Patient adherence and adjustment in renal dialysis: A person x treatment interactive approach

We classified 52 in-center hemodialysis patients and 34 self-treated, continuous ambulatory peritoneal dialysis (CAPD) patients on two latent variable indices reflecting patient coping style (i.e., Information Vigilance and Active Coping). The concurrent and prospective interactive effects of Dialysis Type and Coping Style were examined on patient dietary and medication adherence and on patient depression. In cross-sectional analyses, higher Information Vigilance was associated with better dietary adherence for CAPD patients but poorer adherence for In-Center Hemodialysis patients. No significant effects were found on a measure of medication adherence. Information Vigilance exerted a concurrent main effect on depression, such that higher scores were associated with less depression irrespective of dialysis type. Higher Active Coping scores were associated with lower residualized change in depression for both types of dialysis.Portions of this work were presented at the annual meeting of the Society of Behavioral Medicine, San Francisco, 1993.     

The Illness Management Survey: identifying adolescents' perceptions of barriers to adherence

OBJECTIVE: To develop a self-report measure of barriers to adherence and to evaluate its reliability and validity in a sample of adolescents with asthma. METHODS: The Illness Management Survey (IMS) was developed through item generation, expert panel review, and focus group administration. Adolescents with asthma (N = 152) completed the measure. Participants reported on perceived drawbacks to medication, risk-taking behavior, and social desirability tendencies. Providers rated adolescents' illness severity and adherence. Reliability and validity of the IMS were assessed, and factor structure was examined. RESULTS: The 27-item IMS shows high internal consistency (alpha =.87). Scores correlate with perceived medication drawbacks, risk taking, and self- and provider reports of adherence. Principal-components analysis indicates five domains of barriers, accounting for 52.4% of the variance: disease/regimen issues, cognitive difficulties, lack of social support/lack of self-efficacy, denial/distrust, and peer/family issues. CONCLUSIONS: Preliminary data indicate that the IMS reliably and validly assesses perceived barriers to adherence within this sample of adolescents with asthma. It shows promise as a tool for identifying subgroups of nonadherent adolescents.     

直视下腹膜透析管置入术腹壁固定与非固定效果观察

目的探讨腹膜透析置管术中行腹壁固定与非固定两种方式的效果差异。方法慢性肾功能衰竭患者38例,均选择腹膜透析作为肾脏替代治疗模式。按腹膜透析置管术式分为腹壁固定组与非固定组,比较不同术式的透析液出入速度及超滤量、腹透管移位发生率。结果两组透析液出入及超滤量无明显差异;但腹壁固定组腹透管移位发生率为零,非固定组腹透管移位发生率为15%,二者相差显著（P〈0.01）。结论采用腹壁固定术可有效减少术后腹膜透析导管移位发生。     

腹膜透析治疗老年慢性肾功能衰竭的临床分析

目的分析持续性腹膜透析(PD)治疗老年慢性肾功能衰竭(CRF)患者的临床效果,探讨PD在老年CRF患者中的应用经验。方法回顾性分析89例老年CRF患者接受PD(简称老年PD组)治疗后的临床表现和生化指标、主要并发症、存活率、死亡原因等,并与53例非老年PD组相比较。结果老年PD组的原发疾病以糖尿病(37.08%)、原发性高血压(30.34%)为主,而非老年PD组则以肾小球肾炎(54.72%)为主。两组患者的1年与3年存活率差异无统计学意义,腹膜炎仍是两组患者退出PD的主要原因。老年组的病死率明显高于非老年组,感染与心脑血管病是两组患者的主要并发症和死亡原因。低钾血症在老年PD患者中非常普遍。结论腹膜透析在老年CRF患者的治疗中有效,但长期存活仍受腹膜炎、心脑血管病并发症的影响,老年PD患者的低钾血症应引起足够的重视。     

