TREATMENT ADHERENCE AMONG 1

PATIENTS UNDERGOING
HEMODIALYSIS:
scenario in Nepal
Presentation By:
Ms. Niru Khatiwada
BSc Nursing (BPKIHS), MN (IOM, TU)
Lecturer, Nepal Medical College
(Affiliated to Kathmandu University)
Kathmandu, Nepal
OVERVIEW
 OVERVIEW
3

 Chronic Kidney Disease: a major complication of

Diabetes Mellitus (DM)
 30% of Type 1 DM patients and 10-40% of type 2 DM
patients develop renal failure (National Kidney
Foundation, 2015)
 Hemodialysis: The most common method of
management of renal failure in developing countries like
Nepal.
 Treatment Adherence is the crucial factor in determining
the morbidity and mortality of hemodialysis patients
 Four important domains: Hemodialysis Schedule, Fluid
Restriction, Diet Restriction and Medicine Adherence
 OBJECTIVES OF THE STUDY
4

 To assess the treatment adherence (hemodialysis schedule,

fluid restriction, dietary restriction and medicine
adherence) among the patients undergoing hemodialysis.

 To find out the association between selected demographic

variables and adherence among the patients undergoing
hemodialysis.

 To assess the clinical measures of non-adherence in the

patients undergoing hemodialysis.
 RESEARCH METHODOLOGY
5

Research Design
 Descriptive Cross sectional study

 Quantitative Study Method

Research Setting
 National Kidney Center, Kathmandu, Nepal

Study Population
 Clients undergoing maintenance hemodialysis

Sample
 Those clients attending NKC for hemodialysis and

meeting eligibility criteria during the data collection

period.
6

Sample Size
Sample size calculated for the study was 166 taking the
following values:
 two sided confidence level=95 percent

 d= 8%= 0.08 (allowable error)

 Prevalence of treatment adherence: 58.8% (Paudel &

Gurung, 2009)

Sampling
Purposive Sampling Technique
 EXCLUSION CRITERIA
7

 Patients undergoing hemodialysis for less than 3

months.
 Patients below the age of 18 years.
 Those who had been admitted for treatment within
last 3 months.
 Those who were sick and not able to participate.
 Those who weren’t willing to participate voluntarily.
 Those who had the history of renal transplantation.
 RESEARCH INSTRUMENT
8

 Semi structured interview based questionnaire was

developed based on the review of literature and consultation
with experts.
 The questionnaire consisted of the following parts:
 Section A: Demographic Characteristics and General &
Clinical Information
 Section B: Questions related to Hemodialysis Schedule

 Section C: Questions related to Dietary Restriction

 Section D: Questions related to Fluid Restriction

 Section E: Questions related to Medicine adherence

 Section F: Clinical Information (IDWG, serum potassium,

serum phosphorus and co morbid diseases)
 DATA COLLECTION PROCEDURE
9

 Ethical clearance was obtained from Institutional

Review Board, IOM after the proposal was approved
by the Research Committee, Maharajgunj Nursing
Campus.

 Written permission was obtained from National Kidney

Center, Kathmandu.

 Informed consent was obtained from each respondent

before the collection of data.
 Contd..
10

 Clients undergoing HD were interviewed during their

HD session and immediately stopped if any
complications aroused.

 Confidentiality was maintained by coding the filled

questionnaires.

 Repetition of respondents was avoided by noting the

names and patient number in a separate sheet.

 Respondents found to be non adherent to treatment

were informed about the importance of adherence.
 HD SCHEDULE
11

Adherent
 Not skipped hemodialysis in last one month

 Shortened hemodialysis session due to medical

reasons like cramps, low BP, vomiting and headache.

Non Adherent
 Hemodialysis session skipped at least one session.

 Shortening of hemodialysis >10 minutes for at least 1

session or shortening ≥10 minutes for more than 1
session in last one month
 DIET AND FLUID RESTRICTION
12

 Adherent - Respondents who always followed the

dietary/fluid recommendations (all of the time) in
last one week.

