Determination of
Non-Compliance Frequency and Related Factors among End-Stage Renal Disease
Patients on Hemodialysis
Wijan Lal, Tariq Ali, Muhammad
Khalid Idrees, Abdul Rauf Hafeez, Khadija, Shoukat
Department of
Nephrology, Sindh Institute of Urology and Transplantation Karachi, Pakistan.
Correspondence to: Dr. Muhammad Khalid Idrees,
Email: drkhalid37@gmail.com
Running title: Missed
dialysis treatment sessions
ABSTRACT
Objective: This cross-sectional study
was conducted to find out the frequency and factors responsible for treatment
non-compliance among patients with End-Stage Renal Disease (ESRD) on
hemodialysis.
Methods:
This
cross-sectional study conducted at Sindh Institute of Urology and
Transplantation (SIUT) Karachi, Pakistan from March 2014 to July 2015. ESRD patients of either gender aged 18 to 60
years, who were on maintenance hemodialysis were included. The missing of at
least one hemodialysis sessions per month was labeled as non-compliance.
Moreover, detrimental factors like age, gender, duration of dialysis, lack of
family support, lack of transport facility, and financial constraint were
observed.
Results: Out of
952 patients (mean age 34.38 +- 12.79 years), 238 (25%) were non-compliant. A
significantly higher rate of non-compliance was reported in patients with more
than 40 years of age (p=0.0001) and those on dialysis for more than 12 months
(p<0.001). Among the non-compliant patients, lack of transportation 56.3%
(134/238) was the commonest reason of non-compliance followed by lack of family
support 35.7% (85/238) and financial constraint 11.76% (28/238) cases. The
financial constraint as a reason for compliance was significantly related to
gender (p<0.001) and duration of dialysis (p=0.035) while the absence of
transportation facilities as the reason for non-compliance was associated with
age (p<0.001) and dialysis length (p<0.001). Whereas the absence of
family support was associated only with dialysis duration (p<0.001).
Conclusion: Missing of dialysis treatment
sessions affects a big proportion of maintenance hemodialysis patients. Lack of
transportation was the most common reason for non-compliance.
Keywords: Dialysis, compliance, ESRD,
Hemodialysis
INTRODUCTION
Patients with end-stage renal disease (ESRD) on
maintenance hemodialysis usually require three treatment sessions per week to
prevent complications of renal failure including azotemia/uremia and fluid
overload.1 However, some patients miss their hemodialysis sessions
with consequent increased risk for hospitalization or mortality. This missing of dialysis sessions is termed as
non-compliance and usually defined as skipping one or more hemodialysis
sessions in a month, shortening by 10 or more minutes one or more hemodialysis
sessions in a month, an interdialytic weight gain of more than 5.7% of dry
weight, or a serum phosphate of greater than 7.5 mg/dL.2 The underlying reasons of
missing treatment sessions is not fully understood but include some
contributing factors like depression, unreliable transportation, financial
constraints, demographic factors, lack of social/family support and lack of
motivation.3 Missed dialysis treatment (non-compliance/absenteeism)
is universal but it is more common in United Stated (US) than Japan4
and it is probably rampant in Pakistan.5-7
Dialysis centers are often
far away in Pakistan and patients have to travel to bigger cities for dialysis.
Longer the distance from dialysis facility, the more it becomes cumbersome for
patients to reach there. Furthermore, travel time to the dialysis facility of
more than 1 hour is strongly associated with missed treatment.8
We frequently come across
patients who miss their treatment sessions and present in emergency with fluid
overload or uremic symptoms. This happens despite free of cost services at our
institution. Therefore, we conducted this
study to find out the frequency and factors which are responsible for
non-compliance among hemodialysis patients at our institution. This study may
provide basis for more detailed work on this issue.
METHODS
This cross-sectional study was conducted at hemodialysis unit,
department of Nephrology, Sindh Institute of Urology and Transplantation,
Karachi, Pakistan from March 2014 to July 2015. The participants of the study were
selected by non-probability consecutive sampling. ESRD patients of either
gender aged 18 to 60 years, who were on maintenance hemodialysis (thrice
weekly) for at least 6 months were included. Patients with psychiatric illness,
terminally/seriously ill patients and those unable to consent were excluded
from the study.