腹膜透析治疗老年慢性肾功能衰竭的临床分析

目的 分析持续性腹膜透析(PD)治疗老年慢性肾功能衰竭(CRF)患者的临床效果,探讨PD在老年CRF患者中的应用经验.方法 回顾性分析89例老年CRF患者接受PD(简称老年PD组)治疗后的临床表现和生化指标、主要并发症、存活率、死亡原因等,并与53例非老年PD组相比较.结果 老年PD组的原发疾病以糖尿病(37.08%)、原发性高血压(30.34%)为主,而非老年PD组则以肾小球肾炎(54.72%)为主.两组患者的1年与3年存活率差异无统计学意义,腹膜炎仍是两组患者退出PD的主要原因.老年组的病死率明显高于非老年组,感染与心脑血管病是两组患者的主要并发症和死亡原因.低钾血症在老年PD患者中非常普遍.结论 腹膜透析在老年CRF患者的治疗中有效,但长期存活仍受腹膜炎、心脑血管病并发症的影响,老年PD患者的低钾血症应引起足够的重视.     

持续低效血液透析与连续性肾脏替代治疗在感染性休克急性肾损伤患者的疗效对比

目的对比研究持续低效血液透析(SLED)与连续性肾脏替代治疗(CRRT)在感染性休克急性肾损伤(AKI)患者中治疗效果。方法选择60例感染性休克AKI的患者,其中男性36例,女性24例;年龄28~71岁,平均年龄49.56岁。随机分为SLED组(30例)和CRRT组(30例)。两组患者均按《2016国际严重脓毒症及脓毒症休克诊疗指南》治疗,在此基础上分别予以SLED(每次治疗8~10 h,24 h后重复治疗,每例患者至少进行3次以上)和CRRT[模式为连续性静脉-静脉血液滤过,治疗剂量35~40 mL/(kg·h),初始24 h持续治疗,然后根据病情调整治疗时间]。分别观察两组患者治疗前后的血肌酐、pH、钾离子、每天液体平衡、急性生理与慢性健康评价Ⅱ(APACHEⅡ)评分及治疗期间血流动力学稳定性的变化。并比较两组患者的重症监护病房(ICU)住院时间、90 d病死率。结果与CRRT组比较,SLED组治疗后12 h和治疗后5 d的血肌酐、钾离子水平均显著低于CRRT组(P<0.05)。与CRRT组APACHEⅡ评分[(14.78±3.79)分]比较,SLED组治疗后5 d的APACHEⅡ评分[(10.45±3.02)分]明显低于CRRT组(P<0.05)。两组患者治疗期间,SLED组具有与CRRT组相近的血流动力学稳定性(P>0.05)。其中,SLED组血管加压药指数(VI)为20.32±5.18,血管加压药依赖性(VD)为(22.08±4.41)%;CRRT组VI为21.05±5.63,VD为(22.67±4.95)%。SLED组患者ICU住院时间[(15.32±3.65)d]显著短于CRRT组[(19.76±4.18)d],差异有统计学意义(P<0.05)。但两组患者90 d病死率差异无统计学意义(33.33%vs 36.67%;P>0.05)。结论SLED治疗感染性休克AKI患者的疗效确切,且在治疗期间血流动力学稳定性方面并不亚于CRRT。     

Medication adherence in pediatric asthma: reasoning,responsibility, and behavior

OBJECTIVE: To assess child adherence to preventive asthma medications; to investigate relations between knowledge, reasoning about asthma, and responsibility for management and adherence; and to determine the association between adherence and morbidity. METHODS: Participants were 106 children with asthma and their parents. Medication adherence was electronically monitored for 1 month. Participants completed self-report measures. Children were interviewed to assess reasoning about asthma. RESULTS: Children's adherence was approximately 48% of prescribed doses. Adherence was negatively related to age (r = -.21, p <.05); minority status, F(1, 98) = 7.55, p <.01; and morbidity (r = -.26, p <.01). Age was associated with increased child knowledge (r =.47, p <.001), reasoning about asthma (tau =.23, p <.01), and responsibility for asthma management (r =.44, p <.01). These variables were not associated with adherence. CONCLUSIONS: Although older children know more about asthma and assume more responsibility for disease management, their adherence is lower than that of younger children. No association was found between adherence and child knowledge, reasoning about asthma, or responsibility for asthma management.     

