Fluid compliance among patients having haemodialysis: can an educational programme make a difference?: Fluid compliance among haemodialysis patients

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Abstract

This paper is a report of a study to examine the effectiveness of a patient education programme on fluid compliance as assessed by interdialytic weight gain, mean predialysis blood pressure and rate of fluid adherence. Patients with end stage renal disease who receive haemodialysis are often non-compliant with their treatment regime, especially adherence to fluid restrictions. An exploratory study was conducted in 2004-05 using a quasi-experimental, single group design to examine the effectiveness of patient education on fluid compliance in a dialysis centre located in a major teaching hospital in Kuala Lumpur, Malaysia. Twenty-six patients with an interdialytic weight gain of greater than 2.5 kg were identified as non-compliant and recruited to the study. The intervention was carried out over a 2-month period and included teaching and weekly reinforcement about diet, fluids and control of weight gain. Patients' mean interdialytic weight gain decreased following the educational intervention from 2.64 kg to 2.21 kg (P < 0.05) and adherence to fluid restrictions increased from 47% to 71% following the intervention. Predialysis mean blood pressure did not improve following the intervention, although the maximum recording for predialysis systolic pressure dropped from 220 mmHg to 161 mmHg. Whilst no statistically significant associations were detected between interdialytic weight gain and age, educational level, marital status or employment status, women demonstrated a greater decrease in mean interdialytic weight gain than men. Nephrology nurses often have long-term relationships with their patients and are ideally placed to provide ongoing education and encouragement, especially for those experiencing difficulties in adhering to fluid and dietary restrictions.

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Nonadherence in hemodialysis: associations with mortality, hospitalization, and practice patterns in the DOPPS.

P J Held, Friedrich Port, Akira Saito … (2003)

Nonadherence among hemodialysis patients compromises dialysis delivery, which could influence patient morbidity and mortality. The Dialysis Outcomes and Practice Patterns Study (DOPPS) provides a unique opportunity to review this problem and its determinants on a global level. Nonadherence was studied using data from the DOPPS, an international, observational, prospective hemodialysis study. Patients were considered nonadherent if they skipped one or more sessions per month, shortened one or more sessions by more than 10 minutes per month, had a serum potassium level openface>6.0 mEq/L, a serum phosphate level openface>7.5 mg/dL (>2.4 mmol/L), or interdialytic weight gain (IDWG)>5.7% of body weight. Predictors of nonadherence were identified using logistic regression. Survival analysis used the Cox proportional hazards model adjusting for case-mix. Skipping treatment was associated with increased mortality [relative risk (RR) = 1.30, P = 0.01], as were excessive IDWG (RR = 1.12, P = 0.047) and high phosphate levels (RR = 1.17, P = 0.001). Skipping also was associated with increased hospitalization (RR = 1.13, P = 0.04), as were high phosphate levels (RR = 1.07, P = 0.05). Larger facility size (per 10 patients) was associated with higher odds ratios (OR) of skipping (OR = 1.03, P = 0.06), shortening (OR = 1.03, P = 0.05), and IDWG (OR = 1.02, P = 0.07). An increased percentage of highly trained staff hours was associated with lower OR of skipping (OR = 0.84 per 10%, P = 0.02); presence of a dietitian was associated with lower OR of excessive IDWG (OR = 0.75, P = 0.08). Nonadherence was associated with increased mortality risk (skipping treatment, excessive IDWG, and high phosphate) and with hospitalization risk (skipping, high phosphate). Certain patient/facility characteristics also were associated with nonadherence.

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Impact of hypertension on cardiomyopathy, morbidity and mortality in end-stage renal disease.

P Barre, Brendan D. Murray, David G. Kent … (1996)

A cohort of 432 ESRD (261 hemodialysis and 171 peritoneal dialysis) patients was followed prospectively for an average of 41 months. Baseline and annual demographic, clinical and echocardiographic assessments were performed, as well as serial clinical and laboratory tests measured monthly while on dialysis therapy. The average mean arterial blood pressure level during dialysis therapy was 101 +/- 11 mm Hg. After adjusting for age, diabetes and ischemic heart disease, as well as hemoglobin and serum albumin levels measured serially, each 10 mm Hg rise in mean arterial blood pressure was independently associated with: the presence of concentric LV hypertrophy (OR 1.48, P = 0.02), the change in LV mass index (beta = 5.4 g/m2, P = 0.027) and cavity volume (beta = 4.3 ml/m2, P = 0.048) on follow-up echocardiography, the development of de novo cardiac failure (RR 1.44, P = 0.007), and the development of de novo ischemic heart disease (RR 1.39, P = 0.05). The association with LV dilation was of borderline statistical significance (OR 1.48, P = 0.06). Mean arterial blood pressures greater than 106 mm Hg were associated with both echocardiographic and clinical endpoints. Paradoxically, low mean arterial blood pressure (RR 1.36 per 10 mm Hg fall, P = 0.009) was independently associated with mortality. The association of low blood pressure with mortality was a marker for having had cardiac failure prior to death. We conclude that even moderate hypertension worsens the echocardiographic and clinical outcome in ESRD patients, especially in those without previous clinical cardiac disease.