The
purpose of the study was explained to the patients and informed consent was
taken from each patient before inclusion in the study. The most commonly used
definition of non-compliance has 4 components: skipping one or more
hemodialysis sessions in a month, shortening by 10 or more minutes one or more
dialysis sessions in a month, an interdialytic weight gain of more than 5.7% of
dry weight, or a serum phosphate of greater than 7.5 mg/dL.2
Presence of any one of these four parameters fulfils criteria of
non-compliance. For this study, we defined non-compliance as missing at least
one hemodialysis sessions per month without information/or rescheduling. If
patient comes for dialysis on the next day of missing the dialysis then it is
not considered non-compliance.
Non-compliant
patients were interviewed by the researchers to evaluate the cause of
non-compliance with treatment schedule. All the data was recorded on proforma.
All the
data were analyzed on Statistical Package for Social Sciences (SPSS version
17.0). Mean +-standard deviation (SD) was calculated for continuous variables
like age and duration of disease.
Frequencies and percentages were computed for gender, non-compliance and reasons
for non-compliance. Stratification was done with regard to age, gender and
duration of dialysis dependency to see the effect on outcome through chi-square
test. P-value ≤0.05 was considered significant.
The
study was conducted as per the national and International ethical standards as
describe in the Helsinki Declaration of 1975, as revised in 2008. Moreover all
institutional protocols were followed while conducting the study.
RESULTS
A total of 952 patients with end stage renal disease
on maintenance hemodialysis participated in the study. The average age of the
patients was 34.38 +-12.79 years. Mean duration of hemodialysis was 12.79
+-5.81 months. Out of 952 patients, 695 (73%) were males and 257 (27%) were
females.
Frequency
of non-compliance in ESRD patients was 25% (238/952) as shown in figure 1. The
comparison of compliance with demographic and clinical characteristics showed
significant association with age (p-value <0.001), duration of dialysis
(p-value <0.001), presence of AV fistula (p-value <0.001), mean arterial
pressure (p-value <0.001), and albumin level (p-value 0.003). (Table 1).
Among
these non-compliant patients, lack of transportation 56.3% (134/238) was the
commonest reason of non-compliance followed by lack of family support 35.7%
(85/238) and financial constraint 11.76% (28/238) cases. (Figure 2) Most of the
patients (228/238, 96.0%) described that they did not perceived any immediate
detrimental effects (dyspnea, lethargy) of missing the dialysis treatment session.
The
financial constraint as reason for compliance was significantly associated with
gender (p-value <0.001) and duration of dialysis (p-value 0.035). The lack
of transportation services as the reason for non-compliance was associated with
age (p-value <0.001) and duration of dialysis (p-value <0.001) whereas
lack of family support as reason of non-compliance was significantly associated
with duration of dialysis (p-value <0.001) only (Table 2).
DISCUSSION
Provision
of renal replacement therapy/hemodialysis services is a big challenge for
developing countries. Its cost is increasing day by day as the number of
patients requiring hemodialysis is on rise besides rising cost of supplies and
maintenance of dialysis units.
Twenty-five
percent of our hemodialysis were non-compliant with their treatment schedule
which is less than the earlier data from Pakistan.7 According to Renal
Registry of Pakistan, out of 7260 dialysis dependent patients, only 1537
patients were receiving thrice weekly treatment while 66% (4841) had twice
weekly dialysis and 12% (882) patients has irregular dialysis sessions.5
A study from Abbottabad (Pakistan) found that nearly 2/3rd of ESRD
patients were non-compliant and missed their treatment sessions and reported
back only when symptomatic.7
Lack
of transportation was major reason of non-compliance followed by lack of family
support and financial constraints. It concurs with findings of Chenitz KB who found that most common barrier to
hemodialysis was inadequate or unreliable transportation.9 Most of the patients in our study
were from middle class and poor socioeconomic status who
do not have private transport/vehicles and rely on public transport. A study
has reported most of ESRD patients as young to middle age and mostly sole bread-earner
of the family with poor social and community support.10 Males were
significantly more affected by financial constraints than females while females
were significantly more affected by lack of transportation. This could be due
to the reason that males usually earn, and females are usually dependent on
males for travel and transportation.11
In
contrast to other study findings, missing of treatment sessions was more
