Original articleIllness representations are associated with fluid nonadherence among hemodialysis patients
Introduction
Dialysis is required in end-stage renal disease (ESRD) to remove accumulated toxins and excess fluid resulting from renal failure, which, without treatment, would inevitably prove fatal. Hemodialysis (HD) is the most common form of dialysis, typically requiring the patient to attend hospital three times per week to undergo a 3- to 4-h dialysis treatment session. The complications of ESRD require numerous other treatments, including multiple drugs to facilitate the management of blood pressure, anemia, abnormalities of mineral metabolism, and other problems related to extrarenal comorbidities. A potential significant stressor is the need to restrict the dietary intake of phosphates and potassium-rich foods, and to reduce salt and fluid intake. Adherence to these regimens can be categorized into the following facets: (a) medication, (b) dietary/fluid intake, and (c) dialysis prescription [1]. Adaptation to and maintenance of these requirements are crucial in disease management.
This article focuses on fluid nonadherence, which is associated with adverse clinical outcome, including left ventricular hypertrophy, cardiac failure, and premature death [2]. Fluid intake is driven by thirst which is strongly related to the body's sodium balance. Estimates of fluid nonadherence are varied and largely dependent on methodology and definition. Typically, fluid intake is evaluated by interdialytic weight gain (IDWG). IDWG refers to the amount of fluid gained between two dialysis treatment sessions and is estimated by subtracting postdialysis weight from the predialysis weight of the following treatment session. Although IDWG serves as a suitable physiological proxy of fluid adherence [3], the heterogeneity of definitions used has had a major impact on reported estimates of nonadherence. Critically, IDWG alone is insufficient to define adherence [4]. IDWG is influenced by residual renal function (KRU; the amount of remaining intrinsic renal function of the patient) [3] and dry weight (the patient's “ideal weight” when free of excess fluid) [4], [5], [6]. Both of these confounding factors were considered in the current study.
Section snippets
Leventhal et al.'s common-sense model (CSM) of illness representations
Several factors have been associated with nonadherence among dialysis patients, including age, gender, psychological factors including health beliefs [7], [8], [9], social support [10], [11], personality factors [12], locus of control [4], [7], self-efficacy [13], and depression [4], [14]. Cognitive factors may be more predictive than emotional variables [15], although it is likely that these factors have complex interactions and vary with different behavioral demands [4]. The application of
The present study
This study investigated whether there were significant differences between fluid-adherent patients' and nonadherent patient's illness representations, as measured by the Revised Illness Perception Questionnaire (IPQ-R) [19]. In addition, we investigated whether illness representations predicted fluid nonadherence. Our definition of fluid nonadherence involved computing IDWG as a percentage of a patient's dry weight, thus reducing potential confounding in our measure of nonadherence. Although
Patients
A random sample of adult HD patients from the renal service of the East and North Hertfordshire NHS Trust was approached for inclusion in a larger ongoing study, provided they satisfied the following criteria: (a) fluency in verbal and written English language; (b) not hospitalized at the time of assessment; (c) had been receiving HD for >6 months; (d) no evidence of cognitive impairment, as assessed by an age-adjusted score of <22 on the Mini Mental State Examination (MMSE) [36]; and (e)
Results
One hundred eighteen patients were approached for inclusion in an ongoing study. One hundred patients provided informed consent (17 refused and 1 was excluded after the administration of MMSE). One patient was excluded, as the patient had been receiving dialysis only twice a week during the past 3 months. Data on 99 patients are presented, of which the demographic and clinical characteristics are shown in Table 1 (N=99). The mean IDWG was 1.77 kg [standard deviation (S.D.)=0.85]. Patients'
Discussion
The goal of this investigation was to examine illness representations across fluid-adherent and nonadherent HD patients. Specifically, we were keen on defining “nonadherence” as a clinically relevant group of patients who would be at risk for fluid-related complications. Furthermore, we considered dry weight and KRU, both of which are significant factors associated with the definition of fluid nonadherence based on weight gain [4]. In univariate analysis, nonadherent patients reported
Acknowledgments
This study was kindly supported by a joint British Renal Society–Kidney Research UK Fellowship awarded to J. Chilcot. We wish to thank Prof. Diana Kornbrot for comments on earlier versions of this manuscript, and all patients for their participation.
