Medication beliefs are associated with phosphate binder non-adherence in hyperphosphatemic haemodialysis patients

The efficacy and safety of sertraline in maintenance hemodialysis patients with depression: A randomized controlled study

OBJECTIVE

To determine the efficacy and safety of sertraline in maintenance hemodialysis (MHD) patients with depression.

METHODS

A randomized controlled trial was conducted involving 125 MHD patients with depression. The treatment group received sertraline, while the control group did not receive any antidepressant treatment. After 12 weeks, we compared the changes in the Hamilton Depression Rating Scale (HAMD), the Medication Adherence Report Scale-5 (MARS-5), the Mini Nutritional Assessment short-form (MNA-SF), the Kidney Disease Quality of Life-36 (KDQOL-36) scores, selected clinical and laboratory indicators, and the incidence of drug-related adverse reactions between the two groups.

RESULTS

After 12 weeks of treatment, the HAMD scores of patients in the treatment group significantly decreased compared to before treatment and were lower than those in the control group. The KDQOL-36, MARS-5, and MNA-SF scores in the treatment group also significantly improved compared to before treatment and were superior to those in the control group. Albumin and hemoglobin levels in the treatment group significantly increased, while C-reactive protein significantly decreased. The incidence of nausea was slightly higher in the treatment group, and was mostly relieved after reducing the dosage of sertraline.

LIMITATIONS

This study is a single-center, small-sample study with a relatively short duration of treatment and follow-up.

CONCLUSIONS

Sertraline can alleviate depressive symptoms, and improve the quality of life and treatment compliance of MHD patients, while improving chronic inflammation, malnutrition, and anemia. However, starting with a low dose and reducing the maintenance dose is recommended when administering sertraline.

Non-adherence, medication beliefs and symptom burden among patients receiving hemodialysis -a cross-sectional study

BACKGROUND

Non-adherence to medication is a common and complex issue faced by individuals undergoing hemodialysis (HD). However, more knowledge is needed about modifiable factors influence on non-adherence. This study investigated the prevalence of non-adherence, medication beliefs and symptom burden and severity among patients receiving HD in Denmark. Associations between non-adherence, medications beliefs and symptom burden and severity were also explored.

METHOD

A cross-sectional questionnaire-based multisite study, including 385 participants. We involved patient research consultants in the study design process and the following instruments were included: Medication Adherence Report Scale, Beliefs about Medication Questionnaire and Dialysis Symptom Index. Logistic regression analysis was performed.

RESULTS

The prevalence of non-adherence was 32% (95% CI 27-37%) using a 23-point-cut-off. Just over one third reported being concerned about medication One third also believed physicians to overprescribe medication, which was associated with 18% increased odds of non-adherence. Symptom burden and severity were high, with the most common symptoms being tiredness/ lack of energy, itching, dry mouth, trouble sleeping and difficulties concentrating. A high symptom burden and/or symptom severity score was associated with an increased odd of non-adherence.

CONCLUSION

The study found significant associations between non-adherence and, beliefs about overuse, symptom burden and symptom severity. Our results suggest health care professionals (HCP) should prioritize discussion about medication adherence with patients with focus on addressing patient-HCP relationship, and patients' symptom experience. Future research is recommended to explore the effects of systematically using validated adherence measures in clinical practice on medication adherence, patient-HCP communication and trust. Additionally, studies are warranted to further investigate the relationship between symptom experience and adherence in this population.

TRIAL REGISTRATION

NCT03897231.

Establishing the criterion validity of self-report measures of adherence in hemodialysis through associations with clinical biomarkers: A systematic review and meta-analysis

