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

Enhancing treatment adherence in dialysis patients through digital health interventions: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To systematically assess the efficacy of digital health interventions (DHIs) for improving treatment adherence among dialysis patients through a meta-analysis of randomized controlled trials (RCTs).

METHODS

Five databases were systematically searched from inception to April 2024. Meta-analyses were performed to calculate standardized mean differences (SMDs) and 95% confidence intervals (CIs) for adherence outcomes. Evidence quality was evaluated using the GRADE approach.

RESULTS

Seventeen RCTs involving 1,438 dialysis patients were analyzed. DHIs significantly improved overall adherence (SMD 1.88 [95% CI: 0.46-3.29]; 4 trials, low-certainty evidence). Specifically, DHIs demonstrated large improvements in medication adherence (SMD 1.45 [95% CI 0.38-2.52]; 4 trials, 300 patients; low-certainty evidence) and dialysis treatment adherence (SMD 1.88 [95% CI 0.46-3.29]; 4 trials, 245 patients; low-certainty evidence). Moderate improvements were observed in dietary adherence (SMD 0.58 [95% CI 0.25-0.91]; 4 trials, 344 patients; moderate-certainty evidence) and fluid management adherence (SMD -0.36 [95% CI -0.64 to -0.07]; 7 trials, 619 patients; moderate-certainty evidence).

CONCLUSIONS

Digital health interventions effectively enhance multiple dimensions of treatment adherence in dialysis patients, underscoring their value for incorporation into routine clinical practice.

Treatment Adherence and Factors Influencing It in End-Stage Renal Disease Patients on Maintenance Hemodialysis: A Study From a Tertiary Care Hospital in North India

Background Chronic kidney disease (CKD) has become a significant global health concern, making its effective management crucial. Patients with end-stage renal disease (ESRD) often require multiple medications, restriction of fluid and diet intake, and maintenance hemodialysis (HD) to manage their condition, which together makes it difficult to maintain adherence to treatment. This study aimed to evaluate the prevalence of treatment adherence among ESRD patients and to identify influencing factors, addressing the lack of such data from Northern India. Methods This cross-sectional study was conducted at a tertiary care hospital in Northern India. ESRD patients on maintenance HD for at least three months were recruited from the outpatient and dialysis units of the hospital. Patients were interviewed using a validated and reliable tool, the End-Stage Renal Disease Adherence Questionnaire (ESRD-AQ). The primary objective was to assess the prevalence of treatment adherence among ESRD patients on HD who presented to the hospital, and the secondary objective was to evaluate various factors influencing treatment adherence among these patients. Results A total of 199 patients were enrolled, with a mean age ± standard deviation of 44.34 ± 13.7 years. Among the patients, 51.76% (n = 103) demonstrated good adherence (adherence score >1000), 41.71% (n = 83) showed moderate adherence (adherence score 700-999), and 6.53% (n = 13) exhibited poor adherence (adherence score <700). A significant association was found between adherence scores and patients' perception of treatment regimens (p < 0.0001 for each of the four treatment adherence domains, namely, HD, medication, fluid restriction, and diet restriction) and between adherence scores and the frequency of counseling by medical professionals (p = 0.106, 0.037, 0.014, and 0.002 for HD, medication, fluid restriction, and diet restriction, respectively). Individuals with graduate-level education or higher exhibited significantly better adherence scores than those with education levels below graduation (p = 0.044). However, age, sex, marital status, area of residence, employment status, mode of transportation, and the presence of family members accompanying patients to HD sessions were not significantly associated with treatment adherence. Conclusion Approximately half of the study population exhibited moderate-to-poor adherence, emphasizing the need for substantial improvement in adherence levels. These findings suggest that more frequent and effective counseling is necessary, as low adherence scores were significantly associated with infrequent counseling and poor patients' perceptions of the importance of treatment regimens.

Medication Adherence Among Patients With Kidney Disease: An Umbrella Review

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

Evaluating the Psychometric Properties of Patient-Reported Outcome Measures for Assessing Symptoms in Hemodialysis: A Systematic Review Using COSMIN Guidelines

CONTEXT

Patient-reported outcome measures (PROMs) may have an important role in screening and monitoring for unpleasant symptoms in kidney failure. However, there is still little evidence on the psychometric properties of the measures available to assess physical and psychological symptoms in people on hemodialysis. This gap makes it difficult to decide which measure is the most appropriate for use in clinical practice and research with this population.

OBJECTIVES

This systematic review aimed to critically appraise, compare, and summarize the quality of the measurement properties of PROMs used to assess symptoms in adults on hemodialysis.

METHODS

The protocol for this review was registered in PROSPERO (CRD42023393441). The last database search update was performed on November 25, 2022. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines informed methodological quality assessment, data extraction, analysis, and synthesis.

RESULTS

Twenty-seven primary studies reported the measurement properties of 16 PROMs used to assess physical and psychological symptoms in adults on hemodialysis. Results showed that most measures lacked the necessary psychometric evidence to attest their suitability for this study population, and few underwent rigorous validation procedures. Overall, caveats were found on methodological quality and evidence of content validity and structural validity, and little data was available on responsiveness, measurement error, and cross-cultural validity.

CONCLUSION

The current systematic review provides the basis for identifying PROMs with potential utility for assessing symptoms in hemodialysis care. Several recommendations are presented to help guide future research aimed at improving the rigor of validation and/or translation procedures of existing (and future) measures using COSMIN guidelines.