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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 1  |  Page : 34-38

Compliance to fluid and dietary restriction and treatment adherence among chronic hemodialysis patients in a tertiary care hospital, Puducherry


1 Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Department of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Submission22-May-2019
Date of Decision14-Sep-2019
Date of Acceptance29-Sep-2019
Date of Web Publication13-Jan-2020

Correspondence Address:
Ms. M Anuja
Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_41_19

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  Abstract 


INTRODUCTION: Fluid and dietary restrictions play a vital role in rehabilitative care of patients on dialysis. Good adherence to the treatment regimen in hemodialysis (HD) patients can also reduce hospitalization risk. Therefore, this study was carried out to assess the compliance to fluid and dietary restrictions and treatment adherence among chronic HD.
MATERIALS AND METHODS: A cross-sectional study of chronic HD patients at JIPMER Hospital was carried out from September to October 2018. Compliance to fluid and dietary restriction and medication adherence was measured through the prevalidated End-Stage Renal Disease Adherence Questionnaire. Continuous variables such as age, income, body mass index, and hemoglobin were described as mean and standard deviation and categorized as proportion where necessary. Categorical variables such as gender, marital, comorbidities, adherence characteristics, and perception/attitude behavior were described as proportions with 95% confidence interval.
RESULTS: A total of 96 patients with end-stage renal disease participated in the study. Overall, 83.3% were good, 14.6% had moderate, and 2% had poor in compliance to fluid and dietary restrictions and treatment adherence. Compliance behavior is significantly related to marital status (P = 0.01). The odds of unmarried and widowed are 3.2 times higher than the odds of married within the confidence interval of 0.8–13 for compliance behavior.
CONCLUSIONS: Enhanced patient education plays an important role in slowing the development of kidney failure and detaining the need to begin kidney dialysis. Educational intervention is needed for HD patients to improve the compliance with diet and fluid restrictions.

Keywords: Compliance, dietary restriction, fluid, hemodialysis, Puducherry, treatment adherence


How to cite this article:
Anuja M, Ashok M V. Compliance to fluid and dietary restriction and treatment adherence among chronic hemodialysis patients in a tertiary care hospital, Puducherry. Int J Health Allied Sci 2020;9:34-8

How to cite this URL:
Anuja M, Ashok M V. Compliance to fluid and dietary restriction and treatment adherence among chronic hemodialysis patients in a tertiary care hospital, Puducherry. Int J Health Allied Sci [serial online] 2020 [cited 2020 Jan 18];9:34-8. Available from: http://www.ijhas.in/text.asp?2020/9/1/34/275647




  Introduction Top


Chronic kidney disease (CKD) is an important public health problem with its high prevalence, morbidity, and mortality in India. According to the Global Burden of Disease Study 2015, CKD was ranked the 17th among the causes of deaths globally, with an annual death rate of 19.2 deaths per 100,000 population. However, in India, CKD was ranked as the eighth leading cause of death.[1] The yearly adjusted mortality rate of dialysis patients is still high despite developments in supportive care and dialysis technology.[2]

Adherence to diet, medication regimen, and fluid restrictions are extremely important for the patients with chronic renal failure and could contribute strongly to improving health and feeling well in the patients under hemodialysis (HD).[3] The aim of medication prescriptions is to treat cardiovascular and comorbid conditions such as diabetes mellitus and anemia. Lack of compliance of dietary prescriptions may cause a collection of metabolic by-products and overabundance fluid in the circulatory system which is essential to raise morbidity and mortality for kidney failure patients. Poor adherence in chronic renal failure patients often leads to additional tests, change in treatment design, change in prescribed drug dosage, hospitalization, and finally, increase in health-care costs.

Earlier studies have reported that educational intervention leads to increased adherence with fluid and sodium restrictions and also decreases the interdialytic weight gain (IDWG) and blood pressure values.[4] A higher IDWG is related to higher predialysis and blood pressure as a result of higher ultrafiltration rates and increased mortality.[5] However, such studies are lacking in the Indian context where kidney disease is assuming a larger proportion with high prevalence of risk factors such as diabetes, hypertension, obesity, old age, and family history.


  Materials and Methods Top


This cross-sectional survey design was conducted to assess the compliance to fluid and dietary restrictions and treatment adherence among chronic HD patients attending dialysis unit in a tertiary care hospital, Puducherry. This study was conducted in JIPMER Outpatient HD Center, Old Curie House at JIPMER Campus in Puducherry.

All adult patients (>18 years) diagnosed to have chronic renal failure and undergoing HD at JIPMER for the past 6 months were included in the study. This was an exploratory study; the sample size of 100 was estimated based on the feasibility of data collection in 6 weeks between September and October 2018. Purposive sampling technique was used. The study was approved by the JIPMER Scientific and Institutional Ethical Committee.

