Medication Treatment Complexity and Adherence in Children with CKD

Abstract

SummaryBackground and objectives The complexity of CKD management in children is increased by the number of comorbid conditions. This study assessed the prevalence of comorbidities in pediatric CKD and the frequency with which multiple comorbidities present together by assessing prevalent medication use by CKD stage and diagnosis and their association with clinical or sociodemographic factors. The association between number and frequency of dosing of medications prescribed and self-report of nonadherence was also assessed.Design, setting, participants, & measurements In this cross-sectional analysis of the Chronic Kidney Disease in Children study, medication use at study entry grouped by indication was examined by CKD stage, diagnosis, age, race, ethnicity, income, and CKD duration. Multivariate adjusted predictors of medication use and clustering were examined. Nonadherence was assessed by self-report of missed medications in the past 7 days.Results The 558 eligible participants had a median age of 11 years and median GFR of 44 ml/min per 1.73 m 2 ; 62% of participants were male and 78% had nonglomerular kidney disease. The number of medications for treatment of CKD comorbidities increased with advanced CKD stage (2.5-fold for stages IV versus II; P,0.001) and glomerular disease (1.4-fold versus nonglomerular; P,0.001). Three distinct medication clusters were identified that corresponded to treatment of glomerular disease, advanced renal tubular dysfunction, and proteinuric complications, respectively. Nonadherence was associated with increased medication dosing frequency (administration .2 times/d; P,0.001) but not the number of medications.Conclusions Medical therapy for children with CKD is complex and is affected by glomerular diagnosis, CKD stage, and medication frequency. The need for CKD-related medication treatment cannot be easily predicted by CKD staging alone. Poorer adherence was associated with increased medication frequency, but not with the number of medical problems needing treatment. Consolidating medical treatment and reducing medication frequency may improve adherence rates in children with CKD.

Supported self-care for children and adolescents with chronic disease and their families

“…To evaluate the knowledge of the child/adolescent and/or family about the health condition (18)(19)(20) Question the child/adolescent and/or his/her family about their strategies for self-care (19,21) Ask the child/adolescent and/or family what are the barriers to self-care (21)(22)(23) To assess the importance and degree of confidence of the child/ adolescent and/or family for self-care (19) To evaluate the child/adolescent and/or family adherence in activities present in the self-care plan (17,(24)(25)(26)(27)(28)(29) To evaluate the capacity of the patients and/or family to perform an intervention (14,19,30) To determine the strategies used by the child/adolescent with chronic disease for rehabilitation/coping (21,31) To assess the emotional state (depression, mood, anxiety, etc.) of the child/adolescent and/or the family, which may influence self-care actions (13,17,23,30,(32)(33) To evaluate the process of health care transition (HCT) from pediatric to adult-centered health care delivery systems (16,18,21,(34)(35) Counseling Inform the child/adolescent and/or family about the symptoms of the disease and/or therapeutic measures (17,27,36) , while recognizing the cultural uniqueness (19) Inform the child/adolescent and/or family that behavioral changes are as important as taking medications (20) To report the evidence on behavioral changes in health …”

“…Several studies have investigated this activity (13)(14)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35) . One of the aspects discussed in the research was to determine whether activities for self-care management are adhered to along with therapies and skills already developed by health professionals (17,(24)(25)(26)(27)(28)(29) . Thus, studies in pediatrics have demonstrated a significant association between nonadherence and the frequency of medication use; since medications that needed to be taken more frequently during the day were subject to higher rates of nonadherence (24,28) , this together with the number of tablets ingested per dose (28) .…”

Height at First RRT and Mortality in Children

“…In our study, children with short stature had a higher prevalence of Medicaid use, which may be a marker of lower socioeconomic status that could partially explain the higher mortality risk in shorter children despite transplantation. Other factors such as nonadherence to therapy and lower access to care, which are commonly associated with short stature in children with CKD (19)(20)(21), may also be underlying factors that could contribute to the elevated mortality risk in children with short stature.…”

Medication Adherence and Growth in Children with CKD

“…Treatment of patients with CKD includes multiple medications, high dosing frequency, numerous dose adjustments due to disease progression, and the need for coordination of medication administration timing with meals, all of which create a unique context for medication nonadherence in children (18)(19)(20)(21).…”

“…A recent Canadian study, based on the pharmacy refill rates in a pediatric CKD cohort, demonstrated that on average, patients missed 1 day of medications each week (20). A cross-sectional analysis of baseline CKiD data indicated that medications thought to support optimal growth were among those with the highest rates of nonadherence (21). However, the extent of medication nonadherence in children with CKD over time and its association with poor growth remains poorly understood.…”