MEDICINE ADHERENCE

• Adherent - Respondents who did not miss any

dose of medicine in last one week.
CLINICAL MEASURES OF NON-ADHERENCE
13

Clinical Measures Acceptable Not acceptable

IDWG (Interdialytic ≤5.7% of dry weight >5.7% of dry weight
weight gain)
Serum Potassium ≤6.0 mEq/L >6.0 mEq/L
Serum Phosphorus ≤4.8 mg/dL >4.8 mg/dL
MAJOR FINDINGS
TABLE 1
Socio-demographic Variables of the Respondents
15
n=166

Characteristics Frequency Percentage

Age group (in years)
below 20 2 1.2
20-39 63 38.0
40-59 59 35.5
above 60 42 25.3
Mean ± SD: 46.73±16.62
Range: 18-84
Sex
Male 125 75.3
Female 41 24.7
Residence
Inside valley 74 44.6
 TABLE 1 contd.. n=166
16

Characteristics Frequency Percentage

Educational Status
Illiterate 19 11.4
Can read and write 33 19.9
Primary Level 26 15.7
Secondary Level 40 24.1
Higher Secondary Level and above 48 28.9
Marital Status
Married 134 80.7
Unmarried 23 13.9
Widow/ Widower 8 4.8
Divorced/ Separated 1 0.6
Current Employment Status
Unemployed 121 72.9
Employed 30 18.1
Retired 15 9.0
TABLE 2
Accessibility to Hemodialysis treatment n=166
17

Frequency Percentage
Monthly expenditure for hemodialysis (In Rupees)
less than 10,000 24 14.5
10,000- 30,000 47 28.3
more than 30,000 95 57.2
Mean± SD: 28,147.59±17,101.06
Range: 2,000-80,000
Adequacy of monthly income for HD treatment
Yes 89 53.6
No 77 46.4
If no, other sources for expenditure (n=77)
Financial help from others 28 36.4
Ancestral property 22 28.5
Loan 21 27.3
Others (Agriculture, Pension, Foreign employment,
Donation) 6 7.8
 TABLE 2 contd.. n=166
18
Frequency Percentage
Transportation to come to HD center
Bus 92 55.4
Taxi 28 16.9
Private transport 27 16.3
By walk 19 11.4
Time to reach the HD center
less than 30 min 100 60.2
31 to 60 min 44 26.5
61 to 120 min 18 10.8
more than 120 min 4 2.4
Companion to come to the center
Myself 65 39.2
Spouse 42 25.3
Son/ Daughter 36 21.7
Brother/Sister 9 5.4
Mother/Father 7 4.2
Others (Friends, Personal Assistant, Driver) 7 4.2
 TABLE 3
Hemodialysis treatment (Duration and Frequency)
19

n=166
Information of HD treatment Frequency Percentage
Duration of HD treatment
below 12 months 50 30.1
12 to 36 months 65 39.2
36 to 60 months 30 18.1
more than 60 months 21 12.7
Mean ± SD: 27.36± 23.72
Range: 3-120 months
Frequency of HD in a week
1 day 6 3.6
2 days 143 86.1
3 days 17 10.2
Treatment time in a HD session
3 hours 8 4.8
3 and half hours 16 9.6
4 hours 142 85.5
 TABLE 4
Treatment Adherence
20

n=166

Domains of Adherence Adherers Non adherers

Hemodialysis Schedule 122 (73.5%) 44 (26.5%)

Diet restriction 54 (32.5%) 112 (67.5%)

Fluid restriction 66 (39.8%) 100 (60.2%)

Medication adherence 131 (78.9%) 35 (21.1%)