Accurate measurement of adherence is crucial to rigorously evaluate interventions aimed at improving this outcome in patients undergoing in-center hemodialysis. Previous research has shown great variability in non-adherence rates between studies, mainly due to the use of different direct (e.g., clinical biomarkers) and indirect (e.g., questionnaires) measures. Although self-reported adherence in hemodialysis has been widely explored, it is still unclear which is the most accurate questionnaire to assess this outcome; therefore, the question of how to optimize adherence measurement in research and clinical practice has emerged as a key issue that needs to be addressed. This systematic review and meta-analysis aimed to explore the criterion validity of self-report measures of adherence in hemodialysis established through the association between test scores and clinical biomarkers (the criterion measure). The protocol was registered in PROSPERO (2021 CRD42021267550). The last search was performed on March 29th, 2022, on Web of Science (all databases included), Scopus, CINHAL, APA PsycInfo, and MEDLINE/PubMed. Twenty-nine primary studies were included, and thirty-eight associations were analyzed. The Hunter-Schmidt's meta-analysis was computed for the associations with more than two studies (n = 20). The results showed that six associations were large (16%), 11 were medium (29%) and the remaining were of small strength. The test scores from the End-Stage Renal Disease Adherence Questionnaire (range: 0.212<rc <0.319) and the Dialysis Diet and Fluid Non-Adherence Questionnaire (range: 0.206<rc <0.359) had medium to large strength associations with interdialytic weight gain, serum phosphorus, and potassium levels, indicating that these questionnaires have reasonable concurrent criterion validity to measure fluid control and adherence to dietary restrictions in patients receiving hemodialysis. The available data did not allow exploring the criterion validity of the test scores in relation to hemodialysis attendance (skipping and/or shortening sessions). These results suggest that the decision to use one questionnaire over another must be made with caution, as researchers need to consider the characteristics of the sample and the objectives of the study. Given that direct and indirect methods have their advantages and disadvantages, the combination of adherence measures in hemodialysis is recommended to accurately assess this complex and multidimensional outcome.

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

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

Factors Affecting Adherence to Phosphate-binding Medications among Patients with End-stage Kidney Disease in Makkah City

Despite the evidence that the management of hyperphosphatemia depends heavily on adherence to phosphate-binding (PB) medications, many dialysis patients are non-adherent. Therefore, factors associated with non-adherence to PB medications should be identified and eliminated. This study aimed to identify and highlight factors influencing adherence to PB medications among patients with end-stage kidney disease (ESKD). A cross-sectional survey was conducted in the hemodialysis centers of three major governmental hospitals in Makkah City, Saudi Arabia. The World Health Organization's five dimensions of adherence to medication (patient, socioeconomic, condition, therapy, and health system) were used to guide the analysis. A multivariable logistic regression analysis was used to determine factors influencing adherence to PB medications among patients with ESKD. Three hundred and fifty-eight patients submitted completed questionnaires and were included in this study; of them, 87.99% were adherent to PB medications. The factors sex, adherence to dietary restrictions, and duration on dialysis were found to be significantly and positively associated with adherence to PB medications, whereas the factors difficulty to take medications and difficulty to adhere to a large number of tablets had significant and negative associations with adherence to PB medications. Hyperphosphatemia is a cause for concern as it leads to several life-threatening complications. The results of the present study encourage to recruit representative samples and consider more factors, such as patients' attitudes toward medications and provider-level factors, to inform policy and/or programmatic interventions that increase adherence to PB medications among patients with ESKD.

Assessment of Dietary Folate Intake and Pill Burden among Saudi Patients on Maintenance Hemodialysis

The aim of this study was to assess the adequacy of dietary folate intake and perceptions of pill burden among Saudi patients on maintenance hemodialysis (MHD). This was a cross-sectional study of adults (>18 years) on MHD (>3 months) attending the dialysis unit at King Saud University Medical City. Patient demographics, dietary folic acid intake, and perceptions of pill burden were collected. Fifty-four patients met the eligibility criteria, with a mean age of 57 ± 15.5 years. The majority were females (63%), and the most prevalent comorbidities were diabetes (43%) and hypertension (76%). The average number of medications/patients was 11 ± 2.9, and most patients were receiving folate supplementation (68.5%). The average dietary folate intake was 823 ± 530 mcg/day. Pill burden was bothersome, primarily due to taking too many medications (57%) while taking medications at the workplace was the least bothersome burden (17%). The reported high pill burden and adequate dietary folate intake by Saudi patients on MHD indicates that the omission of folate supplementation may be advantageous for this special population.

Implementation and effectiveness of an intensive education program on phosphate control among hemodialysis patients: a non-randomized, single-arm, single-center trial

BACKGROUND

Hyperphosphatemia is a common complication in patients on maintenance hemodialysis. Patients' adherence to phosphorus control can be improved by consistent education. However, few studies have focused on the model construction and effects of health education on phosphate control for hemodialysis patients.

OBJECTIVE

To develop an intensive education program focusing on phosphate control among hemodialysis patients and to analyze the effectiveness of this program.

DESIGN

A non-randomized, single-arm, single-center trial lasting for 6 months.

