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Back to Journal »Patient Preferences and Compliance» Volume 12

Author Umeukeje EM, Mixon AS, Cavanaugh KL 

Published on July 5, 2018, Volume 2018: 12 pages, 1175—1191 pages

DOI https://doi.org/10.2147/PPA.S145648

Single anonymous peer review

Editor who approved for publication: Dr. Johnny Chen

Video summary provided by Ebele M Umeukeje.

Ebele M Umeukeje,1–3 Amanda S Mixon,3,4 Kerri L Cavanaugh1–3 1 Vanderbilt Kidney Disease Center, Nashville, Tennessee, U.S.; 2 Department of Nephrology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.; 3 Vanderbilt Health Service Research Center, Nashville, Tennessee, USA; 4 Vanderbilt University Medical Center Hospital, Nashville, Tennessee, USA Purpose: This review summarizes and discusses factors related to dialysis patients' adherence to phosphate control strategies Interventions to overcome related challenges. Method: Use PubMed, PsycInfo, CINAHL and embassy. Results: Hyperphosphatemia was associated with cardiovascular and all-cause mortality in dialysis patients. The management of hyperphosphatemia depends on the treatment of phosphorus binders, low phosphorus diet and dialysis. Phosphate binder therapy is associated with survival benefits. Dietary restrictions are complicated because it is necessary to maintain adequate protein intake, and it is not enough to control phosphorus alone. Similarly, due to the kinetics of dialysis for phosphorus removal, conventional hemodialysis alone is not sufficient to control phosphorus. Therefore, all three treatment methods are important contributors, with dietary restriction and dialysis as necessary adjuncts to phosphate binder therapy. The compliance rate of phosphorus control is not optimal, and it is directly affected by the patients, providers and related factors of phosphorus control strategy. Psychosocial factors are considered to be the “driving factors” that affect the compliance behavior of dialysis patients, and self-motivation-based factors are directly related to compliance behavior. The high-risk subgroup of non-adherent patients includes young dialysis patients and non-whites. The provider's attitude may be an important factor in determining the compliance of dialysis patients, but it has not been resolved. Conclusion: Adherence to phosphorus binder, low phosphorus diet and dialysis prescription is not ideal. A multi-component strategy that simultaneously addresses treatment-related factors (such as side effects), self-motivational patient factors, and improved attitudes and provider factors that provide culturally sensitive care shows the best hope for long-term control of phosphorus levels. In addition, it is important to identify the patients who are at highest risk due to lack of control and prepare the plan to provide flexible people-centered strategies through training and dedicated resources to meet the needs of all patients. Keywords: hyperphosphatemia, compliance, phosphorus binders, low phosphorus diet, dialysis

Hyperphosphatemia complicates the management of end-stage renal disease (ESRD). This is due to the inability of dialysis patients to excrete phosphorus, which leads to the accumulation of phosphorus in the body. This increases the risk of spontaneous fractures due to abnormal mineral metabolism and the risk of death due to cardiovascular disease. The management of hyperphosphatemia depends on three methods: the use of drugs called phosphorus binders, dietary phosphorus restriction, and dialysis to remove phosphorus. Adhering to each of these methods is a challenge for dialysis patients due to the burdens associated with medication or dialysis treatment, the complexity of diet, and patient-specific factors. Patient factors related to phosphate control compliance behavior include age, gender, and race. In preliminary studies, patient factors centered on psychosocial autonomy or self-motivation help phosphorus control compliance, and indicate that consistency with the personal value system may be the key to optimizing medication, diet, and dialysis care. Current strategies to improve phosphate control include education and behavioral interventions provided by multidisciplinary dialysis providers. Emerging research shows that dialysis providers vary in their attitudes towards supporting dialysis patients’ self-motivation to comply with prescribed phosphate binder medications, and their perceptions are poor. Improving phosphorus control compliance will require the integration of enhanced provider-level training strategies into existing patient-level interventions, with a focus on efforts to identify patients at high risk of non-compliance who may benefit from more personalized solutions.