TABLE 5
Association of HD Schedule and HD accessibility factors
n=166
HD Attendance
χ2 p- OR
Accessibility Factors Non Total
Adherent Value value (95% CI)
adherent
Duration of HD
less than 12 months 30 (60.0) 20 (40.0) 50 Ref
12 to 36 months 54 (83.1) 11 (16.9) 65 0.469 (0.148-1.484)
7.817 0.050*
37 to 60 months 22 (73.3) 8 (26.7) 30 1.534 (0.464-5.069)
more than 60 months 16 (76.2) 5 (23.8) 21 0.859 (0.237-3.121)
Companion to come to the center
Companion 80 (79.2) 21 (20.8) 101 2.086 (1.036-4.199)
4.323 0.038*
Alone 42 (64.6) 23 (35.4) 65 Ref
Time to reach the center
More than 30 minutes 55 (83.3) 11 (16.7) 66 2.463 (1.140-5.319)
5.445 0.020*
30 minutes and less 67 (67.0) 33 (33.0) 100 Ref
Type of Transportation
Private 21 (77.8) 6 (22.2) 27 Ref
Public 93 (77.5) 27 (22.5) 120 10.853 0.004* 4.812 (1.331-17.405)
By walk 8 (42.1) 11 (57.9) 19 4.736 (1.731-12.958)
21
Pearson Chi Square (χ2) Test *: p value significant at ≤0.05 level
 TABLE 6
Association of Fluid Restriction and Socio
Demographic Variables n=166
Fluid Restriction
Socio Demographic χ2 p- OR
Non Total
Variables Adherent Value value (95% CI)
adherent
Marital Status
Others 18 (56.2) 14 (43.8) 32 2.304 (1.053-5.038)
4.501 0.034*
Married 48 (35.8) 86 (64.2) 134 Ref
Duration of HD
less than 12 months 28 (56.0) 22 (44.0) 50 Ref
12 to 36 months 23 (35.4) 42 (64.6) 65 5.409 (1.591-18.395)
10.165b 0.017*
37 to 60 months 11 (36.7) 19 (63.3) 30 2.327 (0.700-7.743)
more than 60 months 4 (19.0) 17 (81.0) 21 2.461 (0.658-9.195)
Treatment Expenditure
Adequate 43 (48.3) 46 (51.7) 89 2.195 (1.156-4.167)
5.864 0.015*
Not adequate 23 (29.9) 54 (70.1) 77 Ref
Pearson Chi Square (χ2) Test
b: Likelihood Ratio
*: p value significant at ≤0.05 level 22
TABLE 7
Association of Medicine Adherence and Socio
Demographic Variables n=166
Medicine
Socio Demographic Adherence χ2 p- OR
Total
Variables Non Value value (95% CI)
Adherent
adherent
Age
>47 67 (87.0) 10 (13.0) 77 2.617 (1.165-5.880)
5.659 0.017*
≤47 64 (71.9) 25 (28.1) 89 Ref
Residence
Outside Valley 78 (84.8) 14 (15.2) 92 2.208 (1.031-4.725)
4.269 0.039*
Inside Valley 53 (71.6) 21 (28.4) 74 Ref
Duration of HD
less than 12 months 44 (88.0) 6 (12.0) 50 Ref
12 to 36 months 51 (78.5) 14 (21.5) 65 5.500 (1.633-18.523)
8.492 0.037*
37 to 60 months 24 (80.0) 6 (20.0) 30 2.732 (0.959-7.786)
more than 60 months 12 (57.1) 9 (42.9) 21 3.000 (0.865-10.407)
Pearson Chi Square (χ2) Test *: p value significant at ≤0.05 level 23
TABLE 8
Association of IDWG and Socio Demographic
Variables n=165

Socio Demographic IDWG χ2 p- OR

Total
Variables ≤5.7% >5.7% Value value (95% CI)
Age
>47 49 (64.5) 27 (35.5) 76 2.800 (1.486-5.277)
10.373 0.001*
≤47 35 (39.3) 54 (60.7) 89 Ref
Religion
Hindu 69 (55.6) 55 (44.4) 124 2.175 (1.050-4.501)
4.479 0.034*
Others 15 (36.6) 26 (63.4) 41 Ref
Ethnicity
Advantaged Group 62 (57.9) 45 (42.1) 107
2.255 (1.171-4.339)
Disadvantaged 6.028 0.014*
22 (37.9) 36 (62.1) 58 Ref
Group

Pearson Chi Square (χ2) Test *: p value significant at ≤0.05 level

24
 TABLE 8 contd..

Socio Demographic IDWG χ2 OR

Total p- value
Variables ≤5.7% >5.7% Value (95% CI)
Hepatitis C infection
Yes 22 (68.8) 10 (31.2) 32 2.759 (1.213-6.278)
6.139 0.013*
No 59 (44.4) 74 (55.6) 133 Ref
Diabetes Mellitus
Yes 25 (69.4) 11 (30.6) 36 2.696 (1.225-5.937)
6.330 0.012*
No 59 (45.7) 70 (54.3) 129 Ref
Duration of HD
less than 12 months 15 (30.0) 35 (70.0) 50 2.897 (1.331-6.305)
12 to 36 months 36 (55.4) 29 (44.6) 65 2.872 (1.111-7.421)
11.347 0.010*
37 to 60 months 16 (55.2) 13 (44.8) 29 4.667 (1.568-13.886)
more than 60 months 14 (66.7) 7 (33.3) 21 Ref

Pearson Chi Square (χ2) Test *: p value significant at ≤0.05 level

25
 TABLE 9
Association of IDWG and Fluid Restriction
n=165

Fluid IDWG χ2 p- OR
Total
Restriction ≤5.7% >5.7% Value value (95% CI)
Adherent 41 (63.1) 24 (36.9) 65 2.265 (1.193-4.298)
6.354 0.012*
Non adherent 43 (43.0) 57 (57.0) 100 Ref

Pearson Chi Square (χ2) Test

*: p value significant at ≤0.05 level

26
CONCLUSION
27

 About three fourth of the respondents were adherent to

hemodialysis schedule and medicine whereas only
about one third of them were adherent to fluid
restriction and diet restriction.