Compliance to fluid and dietary restriction and medication adherence was measured through the prevalidated End-Stage Renal Disease Adherence Questionnaire. This was used to assess the degree of adherence, perception, and counseling of patients toward HD treatment. It is a reliable and valid instrument used in several studies to assess adherence among HD patients.

Data were entered in Epicollect5, and analysis was done using SPSS software version 22 (IBM Corporation, Puducherry, India) (enter the following license code using the License Authorization Wizard: 9DNCAF2O3QVDV7FBIO696OO 6GWLNXZPPRYTPWF2PPX7C8T6Y24 LMVV2ET7DOLX5CXAL5YDLL 79UPGEFCPDXP5Q8O5E). Continuous variables such as age, income, body mass index, and hemoglobin were described as mean and standard deviation and categorized as proportion where necessary. Categorical variables such as gender, marital, comorbidities, adherence characteristics, and perception/attitude behavior were described as proportions with 95% confidence interval (CI). Association between compliance behavior and sociodemographic and clinical characteristics was tested with significant P < 0.05.


  Results Top


Out of the 96 patients were interviewed, majority (32.3%) belong to 45–59 years, 66.7% were male, 68.8% were married, and 38% had completed at graduate and above. Most of the patients (53.1%) were not involved in any kind of income-generating work. About 44.8% belong to the lower middle class and 49.0% were in <30 min of distance travelled to dialysis center [Table 1].
Table 1: Sociodemographic characteristics (n=96)

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Around 45% of the patients were hypertensive (44.8%) and one-third (35.4%) were severely anemic. Two-thirds of the patients had low hemoglobin levels. Majority of the patients (71, 74.0%) had normal weight, 11% were underweight, whereas 15% were overweight or obese. Most of the patients (89, 92.7%) had abnormal IDWG (>2 kg). Almost all the patients had elevated blood urea nitrogen (100%) and serum creatinine (99%). Majority of the patients had normal sodium (99%), whereas one-fourths had elevated potassium (27%) or calcium levels (25%) [Table 2].
Table 2: Clinical and biomarker characteristics (n=96)

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Majority of the patients, i.e., 88 (91.7%), had not missed the dialysis treatment in the past month or did not have a shortening of dialysis time (92.7%). Around 83.3% of the patients had not missed the medicines in the past week. Comparatively less than one-third of the patients followed their fluid restriction or diet restriction “all the time” (30% and 25%, respectively) in the past week. One fourth of subjects did not follow fluid restriction for more than half of the time, while it was 15% in case of dietary restrictions [Table 3].
Table 3: Adherence characteristics (n=96)

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Majority of the patients' perceptions were favorable toward following their dialysis schedule (82, 85.4%), in following their medicines (71, 74.0%). However, it was lesser in their attitude toward limiting their fluid intake and in watching types of food taken (20% and 13%, respectively) [Figure 1].
Figure 1: Attitude and perceptions regarding adherence behavior

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Out of the 96 patients, 80 (83.3%) were good in compliance to fluid and dietary restrictions and treatment adherence. Around 14 of the patients (14.6%) had moderate compliance, whereas 2% had poor compliance [Figure 2].
Figure 2: Level of compliance

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Compliance behavior is significantly related to marital status (P = 0.01). The odds of unmarried and widowed are 3.2 times higher than the odds of married within the CI of 0.8–13 for compliance behavior [Table 4].
Table 4: Association between compliance behaviors

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  Discussion Top


In the current study, the compliance to fluid and dietary restriction and treatment adherence among chronic HD patients was investigated and analyzed. The findings of our study showed that there was (83%) good compliance to fluid and dietary restriction and treatment adherence among majority participants. This was much higher than other studies which reported poor compliance – 45% had moderate-to-poor adherence.[6]

Majority of the patients (91.7%) were following the dialysis treatment in the past month, and most of them did not have a shortening of dialysis time. More than three-fourths of the participants (83.3%) were adherent to their medications in the past week. However, the level of compliance to dietary restrictions was lower among the study population (59.4%), and it was the least in case of fluid restriction (37.5%).

All of them had abnormal blood urea nitrogen, and only one patient had normal creatinine. Most of the patients were normal in sodium, potassium, and calcium. Comparable results noted in a study done by Nisha et al., shown high sodium, potassium and calcium in before doing HD and it was reduced after doing HD.[7]

Majority of the patients had abnormal IDWG (93%). High level of IDWG is a mark of noncompliance. Comparable results noted in a study done by Lee et al., shown IDWG percentage is ≥4.0 as a significant predictor of the primary outcome in HD patients.[8]

This is corroborated by the fact that only two-thirds of them had followed fluid restriction on most of the time in the past week and around 20% perceived it as little to moderate importance. However, the participants had a better attitude toward medication and dialysis adherence (85% and 74%, respectively) than in limiting their fluid intake or watching types of food taken (63% and 68%, respectively). Other studies have shown similar results where compliance to dialysis schedule (96%) and medication (85.5%) was perceived to be very important compared to fluid intake (88%) and daily diet (77%).