高通量透析可改善维持性血液透析患者肾性贫血

目的 探讨高通量透析对维持性血液透析患者肾性贫血的防治作用及其机制。方法 55例患者随机分为高通量透析组(HPD组)与常规血液透析组(CHD组)，HPD组患者使用聚砜膜F60高通量透析器，CHD组患者使用低通量F6透析器治疗，检测首次透析前后两组患者血尿素氮(BUN)、肌酐(Cr)、K^ 、Na^ 、Cl^-、Ca^2 、P^3-、甲状旁腺素(PTH)，以及透析前后血浆细胞因子(IL-1β、IL-6、IL-8、TNF-α)和透析开始20min后透析废液中上述细胞因子含量，动态观察并记录患者主诉，动态检测透析前后血红蛋白、红细胞压积，透析治疗1年后，复测并比较两组患者临床生化指标。结果 ①HPD组对PTH、P清除高于CHD组(P＜0．05)，透析1年后，HPD组血浆PTH、P水平明显低于CHD组(P＜0．05)。②透析后即刻HPD组透析废液中细胞因子含量显著高于CHD组(P＜0．05)；透析治疗1年后HPD组血浆细胞因子水平呈下降趋势，但与治疗前比较，无统计学意义(P＞05)。③透析后即刻，HPD组与CHD组血红蛋白、红细胞压积水平与透析前比较均呈上升趋势，但无统计学意义(P＞0．05)，两组间比较差异不显著；透析1年后，HPD组血红蛋白、红细胞压积水平较透析前水平变化差异显著(P＜0．05)，两组间比较显著升高(P＜0．05)。结论 HPD可改善维持性血液透析患者的肾性贫血，其机制与HPD能清除一些不易被CHD透析清除、且对红细胞生成和成熟有抑制作用的蛋白类大中分子物质，主要是PTH、精胺、聚胺、细胞因子等有关。     

Comparison of anthropometric data between end-stage renal disease patients undergoing hemodialysis and healthy adults in Korea

Protein-calorie malnutrition is prevalent in hemodialysis (HD) patients. The prevalence of obesity in healthy Korean adults has increased rapidly during the last 10 years. However, there are few large scale data collections available about the current weight status of Korean HD patients. The weight statuses of 10,304 HD patients (data from the Insan Memorial Dialysis Registry 2002, Korean Society of Nephrology) were compared to those of 12,436 control subjects (age > 18) by using body mass index (BMI). Weight status was assessed by WHO classification for Asian-Pacific region [underweight (UW): < 18.5; normal weight (NW): 18.5-22.9; overweight (OW): 23-24.9; obese (OB): 25-29.9; and extremely obese (EOB): > 30 kg/m2] in both the control and HD patients. HD patients had significantly lower body weight and BMI than the controls in all age groups and in both sexes. For the male controls, the proportions of OW and OB showed a reversed U-shape, peaking at the 5th and 6th decades. of the numbers of those classified as NW and UW were relatively small. For the female controls, the proportions of OW and OB progressively increased with age. On the contrary, in HD patients, the proportions of NW and UW were large, up to more than 70%, and those of OW and OB were small in both sexes. In each age group, UW was seen significantly more in the HD group than in the control group. The 6th decade age group showed the highest prevalence ratio for UW in the HD group for both sexes, compared to the controls (Male: 17.33, Female: 17.68). The percentages of UW were related to HD duration and age in both sexes. In conclusion, Korean HD patients seem to have small proportions of OW and OB, compared to the general population, and protein-calorie malnutrition may still be an important nutritional condition.     

Self-regulation predictors of medication adherence among ethnically different pediatric patients with renal transplants.

