and inter-dialytic weight gains did not differ; however, the fall in MAP during dialysis was lower in the higher estimated dietary sodium group (0.9 ± 13.7% versus 6.5 ± 14.1%, P = 0.04).

CONCLUSIONS

Both questionnaires were acceptable to patients and identified higher estimated dietary sodium intake for men, those with greater ECW and, somewhat surprisingly, we found that older patients had a greater dietary sodium intake than expected.

Modified Nutritional Recommendations to Improve Dietary Patterns and Outcomes in Hemodialysis Patients

The renal diet has traditionally been regarded as one of the most complex medical nutrition therapies to teach, understand, and implement. Specifically, patients are instructed to limit fruits, vegetables, nuts, legumes, dairy, and whole grains because of both phosphorus and potassium concerns. Furthermore, hemodialysis patients are often encouraged to decrease fluid intake to control interdialytic weight gain. These restrictions can result in frustration, lack of autonomy, and the perception that there is nothing left to eat. It is possible that the traditional renal diet may be liberalized, with a focus on whole foods low in sodium and phosphorus additives, to afford patients greater choices and ultimately improved outcomes. Therefore, the objective of this review is to concisely assess the evidence in support of a renal diet focused primarily on reducing the intake of sodium and inorganic phosphorus. Finally, the limited evidence for restrictions on dietary potassium intake is summarized.

Design of a randomized controlled clinical trial assessing dietary sodium restriction and hemodialysis-related symptom profiles

Aim

In hemodialysis patients, the need to have intercurrent sodium and water intake removed by ultrafiltration increases disease burden through the symptoms and signs that occur during hemodialysis (HD). This added burden may be mitigated by reduction of dietary sodium intake. The National Kidney Foundation (NKF) recommends 2400 mg of dietary sodium daily for patients on HD, and the American Heart Association (AHA) suggests 1500 mg, evidence is lacking, however, to support these recommendations in HD. Moreover, little is known about the relationship of specific levels of dietary sodium intake and the severity of symptoms and signs during ultrafiltration. Our goal will be to determine the effects of carefully-monitored levels of sodium-intake as set forth by the NKF and AHA on symptoms and signs in patients undergoing (HD).

Methods

We designed a three-group (2400 mg, 1500 mg, unrestricted), double blinded randomized controlled trial with a sample of 42 HD participants to determine whether 1. Symptom profiles and interdialytic weight gains vary among three sodium intake groups; 2. The effect of HD-specific variables on the symptom profiles among the three groups and 3. Whether total body water extracellular volume and intracellular volume measured with bioimpedance varies across the three groups. We will also examine the feasibility of recruitment, enrollment, and retention of participants for the five-day inpatient stay.

Conclusion

Curbing dietary sodium intake may lead to improvement in intradialytic symptom amelioration and potential for better long-term outcomes. Generating empirical support will be critical to ascertain, and espouse, the appropriate level of sodium intake for patients receiving HD.

Exploring Problems in Following the Hemodialysis Diet and Their Relation to Energy and Nutrient Intakes: The BalanceWise Study

OBJECTIVE

To identify the problems experienced by hemodialysis (HD) patients in attempting to follow the HD diet and their relation to energy and nutrient intakes.

DESIGN

Cross-sectional analysis of baseline data from the BalanceWise Study.

SUBJECTS

Participants included community-dwelling adults recruited from outpatient HD centers. After excluding participants with incomplete dietary analyses (n = 50), 140 African American and white (40/60%) men and women (52/48%) on chronic intermittent HD for at least 3 months (median 3 years) were included.

INTERVENTION

Participant responses, on a 5-point Likert scale ranging from "not at all a problem" to "a very important problem for me," to 34 questions pertaining to potential barriers to following the HD diet in the previous 2 months were classified as either a problem (1) or not a problem (2-5).

MAIN OUTCOME MEASURE

Energy and nutrient intakes determined using the Nutrition Data System for Research® based on 3, non-consecutive, unscheduled, 2-pass 24-hour dietary recalls collected on 1 dialysis and 1 non-dialysis weekday, and 1 non-dialysis weekend day.

RESULTS

More than half of participants reported having problems related to specific behavioral factors (e.g., feeling deprived), technical difficulties (e.g., tracking nutrients), and physical condition (e.g., appetite), but issues of time and food preparation and behavioral factors tended to be most deterministic of reported dietary intakes. Longer duration of HD was associated with lower intakes of protein, potassium, and phosphorus (P < .05).

CONCLUSION

Registered dietitian nutritionists should consider issues of time and food preparation, and behavioral factors in their nutrition assessment of HD patients and should continually monitor HD patients for changes in protein intake that may occur over time.