Due to impaired renal phosphorus excretion, hyperphosphatemia is common in end-stage renal disease (ESRD). 1 It is an important part of minerals and bone disease (MBD), which increases the risk of fractures and osteoporosis, 2 and is associated with greater all-cause mortality in cardiovascular and dialysis patients. 3 Hyperphosphatemia can be effectively controlled by phosphorus-binding agent medication, dietary restrictions, and dialysis prescriptions. 1

Phosphate binder drug therapy is the cornerstone of the management of hyperphosphatemia, 4 and is related to survival benefits. Although the existing evidence is strong, it comes from observational studies. 5 This may be a possible opportunity for practical trial design in the future. 6 Optimizing the use of phosphorus binders for ESRD patients to achieve the target serum phosphorus level close to the normal range of 3.5–5.5 mg/dL is essential to minimize the risk of morbidity and mortality. 7,8 However, it is estimated that as many as 74% of ESRD patients do not follow phosphate binder medication. 9,10 Compliance challenges include 1) drug-related factors, such as high pill counts, complex and adjustable schedules, adverse side effects, and financial burden; 11 2) patient-specific factors, such as limited understanding of the importance of taking binder drugs ;11,12 3) Repeated hospitalization disrupts the daily use of adhesive drugs, as well as the accompanying comorbidities such as diabetes and hypertension, the complexity and overall burden of compound drugs; 12 and 4) provider-level facts rs It is related to the education and emotional support of the patient. 11

High dietary phosphorus intake and increased dietary phosphoprotein ratio are associated with ESRD mortality. 11 Low-phosphorus diet is not sufficient to control the serum phosphorus level of well-nourished ESRD patients, and it is complicated to improve 13 dietary phosphorus restriction because it is necessary to maintain sufficient protein intake required by ESRD patients to prevent malnutrition and limit phosphorus intake at the same time The volume is challenging. Perhaps more importantly, many processed foods contain large amounts of phosphate additives, which are often undisclosed and difficult for patients to identify. 11 In ESRD, the ideal daily phosphorus intake is 700 mg/day; however, the usual intake usually averages 1,000-2,000 mg/day. 14 Approximately 60% of phosphorus is absorbed, 15 which results in a significant daily excess of phosphorus. The adherence to a low-phosphorus diet may be as low as 43%,16 and is similarly affected: 1) Diet-specific factors, such as menu choices, the impact of diet on social activities, and the acceptance of diet by friends and family; 16 2) Patient factors , Such as depression, limited self-efficacy and poor coping skills; 16 and 3) provider factors, including insufficient support, 16 infrequent contact with dietitians, and conflicting phosphorus dietary recommendations from different health professionals. 17

Routine dialysis three times a week can remove phosphorus in the range of 1,800-3,600 mg, so it cannot provide sufficient daily phosphorus intake to maintain balance. 18 This is due to the kinetics of phosphorus removal during hemodialysis. Therefore, the serum phosphorus level initially drops within the first 2 hours of treatment and then stabilizes, and then rebounds, resulting in an increase in serum phosphorus level of up to 40% after dialysis. 19 Dialysis treatment is complicated by non-adherence. It is estimated that up to 35% of patients miss the treatment completely, while the treatment time is shortened in another 32%. 20 Reasons for non-compliance with the prescribed dialysis dose include treatment and patient-related factors. Both dialysis year and schedule allocation are related to treatment non-compliance. 21 Patient factors related to non-compliance with dialysis treatment include young people 21, 22 and non-white ethnicity 23 and psychosocial factors, including the negative impact of kidney disease on daily life and lack 22 Non-compliance with dialysis procedures can lead to significant morbidity and increase Risk of death-partly due to uncontrolled mineral bone disease. 9,24

In efforts to control phosphorus, compliance with medications, diet, and dialysis have unique driving factors, but there are also common themes that can be used to optimize all methods at the same time. This review discusses current perspectives and challenges that lead to low adherence to phosphate control, and examines effective and emerging strategies for patient-centered hemodialysis care.

Phosphate control methods for hemodialysis patients

See Table 1 for an overview of phosphate binder drugs. Phosphate binders regulate calcium-phosphate homeostasis and reduce metabolic abnormalities caused by hyperphosphatemia. 25 They prevent the absorption of phosphate from the gastrointestinal tract through different mechanisms. These drugs can be roughly divided into 1) calcium-based and 2) non-calcium-based phosphate binders.

