Strategies to improve dietary, fluid, dialysis or medication adherence in patients with end stage kidney disease on dialysis: A systematic review and meta-analysis of randomized intervention trials

Abstract

BackgroundIn patients with end stage kidney disease (ESKD) on dialysis, treatment non-adherence is common and results in poor health outcomes. However, the clinical benefits of interventions to improve adherence in dialysis patients are difficult to evaluate since trialled interventions and reported outcomes are highly diverse/ heterogeneous. This review summarizes existing literature on randomized controlled trials (RCTs) evaluating adherence interventions in ESKD patients focusing on the intervention category, outcome efficacy and persistence of benefit beyond the intervention.MethodsWe performed electronic database searches in Medline, Embase & Cochrane CENTRAL upto 1st July 2018 for RCTs evaluating interventions to improve diet, fluid, medication or dialysis adherence in ESKD patients. Study characteristics including category of interventions, outcomes, efficacy and follow-up were assessed. Meta-analysis was used to compute pooled estimates of the effects on the commonest reported outcome measures.ResultsFrom 1311 citations, we included 36 RCTs (13 cluster-randomized trials), recruiting a total of 3510 dialysis patients (mean age 55.1 ± 5.8 years, males 58.1%). Overall risk of bias was ‘high’ for 24 and of ‘some concern’ for 12 studies. Most interventions (33 trials, 92%) addressed patient related factors, and included educational/cognitive (N = 11), behavioural / counselling (N = 4), psychological/affective (N = 4) interventions or a combination (N = 14) of the above. A majority of (28/36) RCTs showed improvement in some reported outcomes. Surrogate measures like changes in phosphate (N = 19) and inter-dialytic weight gain (N = 15) were the most common reported outcomes and both showed significant improvement in the meta-analysis. Sixteen trials reported follow-up (1–12 months) beyond intervention and the benefits waned or were absent in nine trials within 12 months post-intervention.ConclusionsInterventions to improve treatment adherence result in modest short-term benefits in surrogate outcome measures in dialysis patients, but significant improvements in trial design and outcome reporting are warranted to identify strategies that would achieve meaningful and sustainable clinical benefits.LimitationsPoor methodological quality of trials. Frequent use of surrogate outcomes measures. Low certainly of evidence.

Comparison of health literacy profile of patients with end-stage kidney disease on dialysis versus non-dialysis chronic kidney disease and the influencing factors: a cross-sectional study

“…Adequate HL enables patients to navigate the complex treatment pathways of kidney diseases including ESKD, which are characterised by a heavy pill burden and the need to adhere to rigorous fluid and dietary restrictions. 7 The interactive HL framework envisions HL, as a relational concept that matches the skills and abilities of the patient with the demands and complexity of the care package. 1 Complexity and burden of disease as well as its treatment including diet, fluid, pharmacotherapy and self-care challenges are worse in ESKD compared with CKD.…”

<p>Interventions Incorporating Therapeutic Alliance to Improve Hemodialysis Treatment Adherence in Black Patients with End-Stage Kidney Disease (ESKD) in the United States: A Systematic Review</p>

“…Long duration of delivery and follow-up, preferably up to 2 years, with multiple time points of outcome assessment and use of reinforcement strategies aid optimal assessment of adherence-behavior change in the setting of ESKD. 18,49 Interventions in the studies in this review were at risk of being too diffuse, because of multiple adherence targets, ie diet, medication, and hemodialysis treatment. While interventions can be designed to target change in multiple behaviors relevant to a specific outcome of interest, 50,51 the ideal intervention should be hemodialysis treatment adherence-specific, rather than being bundled into a complex multilevel intervention targeting heterogeneous outcomes, because this limits the ability to draw meaningful conclusions regarding the efficacy of any intervention.…”

“…Other limitations include the small samples of all interventions, limiting power and increasing the risk of type II error, 26 brief study follow-up periods, limiting the ability to demonstrate sustained effects, lack of study populations comprised of 100% Blacks with ESRD, limiting the ability to make definitive conclusions about the most helpful types of interventions for this population, and heterogeneity of included outcomes, increasing chances of observed improvement in hemodialysis treatment adherence simply due to chance. 49…”

The dietary management of calcium and phosphate in children with CKD stages 2-5 and on dialysis—clinical practice recommendation from the Pediatric Renal Nutrition Taskforce

“…For optimal control of P absorption, regular careful review of the use and administration of P binders is essential. Children and their caregivers benefit from regular diet education sessions [103,104], with help from renal dietitians, as well as doctors and nurses, to understand the complexities of their renal diet [102,105,106].…”