phosphorus levels and treatment adherence in patients with ... 71... · phosphorus levels and...

Phosphorus levels and treatment adherence in patients

with chronic kidney disease on haemodialysis

António Saraiva

Valencia, 19th, September

EDTNA/ERCA 17-20.09.2016 Phosphorus levels and treatment adherence in patients with chronic kidney disease on haemodialysis, António Saraiva © FMC - P

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Presentation outline

Introduction

1

Objectives

2

Methods

3

Preliminary Results

4

Conclusions

5

EDTNA/ERCA 17-20.09.2016 Phosphorus levels and treatment adherence in patients with chronic kidney disease on haemodialysis, António Saraiva © FMC - P

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Hyperphosphatemia in patients undergoing haemodialysis treatments is associated with major health problems. This situation is often associated with non-adherence to treatment.

Authors highlight the need of implementing measures to overcome obstacles on adherence to the treatment.

The lack of knowledge is considered the main obstacle for non-adherence to therapy, therefore, training patients is one of the solutions.

The authors address this issue on two different and dissociated perspectives: pharmacological or nutritional. Therefore we need a interdisciplinary approach that includes these two perspectives.

Introduction

EDTNA/ERCA 17-20.09.2016 Phosphorus levels and treatment adherence in patients with chronic kidney disease on haemodialysis, António Saraiva © FMC - P

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To analyse the relation between phosphorus levels and

adherence to drug therapy and nutrition recommendations;

To assess the impact of a interdisciplinary education program

on phosphorus levels and treatment adherence.

Objectives

EDTNA/ERCA 17-20.09.2016 Phosphorus levels and treatment adherence in patients with chronic kidney disease on haemodialysis, António Saraiva © FMC - P

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Methods

Inclusion criteria:

- Patients who were taking phosphate binders in the beginning of the study (OsvaRen®, Phosphosorb®, Renvela®);

- Patients on Haemodialysis program for at least 4 months;

- Non-institutionalized patients;

- Patients with cognitive ability;

- Patients with an average of phosphorus levels > 3.5 mg/dl over the last 3 months;

This is a quantitative, descriptive, correlational and analytical study

that consists on the implementation of a interdisciplinary education

program for three months.

EDTNA/ERCA 17-20.09.2016 Phosphorus levels and treatment adherence in patients with chronic kidney disease on haemodialysis, António Saraiva © FMC - P

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Methods

n= 45 patients

n= 48 patients Dropouts: (3 Patients)

- 1 Patient hospitalized

- 2 Patients refused

N= 164 patients

Inclusion criteria

EDTNA/ERCA 17-20.09.2016 Phosphorus levels and treatment adherence in patients with chronic kidney disease on haemodialysis, António Saraiva © FMC - P

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Methods

n= 45 patients

Group A n = 17

Phosphorus levels between 3.5 and

5 mg/dl on average over the

last 3 months

Out of the education program

Group B

n = 17

Phosphorus levels between 3.5 and

5 mg/dl on average over the

last 3 months

In the education program

Group C n = 11

Phosphorus levels higher 5 mg/dl over the last 3

months

In the education program

EDTNA/ERCA 17-20.09.2016 Phosphorus levels and treatment adherence in patients with chronic kidney disease on haemodialysis, António Saraiva © FMC - P

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Methods

1st Stage

• Initial assessment of the treatment adherence of patients in

groups A , B and C.

• Adherence to medication was assessed by Measure Treatment

Adherence scale.

• Adherence to nutritional recommendations was assessed through a

questionnaire of knowledge and attitudes about nutrition and food

intake record.

EDTNA/ERCA 17-20.09.2016 Phosphorus levels and treatment adherence in patients with chronic kidney disease on haemodialysis, António Saraiva © FMC - P

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Methods

2nd Stage

- Application of a interdisciplinary education program in groups B

and C, for 3 months.

- This program includes the nutritional and pharmacological

perspective:

Through a group session and two individualized training sessions about

nutrition.

Three individualized training sessions about phosphate binders.

EDTNA/ERCA 17-20.09.2016 Phosphorus levels and treatment adherence in patients with chronic kidney disease on haemodialysis, António Saraiva © FMC - P

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Methods

PATIENTS NUTRITIONIST

Group sessions

Nutrition

NURSE

Individual sessions

Phosphate binders

1st Month: February 2016

1st Training Session

EDTNA/ERCA 17-20.09.2016 Phosphorus levels and treatment adherence in patients with chronic kidney disease on haemodialysis, António Saraiva © FMC - P

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Methods

2nd Month: March 2016 3rd Month: April 2016

2nd/3rd Training Sessions

NURSE

Individual sessions

Phosphate binders

Nutrition

PATIENTS

EDTNA/ERCA 17-20.09.2016 Phosphorus levels and treatment adherence in patients with chronic kidney disease on haemodialysis, António Saraiva © FMC - P

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Methods

3rd Stage

- Assessment of the patients’ treatment adherence in groups A, B and C after the education program.

- Application of the Measure Treatment Adherence Scale and questionnaire of knowledge and attitudes about nutrition and food intake.

- Analysis of the average of phosphorus levels of the three months during and after the education program in group A, B and C.

EDTNA/ERCA 17-20.09.2016 Phosphorus levels and treatment adherence in patients with chronic kidney disease on haemodialysis, António Saraiva © FMC - P

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Methods

Statistics Methodology

Descriptive statistics: Average and Standard

Deviation

Comparison study between different time

points – Paired Samples T Student Test;

Non Parametric Wilcoxon Test.

