An assessment of adherence to management modalities by ambulant end stage renal disease patients undergoing haemodialysis at the Kenyatta National Hospital.

Abstract

Background: Treatment of patients with End Stage Renal Disease (ESRD), entails regular dialysis sessions and medical management of complications of kidney failure. Globally, rates of non-adherence to treatment amongst ESRD patients are high. Implications of nonadherence include an increase in hospitalisations, Intensive Care Unit admissions, mortality, and financial burden to the healthcare system. It is vital to study the level of adherence to ESRD care, as a basis to evaluate whether or not patients will be subjected to the dire consequences of non-adherence. No such study has been conducted in Kenya. Objective: To determine patient’s adherence to their ESRD care, by utilising the ESRD Adherence Questionnaire (ESRD-AQ). Study Design: Descriptive Cross Sectional Study. Setting: Renal Unit of Kenyatta National Hospital. Subjects: Adult ESRD patients undergoing haemodialysis at KNH Renal Unit. Methodology: Adherence to ESRD care was assessed by utilising the ESRD-AQ, which utilises an alphanumerical approach to score patients level of adherence to treatment. Predialytic serum potassium level & mean Interdialytic weight gain,(IDWG) were obtained from patient’s Haemodialysis Flow Sheet. Serum potassium, and IDWG are routine measures of effective management in ESRD care. The association between adherence to dietary restrictions and serum potassium levels, and association between adherence to fluid restriction and patient’s IDWG was determined. Data Analysis: Demographic & clinical characteristics were summarised. Utilising data from ESRD-AQ, the level of adherence to ESRD care, as an aggregate, was computed . Correlations between adherence to dietary recommendations and serum potassium level, & between adherence to fluid restrictions & IDWG were computed. P values of<0.05 were considered significant. Confidence Intervals were calculated. Results: During the 2 month study period between 2nd october-29th November 2019, 87 patients undergoing chronic haemodialysis at the Renal Unit of Kenyatta National Hospital were studied. All patients were black Africans; 51 (59%) were male, with a male: female ratio of 1:0.7. Ages ranged from 18 to 79 years, with 62% of patients aged 50 years or below. Prevalent comorbidities included Hypertension in 97% , Diabetes Mellitus in 26%, polycystic kidney disease in 1.14%,whilst 24.13% had both Diabetes Mellitus and Hypertension. The overall adherence to ESRD Care was Good in 48% (95% CI 38-59) of patients, Moderate in 43% (95% CI 33-53) and Poor in 9 % (95% CI 5-17). A total of 70% (95% CI 60-79) of the ESRD population studied, were adherent to their twice weekly haemodialysis sessions in the month preceding the study period. The magnitude of non-adherence was, such that, among the 26 non-adherent patients, 16 (61.5%) patients missed a single haemodialysis session of the total possible 8 sessions in a month; 7 (27%) patients missed 2 sessions, whilst 3(11.5%) patients missed 3 sessions. A total of 72( 83%; 95%CI 73-89) patients reported adherence to their medications, whilst 59(68% ; 95% CI 57- 78) patients were adherent to their fluid restrictions and,61( 70%;95% CI 60-79) patients were adherent to their dietary restrictions. IDWG was significantly higher amongst the patients who were non-adherent to their fluid restrictions as compared to those who were adherent to fluid restrictions. Conclusion: Overall adherence to ESRD care amongst patients undergoing haemodialysis at KNH Renal Unit is suboptimum; with 52% of patients having overall Moderate or Poor adherence. Amongst the four parameters contributing to ESRD care, adherence to fluid restrictions was poorest , followed by adherence to haemodialysis. IDWG was significantly higher amongst patients who were non-adherent to fluid restrictions. The implications of non-adherence, to a twice weekly schedule, is longer interdialytic intervals, which puts patients at increased risk of all-cause mortality (62). Secondly, high IDWGs above 3Kg, implies the patients are constantly in a hypervolemic state, and apart from risks of predialysis hypertension, uncontrolled intradialytic blood pressures, pulmonary oedema and even death, there are also the risks of hemodynamic instability in subsequent haemodialysis sessions when ultrafiltration is being performed.