2. Co-authors University of Kentucky Kentucky-Lexington Susan K. Frazier, PhD, RN Terry A. Lennie, PhD, RN Peter Sawaya, MD, FACP, FASN

3. 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.

4. 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.

5. Background and Significant ESRD is a permanent damage of the kidney with glomerular filtration rate of < 15 ml/min/1.73 m 2 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

6. 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

7. 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

8. Normal valuesDietary restrictions Fluid intake1000-2000 ml/day< 500ml/day or 15 ml water/kg/day Total energy intake>35Kcal/kg/day30-35 Kcal/kg/day Protein intake1.4 - 2 g/kg/day0.8 - 1.2 g/kg/day Potassium intake2.0 - 5.5 g/day1.5 g/day Phosphorus intake1200 mg/day700 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

9. Depressive symptoms may reduce adherence Cognitive 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 prescription Perceived social support Education level Age Residual renal function Comorbidity burden Duration of hemodialysis

10. Purpose To evaluate the relationship between depressive symptoms and fluid and dietary adherence using objective biomarkers and self- report measures in patients with ESRD

11. 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.

12. Research Design, Participants and Settings Descriptive, cross-sectional design Convenience sample 100 patients receiving hemodialysis Located at seven hemodialysis centers in Kentucky

13. 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

14. 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%

15. 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 845 minutes

16. Biological measures Normal RangeCutoff pointMethod 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/dlThe mean of the last three months Serum Phosphorus 3.5-4.5 mg/dl> 5.5 mg/dlThe mean of the last three months Serum BUN7-25mg/dl> 100 mg/dlThe mean of the last three months

17. 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

18. 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 indicators Compared those who had depressive symptoms with those who did not Compared those who were nonadherent to fluid and diet prescription with those who were adherent Chi-square and t-test analyses depending on level of measure

19. Logistic regression to evaluate whether depressive symptoms were an independent predictor of dietary adherence after controlling for potential confounding variables

21. 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%)

22. Clinical characteristics (N=100) Frequency (%)Mean + SD Residual renal function UOP < 200ml/24hrs 66 (66%) UOP>200ml/24hrs 34 (34%) Total co-morbidity score4.5 ± 1.9 Years of hemodialysis in years4.4 ± 3.8 Serum potassium mEq/dl4.8 ± 0.5 Serum phosphorus mg/dl5.7 ± 1.4 Serum BUN mg/dl54 ± 16 Interdialytic weight gain (kg)2.7 ± 1.4

23. Specific aim1 To determine the prevalence of depressive symptoms in patients with ESRD using the BDI-II and the BSI depression subscale.

24. Comparison of the proportion of patients with depressive symptoms determined by the BDI-II and the BSI * p = < 0.05

25. 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)

26. Specific Aim 2 To determine the prevalence of fluid and diet adherence in patients with ESRD using a self- report measure and biological indicators.

27. Fluid and diet nonadherence by self report and biological measures

28. 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 )

29. 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.

30. Depressive symptoms were an independent predictor of perceived fluid and dietary nonadherence BDI-IIOR 1.1, (p = 0.02) BSI OR 2.2 to 2.6, (p = 0.04)

31. 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.

32. 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).

33. QUESTIONS