SETTING

This program was conducted in a hemodialysis center in a teaching hospital in Zhuhai, China.

PARTICIPANTS

Patients on maintenance hemodialysis with hyperphosphatemia.

METHODS

An intensive hyperphosphatemia control education program lasting for 6 months was conducted among 366 hemodialysis patients applying the First Principles of Instruction model, which focused on mastering four stages: (a) activation of prior experience, (b) demonstration of skills, (c) application of skills and (d) integration of these skills into real-world activities. The controlled percentage of serum phosphorus, knowledge of hyperphosphatemia, and adherence to phosphate binders before and after the education program were assessed.

RESULTS

The proportion of controlled serum phosphorus was significantly increased from 43.5 to 54.9% (P<0.001). The scores on the knowledge of phosphate control were improved significantly from 59.0 ± 18.9 to 80.6 ± 12.4 (P < 0.001). The proportion of high adherence to phosphate binders was increased dramatically from 21.9 to 44.5% (P < 0.001).

CONCLUSION

The intensive education program can effectively improve serum phosphorus, knowledge of hyperphosphatemia, and adherence to phosphate binders among hemodialysis patients.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2100042017 . Retrospectively registered January 12th, 2021.

Illness perceptions and beliefs about medication: impact on health-related quality of life in adolescent kidney transplant recipients

Adolescents diagnosed with chronic kidney disease (CKD) who undergo kidney transplantation have to adjust to pervasive effects of chronic illness and life-long treatment maintenance, alongside normative developmental stressors. The way in which adolescent transplant recipients experience and think about their illness as well as their medication regimen can be a crucial factor impacting psychosocial outcomes. Participants were 26 adolescent kidney transplant recipients (μ = 16.8 years, σ = 1.69 years) who completed self-report surveys during a clinic visit. Multiple linear regressions were used to investigate whether adolescents' beliefs about medications and attitudes and perceptions of their illness are associated with their overall quality of life. Adolescents' negative illness perceptions contributed to lower transplant-specific health-related quality of life ratings (ΔR² =.305, p < .01). Additionally, adolescent beliefs about their specific medication regimens (ie, personal medication concerns) (ΔR² =.342, p < .01), and general beliefs about medication use (ie, harm, overuse) (ΔR² =.241, p < .05) also contribute significantly to the variance in their overall quality of life ratings. Adolescent transplant patients in older grades and those in special education endorsed lower quality of life. Cognitive components (eg, beliefs, perceptions) of an adolescent kidney transplant recipient's experience contribute to transplant-related quality of life outcomes. This highlights a point of intervention where cognitive change interventions may be utilized and efficacious in improving health outcomes.

Phosphate binders usage, patients knowledge, and adherence. A cross-sectional study in 4 centers at Qassim, Saudi Arabia

OBJECTIVES

To assess phosphate binders' usage, knowledge regarding their utilization, and adherence among hemodialysis patients in Qassim, Saudi Arabia.

METHODS

A prospective cross-sectional study conducted at 4 dialysis centers in Qassim, Saudi Arabia with inclusion of 237 patients' undergoing hemodialysis between November 2018 to January 2019. The study involved interviewing the patients, reviewing their medical records for biomarkers used to assess kidney function, and assessing the patients' knowledge-based regarding dietary phosphate control, as well as adherence to phosphate binders' usage. Results: Out of 237 included patients, male to female ratio was 54:46. The prevalence of prescribing non- calcium phosphate binders was 82.7% whereas prescribing calcium phosphate binders was 73.8%. A total of 63% of patients showed a medium level of adherence to phosphate binders. Although adherence level was not poor, therapeutic eficacy was affected by other factors such as administration time adherence positively correlated with the serum phosphate level (p=0.00).

CONCLUSION

Phosphate binders usage is frequent among hemodialysis patients in Qassim centers. Circulating phosphate level was affected by the extent of patients' knowledge of dietary control and adherence to the usage of phosphate binders. Thus, we recommend enhancing patient education in reference to high- and low- phosphate-rich diet to take wise dietary decisions, lower pill burden, and improve adherence toward the control of hyperphosphatemia.

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.

Adherence Behavior in Subjects on Hemodialysis Is Not a Clear Predictor of Posttransplantation Adherence

Introduction

Nonadherence is common in both hemodialysis (HD) and kidney transplant recipients and is a major risk factor for poor clinical outcomes. This retrospective study explored whether nonadherent HD patients become nonadherent transplant recipients.

