title: Nonadherence in hemodialysis: associations with mortality, hospitalization, and practice patterns in the DOPPS.
abstract: BACKGROUND
  Nonadherence among hemodialysis patients compromises dialysis delivery, which could influence patient morbidity and mortality. The Dialysis Outcomes and Practice Patterns Study (DOPPS) provides a unique opportunity to review this problem and its determinants on a global level.
  
  
  METHODS
  Nonadherence was studied using data from the DOPPS, an international, observational, prospective hemodialysis study. Patients were considered nonadherent if they skipped one or more sessions per month, shortened one or more sessions by more than 10 minutes per month, had a serum potassium level openface>6.0 mEq/L, a serum phosphate level openface>7.5 mg/dL (>2.4 mmol/L), or interdialytic weight gain (IDWG)>5.7% of body weight. Predictors of nonadherence were identified using logistic regression. Survival analysis used the Cox proportional hazards model adjusting for case-mix.
  
  
  RESULTS
  Skipping treatment was associated with increased mortality [relative risk (RR) = 1.30, P = 0.01], as were excessive IDWG (RR = 1.12, P = 0.047) and high phosphate levels (RR = 1.17, P = 0.001). Skipping also was associated with increased hospitalization (RR = 1.13, P = 0.04), as were high phosphate levels (RR = 1.07, P = 0.05). Larger facility size (per 10 patients) was associated with higher odds ratios (OR) of skipping (OR = 1.03, P = 0.06), shortening (OR = 1.03, P = 0.05), and IDWG (OR = 1.02, P = 0.07). An increased percentage of highly trained staff hours was associated with lower OR of skipping (OR = 0.84 per 10%, P = 0.02); presence of a dietitian was associated with lower OR of excessive IDWG (OR = 0.75, P = 0.08).
  
  
  CONCLUSIONS
  Nonadherence was associated with increased mortality risk (skipping treatment, excessive IDWG, and high phosphate) and with hospitalization risk (skipping, high phosphate). Certain patient/facility characteristics also were associated with nonadherence.
authors.affiliation: Division of Nephrology, University of Michigan, Ann Arbor, Michigan, USA. rsaran@umich.edu
authors.forename: Rajiv
authors.initials: R
authors.lastname: Saran
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Bragg-Gresham
authors.forename: Hugh C
authors.initials: HC
authors.lastname: Rayner
authors.forename: David A
authors.initials: DA
authors.lastname: Goodkin
authors.forename: Marcia L
authors.initials: ML
authors.lastname: Keen
authors.forename: Paul C
authors.initials: PC
authors.lastname: Van Dijk
authors.forename: Kiyoshi
authors.initials: K
authors.lastname: Kurokawa
authors.forename: Luis
authors.initials: L
authors.lastname: Piera
authors.forename: Akira
authors.initials: A
authors.lastname: Saito
authors.forename: Shunichi
authors.initials: S
authors.lastname: Fukuhara
authors.forename: Eric W
authors.initials: EW
authors.lastname: Young
authors.forename: Philip J
authors.initials: PJ
authors.lastname: Held
authors.forename: Friedrich K
authors.initials: FK
authors.lastname: Port
mesh_terms: D000368:Aged; D005260:Female; D006276:Health Facility Size; D006760:Hospitalization; D006801:Humans; D008297:Male; D008503:Medical Staff; D008875:Middle Aged; D016017:Odds Ratio; D010349:Patient Compliance; D010710:Phosphates / Q000097:blood; D010818:Practice Patterns, Physicians'; D016016:Proportional Hazards Models; D006435:Renal Dialysis / Q000401:mortality; D015430:Weight Gain
chemical_list: D010710:Phosphates