Significance level : ρ≤0,05.

EDTNA/ERCA 17-20.09.2016 Phosphorus levels and treatment adherence in patients with chronic kidney disease on haemodialysis, António Saraiva © FMC - P

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Preliminary Results

SAMPLE

CARACTERISATION

Group A Group

B

Group

C

n 17 17 11

Male 52,9% 64,7% 81,8%

Female 47,1% 35,3% 18,2%

Age (average) 71,94 67,76 57,45

Vascular Access

AVF/Graft 82,4% 88,2% 90,9%

CVC 17,16% 11,8% 9,1%

Time in Dialysis (years) 4,76 6,65 3,18

Residual Function

Yes 52,9% 70,6% 81,8%

No 47,1% 29,4% 18,2%

Diabetes

Yes 52,9% 17,6% 18,2%

No 47,1% 82,4% 81,8%

EDTNA/ERCA 17-20.09.2016 Phosphorus levels and treatment adherence in patients with chronic kidney disease on haemodialysis, António Saraiva © FMC - P

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Preliminary Results

38 39 40 41

Group A

Group B

Group C

Measure Treatment Adherence Scale

After Education

Program

Before Education

Program

p=0,233

p=0,005

p=0,782

EDTNA/ERCA 17-20.09.2016 Phosphorus levels and treatment adherence in patients with chronic kidney disease on haemodialysis, António Saraiva © FMC - P

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Preliminary Results

0

1

2

3

4

5

6

Group A Group B Group C

Before Education Program 4,46 4,23 5,54

After Education Program 4,46 4,57 5,74

Phosphoru

s L

evels

Analysis of the impact of the education program based on average of the first 3 Months after the Education

Program´s beginning.

p=0,989 p=0,027

p=0,494

EDTNA/ERCA 17-20.09.2016 Phosphorus levels and treatment adherence in patients with chronic kidney disease on haemodialysis, António Saraiva © FMC - P

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• Preliminary results show that the education program:

- Increased adherence to phosphate binders, but…

- Was not efficient on improving the phosphorus levels as

expected

Is better adherence to phosphate binders associated to

less concern with nutritional behaviors??

Conclusions

EDTNA/ERCA 17-20.09.2016 Phosphorus levels and treatment adherence in patients with chronic kidney disease on haemodialysis, António Saraiva © FMC - P

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EDTNA/ERCA 17-20.09.2016 Phosphorus levels and treatment adherence in patients with chronic kidney disease on haemodialysis, António Saraiva © FMC - P

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Bibliography

- CEGEA DA UNIVERSIDADE CATÓLICA PORTUGUESA (2007). Estrutura de Mercado e Performance nos Serviços de Hemodiálise em Portugal. [Em linha]. [Consult. 21 de Novembro de 2015]. Disponível em <https://www.ers.pt/uploads/writer_file/document/99/825007_rel.pdf > - SANDLIN K. et al (2013). The impact of nurse-led education on haemodialysis patients’ phosphate binder medication adherence. Journal of Renal Care 39(1), 12–18. - MARTINS et al. (2013). Potentially modifiable factors associated with non-adherence to phosphate binder use in patients on hemodialysis. BMC Nephrology, 14:208. -SAN MIGUEL, S., CURTALE, M, KNAGGE, D, NHAN, C & CHOW, J (2009) Improving patient understanding of phosphate binders: A bony challenge. Renal Society of Australasia Journal 5(3) 119-125.

- FOUQUE D. et al (2014). Balancing nutrition and serum phosphorus in maintenance dialysis. American Journal Of Kidney Diseases: The Official Journal Of The National Kidney Foundation; Vol. 64 (1), pp. 143-50. - Cupisti e D’Alessandro (2011). The impact of known and unknown dietary components to phosphorus intake. Giornale Italiano di Nefrologia ; 28 (3): 278-288. - KARAVETIAN M. E GHADDAR S. (2012). Nutritional education for the management of osteodystrophy (NEMO) in patients on haemodialysis: a randomised controlled trial. Journal of Renal Care 39(1), 1-12. - DELGADO, A.B., & LIMA, M.L. (2001). Contributo para a validação concorrente de uma medida de adesão aos tratamentos. Psicologia: Saúde e Doenças, 1, 81-100.

EDTNA/ERCA 17-20.09.2016 Phosphorus levels and treatment adherence in patients with chronic kidney disease on haemodialysis, António Saraiva © FMC - P

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Acknowledgments

Sandra Ribeiro Nutritionist Fresenius Medical Care – NephroCare Portugal Coimbra – Portugal Alexandra Seabra Head Nurse Fresenius Medical Care – NephroCare Coimbra Coimbra – Portugal Nuno Gomes Deputy Head Nurse Fresenius Medical Care – NephroCare Coimbra Coimbra – Portugal Cristina Antunes Head Nutritionist Fresenius Medical Care – NephroCare Portugal João Fazendeiro Matos Nursing Care Director Fresenius Medical Care – NephroCare Portugal Porto – Portugal Maria Teresa Parisotto Director, Nursing Care Management Fresenius Medical Care NephroCare Coordination Bad Homburg – Germany Clemente Sousa PhD, Nurse Nursing School of Porto Porto - Portugal Rui Camisa Nurse Fresenius Medical Care – NephroCare Coimbra Coimbra – Portugal Lurdes Rosa Clinic Secretary Fresenius Medical Care – NephroCare Coimbra Coimbra – Portugal