 It has been identified that duration of HD, hemodialysis

accessibility factors influenced adherence to
hemodialysis schedule; marital status, duration of HD
and adequacy for treatment expenditure influenced fluid
restriction whereas counseling affected dietary
adherence and duration of HD influenced medicine
adherence.
 Contd..
28

 Similarly, IDWG was found to be influenced by age, co-

morbid diseases, duration of HD and fluid restriction.

 The patients undergoing hemodialysis had to spend more

than an average Nepali's income in hemodialysis
treatment.

 Patients did not perceive adherence important other than

hemodialysis schedule and fluid restriction because of
their immediate effect on their health.
 Contd…
29

 Lack of long term financial support to the hemodialysis

patients and unavailability of feasible transport compel
them to skip or shorten hemodialysis treatment.

 Further, lack of reinforcement, motivation and regular

counseling to the patients as well as family members in
all domains of adherence seem to contribute to lower
adherence.
REFERENCES
30

Alkatheri, A. M., Alyousif, S. M., Alshabanah, N., Albekairy, A. M., Alharbi, S., Alhejaili, F. F.,
. . . Qandil, A. M. (2014). Medication adherence among adult patients on hemodialysis.
Saudi Journal of Kidney Diseases and Transplantation, 25(4), 762. Retrieved from
http://www.sjkdt.org
Arenas, M. D., Malek, T., Gil, M. T., Moledous, A., Alvarez-Ude, F., & Reig-Ferrer, A. (2010).
Challenge of phosphorus control in hemodialysis patients: a problem of adherence. J
Nephrol, 23(5), 525-534. Retrieved from http://www.sin-italy.org/jnonline
Chan, Y. M., Zalilah, M. S., & Hii, S. Z. (2012). Determinants of compliance behaviours among
patients undergoing hemodialysis in Malaysia. PloS one, 7(8), e41362.
doi:10.1371/journal.pone.0041362
Al-Khattabi, G. H. (2014). Prevalence of treatment adherence among attendance at
hemodialysis in Makah. International Journal of Medical Science and Public Health, 3(5),
592-598. doi:10.5455/ijmsph.2014.170320141
Kim, Y., Evangelista, L. S., Phillips, L. R., Pavlish, C., & Kopple, J. D. (2010). The End-Stage
Renal Disease Adherence Questionnaire (ESRD-AQ): testing the psychometric properties
in patients receiving in-center hemodialysis. Nephrology nursing journal: journal of the
American Nephrology Nurses' Association, 37(4), 377. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3077091/
REFERENCES
31

Paudel, K., & Gurung, N. (2009). Hemodialysis at Charak Hospital and Research
Center- The first year's experience. Journal of Gandaki Medical College, 2(4).
Retrieved from http://www.gmc.edu.np/
Saran, R., Bragg-Gresham, J. L., Rayner, H. C., Goodkin, D. A., Keen, M. L., Van
Dijk, P. C., . . . Fukuhara, S. (2003). Nonadherence in hemodialysis:
associations with mortality, hospitalization, and practice patterns in the DOPPS.
Kidney International, 64(1), 254-262. Retrieved from http://www.nature.com/
Wang, S., Alfieri, T., Ramakrishnan, K., Braunhofer, P., & Newsome, B. A. (2014).
Serum phosphorus levels and pill burden are inversely associated with
adherence in patients on hemodialysis. Nephrology Dialysis Transplantation,
29(11), 2092-2099. doi:10.1093/ndt/gft280
Takaki, J., Wang, D. H., Takigawa, T., & Ogino, K. (2007). Gender, marital status,
and compliance in maintenance hemodialysis patients. Dialysis &
Transplantation, 36(6), 304-309. doi:10.1002/dat.20129
 32

THANK YOU
!!!
33

TABLES
 TABLE 2
Adherence to Hemodialysis Attendance
34

n=166
HD Attendance Frequency Percentage
Missed HD in last one month
No 130 78.3
Yes 36 21.7
No of sessions missed (n=36)
1 session 19 52.7
2 sessions 12 33.4
3 sessions 3 8.3
>3 sessions 2 5.6
Cause of missing HD treatment (n=36)
Festival 17 47.2
Financial constraint 8 22.3
Personal work or emergency 9 25.0
Others (Injured, Didn't feel like to come) 2 5.5
HD Attendance Frequency Percentage
Shortening of HD session
No 138 83.1
Yes 28 16.9
If yes, no of sessions shortened (n=28)
1 8 28.6
2 11 39.2
3 7 25.0
>3 2 7.2
Average no of minutes shortened (n=28)
10 minutes or less 3 10.7
11 to 20 minutes 6 21.4
21 to 30 minutes 11 39.3
more than 30 minutes 8 28.6
Cause of shortening of HD (n=28)
Low BP 7 25.0
Personal problem or emergency 5 17.9
Cramps 5 17.9
Headache 3 10.7
Restlessness 3 10.7
Vomiting 3 10.7 35
TABLE 3
Information on Adherence to Diet Restriction of the Respondents
n=166
36