frequent among patients with above forty years of age.3,12
Patients on maintenance hemodialysis for more than 12 months were more likely
to be non-compliant as compared with those whose duration of dialysis
dependency was 6 months to 1 year. Saran R et al3 found that time on dialysis increases the odds of
being non-adherent to treatment time. This phenomenon of increasing absenteeism
with longer duration of dialysis dependence may be due to loss of interest in
self-care with time, depression, lack of social and family support, decreasing
attention/education by staff of dialysis unit and false over-confidence of
being able to cope the effects of missing the
treatment. Most of the patients were not concerned about effects of missing the
dialysis session as they did not feel any immediate ill effect. Furthermore, it
is also reported in literature that patients are more likely to miss dialysis
treatment sessions if they do not perceive any immediate effects of
non-compliance.13
In the
current study, there was statistically significant difference in prevalence of
arterio-venous fistula between the two groups (compliance/non-compliance) of
the patients. As patients missed dialysis sessions, they also missed the
opportunity to get rid of vascular catheters and remain on catheters for longer
period of time. These catheters have high risks of infection and inflammation.14
Low serum albumin carries risk of increased mortality especially among
Pakistani dialysis patients.15,16 Serum potassium was higher among
patient who missed the treatment sessions but this difference is not
statistically significant. High mean arterial pressure (MAP) among those
missing treatments may be reflecting retention of salt and water as well as
non-compliance with anti-hypertensive drugs and may be a contributing factor in
morbidity and mortality.17 The proportion
of patients with serum phosphate above 7.5 mg/dl was significantly high among
non-compliant patients. High serum phosphate among patients missing dialysis
sessions denotes inadequate dialytic removal of phosphate, and non-compliance
to dietary restrictions and phosphate binders can be a
contributing factor.18 Lower hemoglobin among patients
missing dialysis is multifactorial including missing erythropoietin and
parenteral iron, presence of inflammation due to catheters and loss of blood in
catheter care. Patients who missed dialysis are more likely to have poor
control of their anemia, bone mineral milieu and blood pressure, more severe
fluid and electrolyte imbalance resulting in cardiovascular morbidity and
mortality.19
This high frequency of missed
treatments and its adverse impact occurring in an institution where patients
get free treatment dictates that more and more efforts are needed to improve
compliance of patients. Provision of dialysis services close to patients` home
especially in small cities and rural areas is need of hour and requires
political commitment and community mobilization.20,21
CONCLUSION
Missing
of dialysis treatment sessions affects a big proportion of maintenance
hemodialysis patients. Lack of transportation is the major reason behind
missing of dialysis treatment sessions. Provision of cheap and reliable
transportation facility and establishment of dialysis facilities close to
patients` home (rural areas, small cities) may improve compliance of the patients.
Figure 1: Frequency of non-compliance to hemodialysis among ESRD
patients (n=952)
Figure 2: Reason of non-compliance
to hemodialysis (n=238)
|
Table 1: Comparison
of complaints with demographic and clinical characteristics of the patients
(n=952) |
||||
|
Compliant (n=714) |
Non-compliant
(n=238) |
|||
|
Total |
n (%) |
n (%) |
p-value |
|
|
Age, years |
||||
|
≤40 |
367 |
301 (82) |
66 (18) |
<0.001 |
|
>40 |
587 |
413 (70) |
173 (29) |
|
|
Gender |
||||
|
Male |
695 |
514 (74) |
181 (26) |
0.221 |
|
Female |
257 |
200 (78) |
57 (22) |
|
|
Duration of dialysis, months |
||||
|
≤12 |
526 |
438 (83) |
88 (17) |
<0.001 |
|
>12 |
426 |
276 (65) |
150 (35) |
|
|
Urea reduction ratio |
||||
|
<65 |
326 |
235 (72) |
91 (28) |
0.135 |
|
≥65 |
626 |
479 (77) |
147 (23) |
|
|
AV fistula |
||||
|
Yes |
595 |
479 (80) |
116 (20) |
<0.001 |
|
No |
357 |
235 (66) |
122 (34) |
|
|
Mean arterial pressure |
||||
|
<105 |
760 |
607 (80) |
153 (20) |
<0.001 |
|
≥105 |
192 |
107 (56) |
85 (44) |
|
|
Hb, gm/dl |
||||
|
≤10 |
235 |
157 (22) |
78 (33) |
<0.001 |
|
>10 |
717 |
557 (77) |
160 (22) |
|
|
Phosphate, mg/dl |
||||
|
<5.5 |
704 |
535 (76) |
169 (24) |
0.224 |
|
≥5.5 |
248 |
179 (72) |
69 (28) |
|
|
Albumin, gm/dl |
||||
|
≤3.5 |
143 |
93 (65) |
50 (35) |
0.003 |
|
>3.5 |
809 |
621 (77) |
188 (23) |
|
|
Potassium, mmol/dl |
||||
|
140 |
100 (71) |
40 (29) |
0.291 |
|
|
≥6 |
812 |
614 (76) |
198 (24) |
|
|
All
data presented as number (%), chi-square test applied, p-value <0.05 taken
as significant |
||||