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