Diet Restriction Frequency Percentage

Self-reported non adherence to diet in last one week
No deviation 54 32.5
Mild non adherence 56 33.7
Moderate non adherence 30 18.1
Severe non adherence 18 10.8
Very severe non adherence 8 4.8
Difficulty in diet restriction
Yes 94 56.6
No 72 43.4
Cause of difficulty in diet restriction (n=94)
Need to give up favorite food 27 28.7
Difficulty changing food habit 45 47.9
Weakness 21 22.3
Didn't feel like to restrict 1 1.1
Smoking habit
Smokers 5 3.0
Non smokers 161 97.0
 TABLE 4
Information on Adherence to Fluid Restriction of the Respondents
37

n=166

Fluid Restriction Frequency Percentage

Self-reported Non-adherence to fluid in last one week
No deviation 66 39.8
Mild non-adherence 54 32.5
Moderate non-adherence 27 16.3
Severe non-adherence 19 11.4
Difficulty in fluid restriction
Yes 110 66.3
No 56 33.7
Cause of difficulty in fluid restriction (n=110)
Excessive dry mouth and thirst 90 54.2
Can't give up favorite drink 17 10.2
Others 3 1.8
 TABLE 4 contd…
38

Fluid Restriction Frequency Percentage

Importance of weighing daily
Highly important 13 7.8
Very important 14 8.4
Moderately important 30 18.1
A little important 109 65.7
Number of times weighed outside in last week
Not even once 154 92.8
Once 3 1.8
Twice 5 3.0
Others (Daily, Thrice) 4 2.4
TABLE 5
Information on Medicine Adherence of the Respondents
39

n=166
Medicine Adherence Frequency Percentage
No of daily pills
<3 3 1.8
3-6 19 11.4
7-9 34 20.5
10-12 43 25.9
13-15 30 18.1
>15 37 22.3
Mean ± SD: 11.90±4.66
Range: 3-29
 TABLE 5 contd…
40
Medicine Adherence Frequency Percentage
Missed medicine last week
Yes 35 21.1
No 131 78.9
No of doses missed (n=35)
1-2 doses 14 40.0
3-5 doses 6 17.1
6-10 doses 4 11.5
>10 doses 11 31.4
Cause of missing medicine (n=35)
Forgot to take medicine 14 40.0
Financial constraints 8 22.9
Not felt important to take 5 14.3
Difficulty chewing 3 8.5
Forgot to buy medicine 3 8.5
Side effects of the drugs 2 5.8
 TABLE 5 contd…
41

Medicine Adherence Frequency Percentage

Self reported non adherence to medication
No deviation 131 78.9
Mild Non adherence 14 8.4
Moderate Non adherence 6 2.4
Severe Non adherence 4 2.4
Very severe Non adherence 11 6.7
 TABLE 6
Clinical Measures of Non adherence of the Respondents
42
Clinical Measures Frequency Percentage
Serum Potassium (n=47)
≤6.0 mEq/L 39 83.0
>6.0 mEq/L 8 17.0
Mean 5.21±0.88
Range 3.1-7.3
Serum Phosphorus (n=47)
≤4.8 mg/dL 12 25.5
>4.8 mg/dL 35 74.5
Mean 5.53±1.51
Range 3.0-11.5
Interdialytic Weight Gain (n=165)
≤5.7% of dry weight 84 50.9
>5.7% of dry weight 81 49.1
Mean 5.52±2.24
Range 0.00-12.26
 TABLE 7
Co morbid diseases of the Respondents
43

n=166
Co morbid diseases Frequency Percentage
Hypertension 166 100.0
Diabetes Mellitus 37 22.2
Hepatitis C 32 19.2
Hypothyroidism 11 6.6
Retinopathy 4 2.4
Coronary Artery Disease 4 2.4
Tuberculosis 2 1.2
Ischemic Heart Disease 2 1.2
Valvular Heart Disease 1 0.6
BPH 1 0.6