Strategies to promote adherence to nutritional advice in patients with chronic kidney disease: a narrative review and commentary

Chronic kidney disease (CKD) requires extensive changes to food and lifestyle. Poor adherence to diet, medications, and treatments has been estimated to vary between 20% and 70%, which in turn can contribute to increased mortality and morbidity. Delivering effective nutritional advice in patients with CKD coordinates multiple diet components including calories, protein, sodium, potassium, calcium, phosphorus, and fluid. Dietary intake studies have shown difficulty in adhering to the scope and complexity of the CKD diet parameters. No single educational or clinical strategy has been shown to be consistently effective across CKD populations. Highest adherence has been observed when both diet and education efforts are individualized to each patient and adapted over time to changing lifestyle and CKD variables. This narrative review and commentary summarizes nutrition education literature and published strategies for providing nutritional advice in CKD. A cohort of practical and effective strategies for increasing dietary adherence to nutritional advice are provided that include communicating with "talking control" principles, integrating patient-owned technology, acknowledging the typical food pattern may be snacking rather than formal meals, focusing on a single goal rather than multiple goals, creating active learning and coping strategies (frozen sandwiches, visual hands-on activities, planting herb gardens), and involving the total patient food environment.

Dietary Quality and Adherence to Dietary Recommendations in Patients Undergoing Hemodialysis

BACKGROUND

The multiple dietary restrictions recommended to hemodialysis patients may be difficult to achieve and, at the same time, may result in nutritional deficiencies rendering a poor dietary quality. We here assess the dietary quality and adherence to renal-specific guideline recommendations among hemodialysis patients from a single center in Canary Islands, Spain.

METHODS

Cross-sectional study, including 91 patients undergoing maintenance hemodialysis. Clinical data and 3-day dietary records were collected. We compared patient's reported nutrients intake with guideline recommendations. We also evaluated their alignment with current American Heart Association dietary guidelines for cardiovascular prevention.

RESULTS

Seventy-seven percent and 50% of patients consumed less than the recommended daily energy and protein, respectively. Although half of the patients met the recommendations for dietary fat intake, this was accounted by an excess of saturated fat in 92% of them. Only 22% consumed sufficient fiber. A very small proportion of patients (less than 50%) met the requirements for vitamins and other micronutrients. Insufficient dietary intake was observed in most patients for all vitamins except for cobalamin. Similarly, inadequate dietary intake was observed for many minerals, by both excess (phosphorus, calcium, sodium, and potassium) and defect (magnesium). Most patients met the recommendations for iron and zinc in their diets.

CONCLUSIONS

A large proportion of hemodialysis patients at our center did not meet current renal-specific dietary recommendations. The quality of the diet was considered poor and proatherogenic according to American Heart Association guidelines.

A systematic review of adherence to restricted diets in people with functional bowel disorders

Functional bowel disorders such as irritable bowel syndrome are commonly experienced within the population, and have an adverse impact on emotions, physical well-being, social activity, and occupational output. Adherence to a restricted diet can reduce symptoms, which in turn leads to increased quality of life and well-being. The aim of this review was to assess the extent to which predictors of dietary adherence have been considered in studies relating to functional bowel disorders and following a restricted diet. This was done firstly by examining such studies which contained a measure or indicator of adherence, and then by examining predictors of adherence within and between studies. A search of PsycINFO, Medline, CINAHL, Web of Science, and Cochrane databases was performed during July 2014, with the search criteria including relevant terms such as gastrointestinal disorder, irritable bowel syndrome, diet, and adherence. Of an initial 7927 papers, 39 were suitable for inclusion. Fourteen of the 39 studies included had a structured measure or indicator of dietary adherence, and the remaining 25 mentioned adherence without any structured levels of adherence. There was little investigation into the predictors of adherence, with symptom relief or induction being the primary goal of most of the studies. This review indicates that predictors of dietary adherence are rarely considered in research regarding functional bowel disorders. Further investigation is needed into the variables which contribute to rates of adherence to restricted diets, and more rigorous research is needed to characterise those individuals most likely to be non-adherent. Such research is necessary to ensure that people with these conditions can be provided with appropriate support and interventions.

Results of a novel screening tool measuring dietary sodium knowledge in patients with chronic kidney disease

BACKGROUND

Reducing dietary sodium has potential to benefit patients with chronic kidney disease (CKD). Little research is available defining dietary sodium knowledge gaps in patients with pre-dialysis CKD. We designed a brief screening tool to rapidly identify patient knowledge gaps related to dietary sodium for patients with CKD not yet on dialysis.

METHODS

A Short Sodium Knowledge Survey (SSKS) was developed and administered to patients with pre-dialysis CKD. We also asked patients if they received counseling on dietary sodium reduction and about recommended intake limits. We performed logistic regression to examine the association between sodium knowledge and patient characteristics. Characteristics of patients who answered all SSKS questions correctly were compared to those who did not.

