Nursing Clinical Trial
Official title:
Fluid Distribution Timetable on Adherence to Fluid Restriction of Patients With End-Stage Renal Disease Undergoing Hemodialysis: A Single-Blind, Randomized-Controlled Pilot Study
Fluid restriction is necessary among patients with chronic kidney disease. However, treatment adherence remains a challenge. Hence, this study determined the effects of a fluid distribution timetable on adherence to fluid restriction of patients with end-stage renal disease undergoing hemodialysis. This study used a single-blind, randomized-controlled pilot study design. Patients with end-stage renal disease were randomly-assigned using computer-generated sequences of randomly permuted blocks stratified according to sex to receive the fluid distribution timetable or standard care. Adherence to fluid restriction was measured using two indicators - thirst and interdialytic weight gain - and were compared using One-way RM-MANOVA and MANCOVA. Secondary outcomes included baseline patient demographic and clinical characteristics and were compared according to treatment allocation. Both groups were followed-up for four weeks, assessing outcome measures during the second hemodialysis session for each week.
End-stage renal disease (ESRD), defined as a condition in which the kidneys are damaged or
cannot filter blood similar to a healthy kidney (Centers for Disease Control and Prevention,
2017), is a rising global dilemma. In fact, it has been a leading cause of morbidity and
mortality worldwide, afflicting approximately 8% - 16% of the global population (Jha et al.,
2013) and ranking eighth among the leading causes of death. It has also been acknowledged as
a troublesome disorder causing a myriad of health-related problems (Lowney et al., 2015),
financial burden (Bavanandan et al., 2016), and poor survival outcomes (Halle et al., 2016).
Hemodialysis, a form of renal replacement treatment, has been the mainstream management for
patients with kidney diseases (Smeltzer et al., 2010) despite several health complications
(Smeltzer et al., 2010; Lowney et al., 2015). However, dietary and fluid therapy are also
necessary components of the management for patient with ESRD. A common concern among patients
on hemodialysis is the non-adherence to fluid therapy. Although this management is simple, it
remains a challenge to patients on hemodialysis because of several physiologic changes
brought by ESRD. As a result, numerous problems such as fluid overload, electrolyte
imbalances, and acid-base imbalances occur which are detrimental to the patient's overall
health. Since patients on hemodialysis are the key players in promoting their health, it is,
therefore, imperative to develop individualized and empowering strategies what will promote
their adherence to fluid therapy. The proposed strategy in this study is the fluid
distribution timetable, a simple and health promotive intervention involving scheduled
distribution of pre-determined amounts of fluid intake on a daily basis. This intervention
consider the various sources and usage of fluids per day and allocates fluid intake according
to the patient's prescribed fluid restriction. Hence, this study determined the effects of a
fluid distribution timetable on adherence to fluid restriction of patients with end-stage
renal disease undergoing hemodialysis.
This study is a single-blind, single-center, randomized-controlled pilot study at the
dialysis unit of a tertiary level government-owned institution in Quezon City, Philippines.
Patients were randomly-allocated to receive fluid distribution timetable with standard care
(intervention) or standard care alone (control). Random allocation of respondents was
conducted using computer-generated sequences of randomly permuted blocks (sizes of three,
four, and five) at our office. Randomization was carried out by an independent statistician
and was stratified according to their sex. During the study period, treatment allocation was
masked from site personnel and patients. Post-hoc power analysis for two group means, using
GPower version 3.1, revealed that a sample size of 24 patients with a 1:1.20 group allocation
ratio yields a power of 99% at a significance of 5% (two-sided) and detects an effect size of
0.80.
The control group received the standard care for patients on hemodialysis. The standard care
involves a 10 -15-minute face-to-face health teaching of their treatment regimen including
pharmacologic management, dialysis schedule, dietary and fluid restrictions or nutritional
therapy, care for vascular access, and other necessary lifestyle modifications. The treatment
group, on the other hand, received a combination of the standard care and the intervention,
the fluid distribution timetable. It is a scheduled distribution of pre-determined amounts of
fluid intake on a daily basis depicted via a 5x6 table. The timetable includes three major
columns. The first column has six timepoints of a day with a four-hour interval. The second
column, which was further divided into four sub-columns, reflects the percentage of fluid
allotment for food, activities, medication, and thirst encounters. The percentage of fluid
allocation was computed based on the patient's prescribed fluid restriction, usual time of
food intakes in a day, usual level of activity, time of medication intake, and common time
they encounter thirst in a day. Lastly, the third column indicates the converted percentages
of fluid allotment in milliliters. In designing the intervention, we selected three
behavior-specific cognitions from the Health Promotion Model by Nola J. Pender: perceived
benefits, barriers, and self-efficacy. These cognitions are modifiable determinants of
behavior that promote well-being. As such, the fluid distribution timetable enumerated the
advantages of adherence and the disadvantages of non-adherence to fluid restriction.
Adherence to fluid restriction was measured using two indicators - thirst and interdialytic
weight gain - and were compared using One-way RM-MANOVA and MANCOVA. Thirst was measured
using a self-reported questionnaire the Dialysis Thirst Inventory, while interdialytic weight
gain computed using a calibrated calculator by subtracting post-dialysis weight at the end of
the previous hemodialysis session from the pre-dialysis weight during the current
hemodialysis session. Secondary outcomes included baseline patient demographic and clinical
characteristics and were compared according to treatment allocation. Both groups were
followed-up for four weeks, assessing outcome measures during the second hemodialysis session
for each week.
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