OBJECTIVE: To predict medication adherence among ethnically different pediatric patients with renal transplants between the ages of 6 and 20 years old, using self-regulation variables including motivation, perceived control and responsibility, and perceived support. METHODS: Twenty-six African American children and 42 Caucasian children were verbally administered the Self-Regulation of Medication Adherence Battery to assess their (1) motivation to be medication adherent, (2) perceived control of and responsibility for medication adherence, and (3) perceived support of medication adherence from their primary caregiver. Four measures were used to assess medication adherence: self-ratings, nephrologists' ratings, cyclosporine levels, and pill count/refill histories. RESULTS: For the African American patients, regression analyses revealed that responses to motivation and perceived control questions that focused on self-efficacy were unique predictors of medication adherence as rated by their primary nephrologist. For the Caucasian patients, one motivation question regarding how often they forget to take their medication predicted their self-reported adherence. CONCLUSIONS: Facilitating their beliefs that they can regularly take their medications may help promote medication adherence among African American children with renal transplants, whereas for Caucasian children, providing cues and reminders to take their medications may help. We discuss implications of the results for multimodal assessment of medication adherence and for ethnic group-specific medication adherence research and interventions.     

Family support,physical impairment,and adherence in hemodialysis: An investigation of main and buffering effects

Patient noncompliance is a pervasive problem among end-stage renal disease (ESRD) patients. Previous studies have implicated social support as an important correlate of adherence behavior in other chronic illness groups, but little research has examined this relationship in a hemodialysis population. The present study examined the main and interactive effects of social support in the family and illness-related physical impairment with regard to patient compliance in a sample of 78 hemodialysis patients. Results indicated that patients holding perceptions of a more supportive family environment exhibited significantly more favorable adherence to fluid-intake restrictions than did patients reporting less family support. Family support was not associated with adherence to dietary restrictions. The effect of family support on fluid-intake adherence was not moderated by level of physical impairment. This pattern suggests that the influence of support on adherence is more attributable to a main or direct effect, as opposed to a buffering process in the face of increased physical impairment.This research was supported in part by a Marriner S. Eccles Graduate Fellowship for research in public policy awarded to Alan Christensen.     

Agreements between indirect calorimetry and prediction equations of resting energy expenditure in end-stage renal disease patients on continuous ambulatory peritoneal dialysis

Purpose

Equations are frequently used to estimate resting energy expenditure (REE) in a clinical setting. However, few studies have examined their accuracy in end-stage renal disease (ESRD) patients.

Materials and Methods

To investigate agreement between indirect calorimetry and several REE estimating equations in 38 ESRD patients on peritoneal dialysis, we performed indirect calorimetry and compared the results with REEs estimated using 5 equations [Harris-Benedict (HBE), Mifflin, WHO, Schofield, and Cunningham].

Results

Measured REE was 1393.2 ± 238.7 kcal/day. There were no significant differences between measured and estimated REEs except Mifflin (1264.9 ± 224.8 kcal/day). Root mean square errors were smallest for HBE, followed by Schofield, Cunningham, and WHO, and largest for Mifflin (171.3, 171.9, 174.6, 175.3, and 224.6, respectively). In Bland-Altman plot, correlation coefficients between mean values and differences were significant for HBE (r = 0.412, p = 0.012) and tended to be significant for Cunningham (r = 0.283, p = 0.086). In DM patients and patients with overhydration, HBE showed significant underestimation when REE increased.

Conclusion

In ESRD patients on continuous ambulatory peritoneal dialysis (CAPD), REE-estimating equations have no significant differences from indirect calorimetry, except Mifflin. However, HBE showed greater bias than others when REE was high.     

Oxidative stress and DNA hypermethylation status in renal cell carcinoma arising in patients on dialysis

Renal cell carcinoma (RCC) is more frequently observed in patients on dialysis than in patients with normal renal function. However, the mechanism underlying carcinogenesis in RCC patients on dialysis is still unclear. We hypothesized that oxidative stress affects patients on dialysis and generates new neoplasms, and therefore analysed the correlation between the influences of various markers of oxidative stress and carcinogenesis in those patients. We evaluated the immunohistochemical expression of oxidative stress markers, such as iNOS, 8-OHdG, and COX-2 in 42 cases on dialysis and 51 cases with normal renal function as a control. The methylation status of p16INK4a, p14ARF, VHL, and RASSF1A was analysed together with clinicopathological factors. Histologically, the papillary type was observed more frequently in dialysis RCC than in sporadic RCC. Immunohistochemically, overexpression of iNOS (p < 0.0001) and COX-2 (p = 0.0002) was more frequently observed in dialysis RCC. Furthermore, the 8-OHdG labelling index was significantly higher in dialysis RCC than in sporadic RCC. Hypermethylation of p16INK4a was more frequently found in dialysis RCC (p < 0.05). However, no significant correlations between oxidative stress markers and DNA hypermethylation status were observed. The overexpression of iNOS, COX-2, and 8-OHdG in dialysis RCC suggests that patients on dialysis are affected by oxidative stress and that this effect plays an important role in the genesis of dialysis RCC.     