Methods

Data were collected for 88 patients from the electronic patient system at a subregional renal unit about adherence to HD regimens in the 6 months before transplantation, and for 1 year posttransplantation following return transfer to the posttransplantation clinic from the transplanting center. Pretransplantation definitions of nonadherence included whether the patients: on average, shortened their dialysis prescription by >10 minutes; shortened it by >15 minutes; missed 2 or more HD sessions; and had mean serum phosphate levels >1.8mmol/l. Posttransplantation definitions of nonadherence included mean tacrolimus levels outside 5 to 10 ng/ml; and missed 1 or more posttransplantation clinic appointments.

Results

Nonadherence ranged from 25% to 42% pretransplantation and from 15.9% to 22.7% posttransplantation, depending on how it was operationalized. There was little relationship between pretransplantation data and posttransplantation adherence, with the exception of a significant relationship between pretransplantation phosphate and posttransplantation clinic attendance. Patients who had missed 1 or more transplant clinic appointments had higher mean pretransplantation phosphate levels. Nonadherent patients with high phosphate levels pretransplantation and missed clinic appointments posttransplantation were significantly younger.

Conclusion

Our findings provide little support for the likelihood of a strong direct relationship between pre and posttransplantation behaviors. The findings require confirmation and further research to assess whether interventions in relation to pretransplantation adherence may enhance adherence posttransplantation and improve outcomes.

Is successful treatment of depression in dialysis patients an achievable goal?

Depression is undisputedly common among individuals with End-Stage Kidney Failure and associated with adverse outcomes. It is well recognized that effective treatments for depression are needed within routine dialysis care. But, are we any closer to successfully treating depression in dialysis patients? We consider this question here with respect to two common treatments, antidepressant medication and cognitive behavioural therapy (CBT). Currently, there are limited data from randomized placebo-controlled trials regarding the acceptability and efficacy of antidepressants. CBT trials appear to show more consistent treatment effects, albeit the feasibility of routine delivery remains unknown. No studies in dialysis patients has evaluated the combined effects of CBT with antidepressants. There is a need to consider pragmatic depression treatment trials in dialysis patients in order to increase study recruitment in order to have more reliable data from which to evaluate the evidence base. Furthermore, we need to understand why treatments work, and for whom do they work? Lastly, addressing issues surrounding treatment acceptability and implementation as part of regular care remain as key challenges that require attention if we are to improve the mental health of individuals on dialysis.

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.

Nonadherence to Medication Therapy in Haemodialysis Patients: A Systematic Review

Background

End-stage kidney disease (ESKD) patients are often prescribed multiple medications. Together with a demanding weekly schedule of dialysis sessions, increased number of medicines and associated regimen complexity pre-dispose them at high risk of medication nonadherence. This review summarizes existing literature on nonadherence and identifies factors associated with nonadherence to medication therapy in patients undergoing haemodialysis.

Methods

A comprehensive search of PubMed, Embase, CINAHL, PsycInfo, and Cochrane Database of Systematic Reviews covering the period from 1970 through November 2014 was performed following a predefined inclusion and exclusion criteria. Reference lists from relevant materials were reviewed. Data on study characteristics, measures of nonadherence, prevalence rates and factors associated with nonadherence were collected. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines was followed in conducting this systematic review.

Results

Of 920 relevant publications, 44 were included. The prevalence of medication nonadherence varied from 12.5% to 98.6%, with widespread heterogeneity in measures and definitions employed. Most common patient-related factors significantly associated with nonadherence were younger age, non-Caucasian ethnicity, illness interfering family life, being a smoker, and living single and being divorced or widowed. Similarly, disease-related factors include longevity of haemodialysis, recurrent hospitalization, depressive symptoms and having concomitant illness like diabetes and hypertension. Medication-related factors such as daily tablet count, total pill burden, number of phosphate binders prescribed and complexity of medication regimen were also associated with poor adherence.

Conclusions

A number of patient-, disease-, and medication-related factors are associated with medication nonadherence in haemodialysis patients. Clinicians should be aware of such factors so that adherence to medications can be optimised in haemodialysis patients. Future research should be directed towards well-designed prospective longitudinal studies developing standard definitions and validating available measurement tools, while focusing on the role of additional factors such as psychosocial and behavioural factors in predicting nonadherence to medications.