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Co-authors
University of Kentucky Kentucky-Lexington
Susan K. Frazier, PhD, RN Terry A. Lennie, PhD, RNPeter Sawaya, MD, FACP, FASN
Funding This work was supported in part by a
Center grant to the University of Kentucky College of Nursing from NIH, NINR, 1P20NR010679.
Sigma Theta Tau International Award, University of Kentucky/College of Nursing Chapter.
Acknowledgements
The support of the Dialysis Clinics, Inc. and the Fresenius Dialysis Clinics were invaluable to this study. I would like to thank the medical directors, administrators, technicians, nurses and support staff.
Background and Significant ESRD is a permanent damage of the kidney with
glomerular filtration rate of < 15 ml/min/1.73 m2 Individuals with ESRD require some form of renal
replacement therapy like hemodialysis
Adjusted prevalence rate of ESRD in the US in 2007 was 1500 per million population
By 2007 60% of patients (300,000) with ESRD were receiving hemodialysis
The mortality rate in patients receiving hemodialysis is 8 times higher than in the general population
2009 Annual Data report of ESRD in US
Stress-Related Factors in
Hemodialysis
Medication regimen
Prolonged & intense
treatment
Dietary & fluid
restrictions
Social & sexual
limitations
Loss of work and changes in life style
Depressive symptoms
Depressive symptoms are the most common psychological complication in patients receiving hemodialysis (20% to 90%).
Depressive symptoms include feeling of sadness that is accompanied with somatic symptoms and loss of pleasure in most daily activities
Depressive symptoms influence outcomes: Morbidity Mortality QoL Ability to adhere to prescribed therapy
Kimmel et al. Kidney International, 2000
Normal values Dietary restrictions
Fluid intake 1000-2000 ml/day < 500ml/day or 15 ml water/kg/day
Total energy intake >35Kcal/kg/day 30-35 Kcal/kg/day
Protein intake 1.4 - 2 g/kg/day 0.8 - 1.2 g/kg/day
Potassium intake 2.0 - 5.5 g/day 1.5 g/day
Phosphorus intake 1200 mg/day 700 mg/day
Prescribed Diet and fluid includes:
In prior studies, fluid and dietary nonadherence ranged from 40% to 85%
Vlaminck et al. Journal of clinical Nursing, 2001
Depressive symptoms may reduce adherenceCognitive changes, forgetfulness, hopelessness,
lack of ability to concentrate and make decisions
There are other identified factors that also influence ability to adhere to fluid and diet prescriptionPerceived social support Education levelAgeResidual renal functionComorbidity burdenDuration of hemodialysis
Purpose
To evaluate the relationship between depressive symptoms and fluid and dietary adherence using objective biomarkers and self-report measures in patients with ESRD
Specific Aims To determine the prevalence of depressive symptoms in
patients with ESRD using the BDI-II and the BSI depression subscale.
To determine the prevalence of fluid and diet adherence in patients with ESRD using a self-report measure and biological indicators.
To examine whether depressive symptoms were an independent predictor of fluid and dietary adherence after controlling for age, residual renal function, comorbidities, perceived social support, hemodialysis duration, and educational level.
