Breaking the adherence barriers: Strategies to improve treatment adherence in dialysis patients

Abstract

Patients with end-stage kidney disease (ESKD) who are on dialysis have to make significant adaptions to their life, accepting dietary and fluid restrictions, rigorous medication regimens, and complex renal replacement therapy routines. 1 Patients also have to cope with the multiple self-management challenges related to complications and comorbidities associated with ESKD, diminished independence, loss of time spent on dialysis, travel limitations, and financial burden. 2 Adherence to the demanding physical and behavioral adaptions are central to the effective delivery of ESKD care, 1 yet low adherence to all domains of ESKD therapy (diet, fluid, medication, and dialysis) is common. 3-5 Nonadherence to treatment is associated with increased risk of mortality, hospitalizations, complications, and poor quality of life in dialysis patients. 6-8 Given the high baseline risk of adverse outcomes experienced by ESKD patients, it is instinctive to examine whether strategies to promote treatment adherence could improve clinical outcomes. In the context of long-term therapies of chronic diseases, it has been suggested that a more significant impact on the population health outcomes could result from the introduction of effective adherence interventions than any improvement in specific medical treatments. 9 Several randomized and nonrandomized trials have examined the effectiveness of diverse adherence intervention strategies on the direct or indirect markers of adherence in dialysis patients. 10-12 In this review, we plan to explore the nature of these

Ethical Duties of Nephrologists: When Patients Are Nonadherent to Treatment

“…Causes of dialysis nonadherence are multifactorial [5], and it may manifest in various forms [6]. Some are harmful only to the patient in question, such as missed sessions/early departure, poor care of dialysis access, and nonadherence to an appropriate diet and/or medication.…”

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

“…Research has also evidenced that non-adherence to in-center hemodialysis sessions varies widely, as 8 to 31% of patients choose to withdraw, withhold, or discontinue treatment [ 13 ], whereas 30 to 86% fail to attend dialysis sessions as prescribed [ 14 ]. This discrepancy has been mainly attributed to the lack of a gold standard assessment of adherence, as several direct (e.g., biochemical and physiological markers) and indirect (e.g., questionnaires) measures have been used to assess the different domains of adherence in hemodialysis [ 15 ].…”

“…Regarding direct assessment, studies have relied on clinical biomarkers such as interdialytic weight gain (IDWG), pre-dialysis serum potassium, and/or phosphorous levels as objective measures of fluid and dietary non-adherence, and medication intake [ 16 ]. However, the lack of universally accepted cutoff values for each indicator makes comparisons between studies difficult [ 15 , 17 ]. In turn, self-report measures have been increasingly applied in research and renal care settings, since they are generally inexpensive, flexible, easy to interpret, timesaving, and allow for wide use [ 18 ].…”

“…The ability to understand patients’ perceptions and explore the reasons for non-adherence is another advantage of indirect measurement [ 19 ]. In this context, several questionnaires have been used, namely the End-Stage Renal Disease Adherence Questionnaire (ESRD-AQ), the Dialysis Diet and Fluid Non-Adherence Questionnaire (DDFQ), the Renal Adherence Behavior Questionnaire (RABQ), and other researcher designed/modified instruments [ 15 ]; however, their characteristics vary substantially in terms of domain assessed, single or multiple items, and recall period [ 20 ]. Furthermore, some lack the necessary validity studies and, therefore, it is still unclear which is the most appropriate to assess self-reported adherence in hemodialysis [ 9 , 11 ].…”

“Together We Stand”: A Pilot Study Exploring the Feasibility, Acceptability, and Preliminary Effects of a Family-Based Psychoeducational Intervention for Patients on Hemodialysis and Their Family Caregivers

“…Furthermore, depression in ESRD has been related to poor adherence [10]. It is also well known that non-adherence to HD requirements can result in poor clinical outcomes (e.g., bone demineralization, clots in the access site, electrolyte imbalances, pulmonary congestion, heart failure) and decrease survival [11,12].…”