RESULTS

One-hundred fifty-five patients were surveyed. The mean (SD) age was 56.6 (15.1) years, 84 (54%) were men, and 119 (77%) were white. Sixty-seven patients (43.2%) correctly identified their daily intake sodium limit. Fifty-eight (37.4%) were unable to answer all survey questions correctly. In analysis adjusted for age, sex, race, education, health literacy, CKD stage, self-reported hypertension and attendance in a kidney education class, women and patients of non-white race had lower odds of correctly answering survey questions (0.36 [0.16,0.81]; p = 0.01 women versus men and 0.33 [0.14,0.76]; p = 0.01 non-white versus white, respectively).

CONCLUSIONS

Our survey provides a mechanism to quickly identify dietary sodium knowledge gaps in patients with CKD. Women and patients of non-white race may have knowledge barriers impeding adherence to sodium reduction advice.

Altered dietary salt intake for people with chronic kidney disease

BACKGROUND

Salt intake shows great promise as a modifiable risk factor for reducing heart disease incidence and delaying kidney function decline in people with chronic kidney disease (CKD). However, a clear consensus of the benefits of reducing salt in people with CKD is lacking.

OBJECTIVES

This review evaluated the benefits and harms of altering dietary salt intake in people with CKD.

SEARCH METHODS

We searched the Cochrane Renal Group's Specialised Register to 13 January 2015 through contact with the Trials' Search Co-ordinator using search terms relevant to this review.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared two or more levels of salt intake in people with any stage of CKD.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for eligibility and conducted risk of bias evaluation. Results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. Mean effect sizes were calculated using the random-effects models.

MAIN RESULTS

We included eight studies (24 reports, 258 participants). Because duration of the included studies was too short (1 to 26 weeks) to test the effect of salt restriction on endpoints such as mortality, cardiovascular events or CKD progression, changes in salt intake on blood pressure and other secondary risk factors were applied. Three studies were parallel RCTs and five were cross-over studies. Selection bias was low in five studies and unclear in three. Performance and detection biases were low in two studies and unclear in six. Attrition and reporting biases were low in four studies and unclear in four. One study had the potential for high carryover effect; three had high risk of bias from baseline characteristics (change of medication or diet) and two studies were industry funded.There was a significant reduction in 24 hour sodium excretion associated with low salt interventions (range 52 to 141 mmol) (8 studies, 258 participants: MD -105.86 mmol/d, 95% CI -119.20 to -92.51; I(2) = 51%). Reducing salt intake significantly reduced systolic blood pressure (8 studies, 258 participants: MD -8.75 mm Hg, 95% CI -11.33 to -6.16; I(2) = 0%) and diastolic blood pressure (8 studies, 258 participants: MD -3.70 mm Hg, 95% CI -5.09 to -2.30; I(2) = 0%). One study reported restricting salt intake reduced the risk of oedema by 56%. Salt restriction significantly increased plasma renin activity (2 studies, 71 participants: MD 1.08 ng/mL/h, 95% CI 0.51 to 1.65; I(2) = 0%) and serum aldosterone (2 studies, 71 participants: 6.20 ng/dL (95% CI 3.82 to 8.58; I(2) = 0%). Antihypertensive medication dosage was significantly reduced with a low salt diet (2 studies, 52 participants): RR 5.48, 95% CI 1.27 to 23.66; I(2) = 0%). There was no significant difference in eGFR (2 studies, 68 participants: MD -1.14 mL/min/1.73 m(2), 95% CI -4.38 to 2.11; I(2) = 0%), creatinine clearance (3 studies, 85 participants): MD -4.60 mL/min, 95% CI -11.78 to 2.57; I(2) = 0%), serum creatinine (5 studies, 151 participants: MD 5.14 µmol/L, 95% CI -8.98 to 19.26; I(2) = 59%) or body weight (5 studies, 139 participants: MD -1.46 kg; 95% CI -4.55 to 1.64; I(2) = 0%). There was no significant change in total cholesterol in relation to salt restriction (3 studies, 105 participants: MD -0.23 mmol/L, 95% CI -0.57 to 0.10; I(2) = 0%) or symptomatic hypotension (2 studies, 72 participants: RR 6.60, 95% CI 0.77 to 56.55; I(2) = 0%). Salt restriction significantly reduced urinary protein excretion in all studies that reported proteinuria as an outcome, however data could not be meta-analysed.

AUTHORS' CONCLUSIONS

We found a critical evidence gap in long-term effects of salt restriction in people with CKD that meant we were unable to determine the direct effects of sodium restriction on primary endpoints such as mortality and progression to end-stage kidney disease (ESKD). We found that salt reduction in people with CKD reduced blood pressure considerably and consistently reduced proteinuria. If such reductions could be maintained long-term, this effect may translate to clinically significant reductions in ESKD incidence and cardiovascular events. Research into the long-term effects of sodium-restricted diet for people with CKD is warranted, as is investigation into adherence to a low salt diet.