Research Design, Participants and Settings
Descriptive, cross-sectional design Convenience sample
100 patients receiving hemodialysis Located at seven hemodialysis
centers in Kentucky
Inclusion Criteria
Older than 21 years of age Able to read and write English Free of major psychiatric disorders or
cerebrovascular disease. Receiving hemodialysis for at least 3
months
Exclusion criteria
Presence of a coexisting terminal illness Prescribed antidepressant medication at
time of recruitment History of missing more than one
hemodialysis session or shortening a session by more than 10 minutes during the previous two weeks
Serum bicarbonate level of ≤ 12 mEq/L within the previous 2 weeks
Mean urea reduction ratio (URR) less than 65%
Measurements
Self Report Measures
# of Items
Response Option for Each Item
Range of Scores, (cut-point)
Time to complete
BDI-II (1996) 21 items
A 4-point scale from 0-3
0 to 63, (13) 10 minutes
BSI (1983) 7 items
A 5-point Likert scale from 0-4
0-4, (.28) 5 minutes
Dialysis Diet and fluid Adherence Questionnaire (2001)
4 items
A 5-point Likert scale from 0-4
0 to 56 for each fluid and dietary adherence subscale, (14)
5 minutes
Perceived Social Support (1988)
12 items
A 7-point Likert scale from 1-7
7 to 84 5 minutes
Biological measures
Normal Range Cutoff point Method of calculation
Interdialytic Weight Gain
< 5% of dry weight
>5% of dry body weight
predialysis weight - the postdialysis weight from the previous session in the last three months
Serum Potassium
3.5-5meq/dl > 5.5 meq/dl The mean of the last three months
Serum Phosphorus
3.5-4.5 mg/dl > 5.5 mg/dl The mean of the last three months
Serum BUN 7-25mg/dl > 100 mg/dl The mean of the last three months
Procedure
Expedited IRB approval Convenient sampling Demographic and clinical data were
obtained by interview and medical record review
Four instruments were completed by the patients in the same order
Data analysis
Data Analysis
Descriptive statistics to characterize the sample
Calculated proportion of those with depressive symptoms and those who perceived nonadherence and were nonadherent based on biological indicatorsCompared those who had depressive symptoms
with those who did notCompared those who were nonadherent to fluid and
diet prescription with those who were adherentChi-square and t-test analyses depending on level
of measure
Logistic regression to evaluate whether depressive symptoms were an independent predictor of dietary adherence after controlling for potential confounding variables
Patients Characteristics (N= 100)
Frequency (%) Mean + SD
Age (years) 61.6 ± 14.9
Male 44 (44%)
Ethnicity
Caucasian 43 (43%)
African-American 55 (55%)
Employment
Full-time/part-time 10 (10%)
Unemployed/ Retired/ disabled 90 (90%)
Education
Less than high school 25 (25%)
High school graduate 40 (40%)
College/University 35 (35%)
Clinical characteristics (N=100)
Frequency (%) Mean + SD
Residual renal function
UOP < 200ml/24hrs 66 (66%)
UOP>200ml/24hrs 34 (34%)
Total co-morbidity score 4.5 ± 1.9
Years of hemodialysis in years
4.4 ± 3.8
Serum potassium mEq/dl 4.8 ± 0.5
Serum phosphorus mg/dl 5.7 ± 1.4
Serum BUN mg/dl 54 ± 16
Interdialytic weight gain (kg) 2.7 ± 1.4
Specific aim1
To determine the prevalence of depressive symptoms in patients with ESRD using the BDI-II and the BSI depression subscale.
Comparison of the proportion of patients with depressive symptoms determined by the BDI-II
and the BSI
* p = < 0.05
When those with depressive symptoms were compared to those without using either measure (BDI-II or BSI), patients with depressive symptoms had:Lower education levels (p = 0.002)Less perceived social support (0.04)
Specific Aim 2
To determine the prevalence of fluid and diet adherence in patients with ESRD using a self-report measure and biological indicators.
Fluid and diet nonadherence by self report and biological measures
When those who were nonadherent to fluid and diet prescription were compared with those who were adherent
Patients with perceived dietary nonadherence○ Were primarily African American (p =
0.02 )○ Had lower educational levels (p =
0.04 )Patients whose biological markers
indicated dietary nonadherence○ Were younger (p = 0.009 )
Specific aim 3
To examine whether depressive symptoms were an independent predictor of fluid and dietary adherence after controlling for age, residual renal function, comorbidities, perceived social support, hemodialysis duration, and educational level.
Depressive symptoms were an independent predictor of perceived fluid and dietary nonadherence
BDI-II OR 1.1, (p = 0.02) BSI OR 2.2 to 2.6, (p = 0.04)
Conclusion
Depressive symptoms were highly prevalent among patients with ESRD receiving hemodialysis regardless of the measures used.
Dietary nonadherence was common among patients with ESRD receiving hemodialysis.
Depressive symptoms were highly associated with dietary nonadherence .
Clinical implications Regular screening for depressive
symptoms
Regular evaluation of fluid and dietary prescription adherence using multiple measures.
Interventions focused on depressive
symptoms might improve dietary adherence (Cognitive-behavioral therapy, pharmacological intervention).
QUESTIONS