Purpose Predictors of and outcomes associated with non-adherent behavior among patients on chronic hemodialysis (HD) have been incompletely elucidated. We conducted a post-hoc analysis of data from the SMILE trial to identify patient factors associated with non-adherence to dialysis-related treatments and the associations of non-adherence with clinical outcomes. Methods We defined non-adherence as missed HD and abbreviated HD. We used negative binomial regression to model the associations of demographic and clinical factors with measures of non-adherence, and negative binomial and Cox regression to analyze the associations of non-adherence with hospitalizations and mortality, respectively. Results We followed 286 patients for up to 24 months. Factors independently associated with missing HD included Tuesday/Thursday/Saturday HD schedule (Incident rate ratio: IRR 1.85, p<0.01), current smoking (IRR 2.22, p<0.01), higher pain score (IRR 1.04, p<0.01), lower healthy literacy (IRR 3.01, p<0.01), lower baseline quality of life (IRR 0.89, p=0.01), and younger age (IRR 1.35, p<0.01). Factors independently associated with abbreviating HD included dialysis vintage (IRR 1.07, p<0.01), higher pain score (IRR 1.02, p<0.01), current nonsmoking (IRR 1.32, p=0.03), and younger age (IRR 1.22, p<0.01). Abbreviating HD was independently associated with an increased number of total (IRR 1.70, p<0.01) and ESRD-related (IRR 1.66, p<0.01) hospitalizations, while missing HD was independently associated with mortality (HR 2.36, p=0.04). Conclusions We identified several previously described and novel factors independently associated with non-adherence to HD-related treatments, and independent associations of non-adherence with hospitalization and mortality. These findings should inform the development and implementation of interventions to improve adherence and reduce health resource utilization.

Background and objectives Depression is common in patients receiving chronic hemodialysis but seems to be ineffectively treated. We investigated the acceptance of antidepressant treatment by patients on chronic hemodialysis and their renal providers. Design, setting, participants, & measurements As part of a clinical trial of symptom management in patients on chronic hemodialysis conducted from 2009 to 2011, we assessed depression monthly using the Patient Health Questionnaire 9. For depressed patients (Patient Health Questionnaire 9 score $10), trained nurses generated treatment recommendations and helped implement therapy if patients and providers accepted the recommendations. We assessed patients' acceptance of recommendations, reasons for refusal, and provider willingness to implement antidepressant therapy. We analyzed data at the level of the monthly assessment. Results Of 101 patients followed for #12 months, 39 met criteria for depression (Patient Health Questionnaire 9 score $10 on one or more assessments). These 39 patients had depression on 147 of 373 (39%) monthly assessments. At 103 of these 147 (70%) assessments, patients were receiving antidepressant therapy, and at 51 of 70 (70%) assessments, patients did not accept nurses' recommendations to intensify treatment. At 44 assessments, patients with depression were not receiving antidepressant therapy, and in 40 (91%) instances, they did not accept recommendations to start treatment. The primary reason that patients refused the recommendations was attribution of their depression to an acute event, chronic illness, or dialysis (57%). In 11 of 18 (61%) instances in which patients accepted the recommendation, renal providers were unwilling to provide treatment. Conclusions Patients on chronic hemodialysis with depression are frequently not interested in modifying or initiating antidepressant treatment, commonly attributing their depression to a recent acute event, chronic illness, or dialysis. Renal providers are often unwilling to modify or initiate antidepressant therapy. Future efforts to improve depression management will need to address these patient-and provider-level obstacles to providing such care.

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A 34-year-old man with a history of depression and alcoholism presented with altered mental status after tapering off his alcohol intake. On examination, he appeared obtunded, jaundiced, and cachectic. Blood pressure was 98/54 mm Hg and heart rate was 104 beats/min. Cardiopulmonary and abdominal examination findings were unremarkable. Neurologic examination showed lethargy, disorientation, and tremulousness, but no focal signs. Blood tests revealed the following values: hemoglobin, 8.3 g/dL; platelet count, 66 310 3 /mL; ammonia, 35 mmol/L; serum sodium, QUIZ PAGE xvi Am J Kidney Dis. 2016;68(5):xv-xvii QUIZ PAGE NOVEMBER 2016 ANSWERS