The localization of aluminium and other elements inbone tissue of a case of renal osteodystrophy with an associated dialysis encephalopathy syndrome

Bone tissue from a patient with chronic renal failure and a dialysis encephalopathy syndrome has been studied by histological and histochemical means, by flame emission spectroscopy and by electron probe X-ray microanalysis. There was significant renal osteodystrophy manifest as an osteomalacia. Emission spectroscopy showed the presence of iron (Fe), aluminium (Al), silicon (Si), zinc (Zn), strontium (Sr), lead (Pb) and copper (Cu) in the concentration range 100–1000 parts per million (ppm). Electron probe X-ray microanalysis showed focal concentrations of Fe and Si in the marrow tissue only, whereas Al was localized to the calcification front zones at the junction of osteoid and mineralized tissue of both trabecular and cortical bone. It is concluded that the presence of Al at these sites could interfere with the mineralization process and significantly contribute to the pathogenesis of haemodialysis-related osteomalacia and that it is unlikely that the other elements detected are significant in this regard.     

Personality and insomnia symptoms in older adults: the Baltimore Longitudinal Study of Aging

Study ObjectiveTo examine associations of personality dimensions and facets with insomnia symptoms in a community sample of older adults.MethodsWe studied 1049 participants aged 60–97 years in the Baltimore Longitudinal Study of Aging. Personality was assessed by the Revised NEO Personality Inventory (NEO-PI-R), and insomnia symptom severity was measured by the Women’s Health Initiative Insomnia Rating Scale (WHIIRS).ResultsAdjusting for demographic characteristics, higher neuroticism, lower conscientiousness, and lower extraversion were associated with greater insomnia symptom severity. These associations remained significant for neuroticism and conscientiousness when further adjusting for depressive symptoms and comorbidities. Higher scores on neuroticism facets Anxiety, Angry Hostility, and Depression, and lower scores on conscientiousness facets Competence, Order, and Achievement Striving and on agreeableness facet Altruism were associated with greater insomnia symptom severity in fully adjusted models. Results were similar among cognitively normal older adults (N = 966), except higher scores on extraversion facets Warmth and Assertiveness associated with lower insomnia symptom severity, and agreeableness facet Altruism was unassociated.ConclusionAmong older adults, insomnia symptoms appear partially related to personality, with persons higher in neuroticism experiencing greater insomnia symptom severity, and those higher in conscientiousness experiencing lower insomnia symptom severity. Exploring facets of the Big-Five dimensions may provide additional insight regarding the etiology and resolution of sleep disturbance, and some of these associations may differ based on cognitive status. Future studies should investigate the hypothesis that sleep impairment mediates part of the association between specific personality traits and health-related outcomes.     

血浆HCY检测在慢性肾衰血透患者中的临床意义

目的:观察慢性肾衰血透患者的血浆同型半胱氨酸(HCY)水平及与心脑血管并发症的关系。方 法:对38例透析组患者在服用叶酸和VitB12前后及40例健康对照组作了HCY的测定。结果:慢性肾功能衰竭 (CRF)血透患者血浆HCY水平为(25.12±12.51)μmol/L,明显高于正常对照组(8.2±4.51)μmol/L(P< 0.01)。伴有心脑血管病变者血浆HCY水平(36.8±16.54)μmol/L,明显高于无心脑血管病变者血浆HCY水 平(17.9±5.32)μmol/L(P<0.01)。透析组患者服用叶酸和VitB128周前后HCY水平分别为(25.1±12.51) μmol/L,(13.2±5.74)μmol/L(P<0.01)。结论:CRF血透患者存在高同型半胱氨酸血症,其血浆HCY水平的 升高为心脑血管疾病的独立危险因子,服用叶酸、VitB12可降低HCY水平及防止心脑血管并发症的发生。     