In our study, the compliance behavior of the patient is statistically significant to marital status (P = 0.01), with an odds ratio of 3.6 (95% CI = 1.19–10.9). Similar results were found by Baraz S et al. which found that marital status (P = 0.005) is statistically significant, with an odds ratio of 0.26 (95% CI = 0.10–0.67).[9]


  Conclusions Top


Poor knowledge of patients' regimen was shown to be an essential predictor of nonadherence in other studies. Enhanced patient education plays an important role in slowing the development of kidney failure and detaining the need to begin kidney dialysis. Educational intervention is needed for HD patients to improve the compliance with diet and fluid restrictions. The 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. Cardiac care, skilled dietary counseling, and regular bio-impedance analysis have yielded marked improvement in the patients' attitude to lifestyle changes, salt and water intake, and compliance with medications.[10]

Spreading awareness alone is not beneficial; rather, targeting knowledge gaps is more essential. Hence, further research needs to look at multifaceted interventions focusing on behavioral factors and family support. Research needs to be done to identify acceptable methods for accurate self-assessment in the local context and means to augment social support networks. Psychosocial rehabilitation programs for chronic disease care need to be considered with the increasing burden of noncommunicable diseases.[11]

Acknowledgment

The authors would like to thank patient support to carry out this research.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
IANS. World Kidney Day 2018: Kidney Dysfunction More Common in Women than Men | Lifestyle News, The Indian Express. IANS; March, 2018. Available from https://indianexpress.com/article/ lifestyle/health/kidney-dysfunction-more- common-in-women-than-men-5090429/. [Last accessed on 2019 Jan 23].  Back to cited text no. 1
    
2.
Ferraz SF, Freitas AT, Vaz IM, Campos MI, Peixoto Mdo R, Pereira ER. Nutritional status and interdialytic weight gain of chronic hemodialysis patients. J Bras Nefrol 2015;37:306-14.  Back to cited text no. 2
    
3.
Rafiee Vardanjani L, Parvin N, Mahmoodi Shan G. The effects of an individual, multistep intervention on adherence to treatment in hemodialysis patients. Disabil Rehabil 2016;38:768-72.  Back to cited text no. 3
    
4.
Chan YM, Zalilah MS, Hii SZ. Determinants of compliance behaviours among patients undergoing hemodialysis in Malaysia. PLoS One 2012;7:e41362.  Back to cited text no. 4
    
5.
Ipema KJ, Kuipers J, Westerhuis R, Gaillard CA, van der Schans CP, Krijnen WP, et al. Causes and consequences of interdialytic weight gain. Kidney Blood Press Res 2016;41:710-20.  Back to cited text no. 5
    
6.
Naalweh KS, Barakat MA, Sweileh MW, Al-Jabi SW, Sweileh WM, Zyoud SH. Treatment adherence and perception in patients on maintenance hemodialysis: A cross-sectional study from Palestine. BMC Nephrol 2017;18:178.  Back to cited text no. 6
    
7.
Nisha R, Srinivasa Kannan SR, Thanga Mariappan K, Jagatha P. Biochemical evaluation of creatinine and urea in patients with renal failure undergoing hemodialysis. J Clin Path Lab Med 2017; 1:1-5.  Back to cited text no. 7
    
8.
Lee MJ, Doh FM, Kim CH, Koo HM, Oh HJ, Park JT, et al. Interdialytic weight gain and cardiovascular outcome in incident hemodialysis patients. Am J Nephrol 2014;39:427-35.  Back to cited text no. 8
    
9.
Baraz S, Parvardeh S, Mohammadi E, Broumand B. Dietary and fluid compliance: An educational intervention for patients having haemodialysis. J Adv Nurs 2010;66:60-8.  Back to cited text no. 9
    
10.
Beerendrakumar N, Ramamoorthy L, Haridasan S. Dietary and fluid regime adherence in chronic kidney disease patients. J Caring Sci 2018;7:17-20.  Back to cited text no. 10
    
11.
Mangal A, Kumar V, Panesar S, Talwar R, Raut D, Singh S. Updated BG Prasad socioeconomic classification, 2014: A commentary. Indian J Public Health 2015; 59:42-4.  Back to cited text no. 11
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