References (60)
- et al.
Noncompliance in hemodialysis: predictors and survival analysis
Am J Kidney Dis
(1998) - et al.
Assessment of compliance in hemodialysis adaptation
J Psychosom Res
(1986) - et al.
Interdialytic weight gain and survival in hemodialysis patients: effects of duration of ESRD and diabetes mellitus
Kidney Int
(2000) Psychosocial factors in adult end-stage renal disease patients treated with hemodialysis: correlates and outcomes
Am J Kidney Dis
(2000)Compliance behavior and long-term maintenance dialysis
Am J Kidney Dis
(1990)- et al.
Depression is an important contributor to low medication adherence in hemodialyzed patients and transplant recipients
Kidney Int
(2009) - et al.
Illness perceptions predict attendance at cardiac rehabilitation following acute myocardial infarction: a systematic review with meta-analysis
J Psychosom Res
(2006) - et al.
Illness perceptions, coping and functioning in patients with rheumatoid arthritis, chronic obstructive pulmonary disease and psoriasis
J Psychosom Res
(1998) - et al.
The role of illness severity and illness representations in adjusting to multiple sclerosis
J Psychosom Res
(2003) - et al.
Patients' beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness
J Psychosom Res
(1999)
The prediction of self-care behaviors in end-stage renal disease patients using Leventhal's Self-Regulatory Model
J Psychosom Res
“Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician
J Psychiatr Res
Validation of 2 depression screening tools in dialysis patients
Am J Kidney Dis
Identical decline of residual renal function in high-flux biocompatible hemodialysis and CAPD
Kidney Int
Are illness perceptions about coronary artery disease predictive of depression and quality of life outcomes?
J Psychosom Res
Integrating co-morbid depression and chronic physical disease management: identifying and resolving failures in self-regulation
Clin Psychol Rev
Variation in hemodialysis patient compliance according to demographic characteristics
Soc Sci Med
Dietary compliance of chronic hemodialysis patients
J Am Diet Assoc
Hemodialysis compliance: assessment, prediction, and intervention: Part 1
Semin Dial
Psychosocial and cognitive factors associated with adherence to dietary and fluid restriction regimens by people on chronic haemodialysis
Psychother Psychosom
The Janus-faced aspect of ‘dry weight’
Nephrol Dial Transplant
Psychosocial predictors of non-compliance in haemodialysis and peritoneal dialysis patients
Nephrol Dial Transplant
Psycho-social factors affecting adherence to medical regimens in a group of hemodialysis-patients
Med Care
Nonadherence with diet and fluid restrictions and perceived social support in patients receiving hemodialysis
J Nurs Scholarsh
Personality and patient adherence—correlates of the 5-factor model in renal dialysis
J Behav Med
An investigation of factors associated with fluid adherence among hemodialysis patients: a self-efficacy theory based approach
Ann Behav Med
Fluid noncompliance and symptomatology in end-stage renal disease: cognitive and emotional variables
Health Psychol
The common sense representation of illness danger
Illness representations and coping with health threats
A meta-analytic review of the common-sense model of illness representations
Psychol Health
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2019, Journal of Renal NutritionCitation Excerpt :When the residual renal function is maintained, water and sodium are excreted from the urine, and it can be assumed that IDWG is apparently less even with the same sodium and water intake. It was reported that patients who maintained residual renal function with KRU (residual renal creatinine clearance) > 1 had lower risk of IDWG nonadherence,43 and the evaluation of sodium and water intake seemed optimistic; even if the intake is high, it corresponds to the adherence. We only assessed sodium and fluid adherence by RIDWG.
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