Factors associated with the accuracy of physicians' predictions of patient adherence

Objective

Physicians are inaccurate in predicting non-adherence in patients, a problem that interferes with physicians’: (1) appropriate prescribing decisions and (2) effective prevention/intervention of non-adherence. The purpose of the current study is to investigate potential reasons for the poor accuracy of physicians’ adherence-predictions and conditions under which their predictions may be more accurate.

Methods

After the medical encounter, predictions of patient-adherence and other ratings from primary-care physicians (n = 24) regarding patient-factors that may have influenced their predictions were collected. Patients (n = 288) rated their agreement regarding the prescribed treatment after the encounter and reported adherence 1 month later.

Results

Several factors were related to physicians’ adherence-predictions, including physicians’ perceptions of patient-agreement regarding treatment. However, some factors were not related to adherence and agreement-perceptions were inaccurate overall, potentially contributing to the poor accuracy of adherence-predictions. The degree to which physicians discussed treatment-specifics with the patient moderated agreement-perception accuracy but not adherence-prediction accuracy.

Conclusions

Training providers to discuss certain treatment-specifics with patients may improve their ability to perceive patient-agreement regarding treatment and may directly improve patient-adherence.

Practice implications

Discussing treatment-specifics with patients may directly improve adherence, but providers should not rely on these discussions to give them accurate estimates of the patients’ likely adherence.     

基于血清蛋白组学的慢性肾衰预测模型探讨

 目的 通过比较慢性肾衰（CRF）患者与正常人血清蛋白表达谱的差异,筛选血清蛋白标志物并建立诊断模型,探讨其在慢性肾衰血清学诊断中的意义。方法 收集62例CRF患者和28例正常人的血清,经表面增强激光解析离子化飞行时间质谱(SELDI-TOF-MS)检验并筛选血清蛋白标志物。经生物信息学分析建立预测模型并进行验证。结果 在质荷比(m/z)1500～30000范围内,检测到51个有效蛋白峰,发现有19个峰有显著差异 (P<0.001),其中18个峰呈低表达,1个峰呈高表达;且CRF组和正常组的聚类性质明显不同;组内样本彼此靠近,组间样本彼此分开。构建的"慢性肾衰组－正常组"诊断决策树模型,预测正确率为87.8%,灵敏度为87.1%,特异度为89.3%。结论 该决策树模型能对慢性肾衰做出较为准确的预测判断,为慢性肾衰的临床早期发现提供一定的实验依据     

A structural equation model of relationships of health literacy,illness and medication beliefs with medication adherence among patients with chronic obstructive pulmonary disease

ObjectiveTo determine the relative contributions of health literacy (HL) and illness and medication beliefs to medication adherence among older COPD patients and determine the pathways through which they operate.MethodsThe study was conducted using data from a prospective cohort of COPD patients in New York City and Chicago. We used structural equation modeling to examine the pathways linking HL, through medications and illness beliefs, with COPD medication adherence.ResultsOut of 393 older adults with COPD, 123 (31%) had limited HL and 208 (53%) reported low adherence to daily COPD medications. Those with limited HL were more likely to have low medication adherence (p < 0.0001). Medications concerns (p = 0.001) and medication necessity (p = 0.003) demonstrated a mediational role between HL and adherence. However, in the final multivariate model, HL did not have direct effect on medication adherence (p = 0.12) and illness beliefs (p = 0.16) did not demonstrate a mediational role between HL and adherence.ConclusionOur findings suggest that low HL is not a direct predictor of poor medication adherence among COPD patients.Practice implicationsAddressing medication concerns and reinforcing the need for daily COPD medications may be a more effective strategy for increasing adherence in this population.