Table 1 Overview of existing phosphorus binders Note: *The time and dosage of phosphorus binders are adjusted according to the time of meals/snacks and the phosphorus content. Copyright © 2013. Kovic and Rastogi; Reprinted by licensees BioMed Central Ltd. with permission from Covic A and Rastogi A. Hyperphosphatemia in ESRD patients: assessment of current evidence linking results to treatment adherence. BMC kidney. 2013;14(1):153.11 Abbreviations: GI, gastrointestinal tract; hydrochloric acid, hydrochloride.

Calcium-based phosphate binders, including calcium acetate, calcium citrate, and carbonate, dissociate in the gastrointestinal tract and combine with phosphate to form insoluble precipitates. They are cheaper than non-calcium binders,10 but due to the positive calcium balance, the risk of vascular calcification is greater. 26

Non-calcium-based binders include sevelamer, lanthanum, and iron-based binders (for example, ferric citrate and sucralose oxyhydroxide). 26 Sevelamer is an anion exchange resin that can exchange chloride ions into phosphate ions, while lanthanum binds to phosphate through its trivalent cations. Both are related to gastrointestinal side effects, such as bloating, diarrhea, and constipation. Compared with Sevelamer, lanthanum has a lower pill burden. Sevelamer carbonate is available as a powder to patients who may benefit from different formulations; 11 However, patients are often tired of taking it and often require replacement of the phosphate binder formulation. 27 The pill form of Sevelamer is relatively large and, given its attendant high pill burden, it requires a lot of water intake. 7

Iron-based phosphate binders include iron citrate and iron hydroxide. Iron citrate is partially absorbed, so it is an ideal choice for the treatment of hyperphosphatemia in patients with iron deficiency; however, the citrate content increases the possibility of aluminum absorption and possible toxicity​​​​ 28 Sucroferric oxyhydroxide is more suitable for dialysis patients who do not require iron supplementation, and has the added benefit of low pill burden. 28 The results of a recent meta-analysis showed that niacin is a major form of vitamin B3 and may be a new effective alternative or adjunct to reduce the serum phosphorus concentration of dialysis patients. 29 It reduces the absorption of phosphorus from the gastrointestinal tract and has a unique anti-lipid effect. It is worthy of further study on its long-term safety and effectiveness. 29

The tolerance of patients to different phosphorous binders varies, and the reasons for discontinuing these drugs reported by patients also vary depending on the type of binder. 30 ESRD patients may not comply with phosphate binder treatment because of the misconception that non-compliance does not lead to immediate symptoms or risks. 10,11 Systematic reviews of non-compliance drugs in hemodialysis patients describe drug side effects, pill burden, and tablets Large size, unpleasant taste, complicated medication regimen, difficulty in opening medication containers and refilling medications are the key factors leading to non-compliance. 12 These drug-based factors are special characteristics of phosphate binders and therefore represent the goals of control strategies.

Epidemiology of phosphate binder adhesion

The non-compliance with the phosphorus binder ranges from 13% to 99%, with an average of 53%. 12 This wide range is partly due to the heterogeneity of the methods used to characterize non-compliance. 12 Current methods for assessing non-compliance with phosphorus binders include 1) subjective measurement, 2) objective measurement, and 3) biochemical assessment of serum phosphorus levels. The non-compliance rates assessed by subjective and objective measurements and biochemical assessment of serum phosphorus levels were 48%, 78%, and 29%, respectively. 12

Subjective measures using validated scales 31, 32 or unvalidated scales or interviews 33, 34 are the most widely used non-compliance assessment methods. 12 Objective measurements including pill count, 35 bottles of equipment used, such as drug event monitoring system (MEMS) caps 36, 37 and drug occupancy 38 are the least used evaluation methods. 12 Biochemical assessment of serum phosphorus levels is often performed as part of routine dialysis care, but is complicated by the variable definition of the upper limit of the acceptable range. 31,39 In addition, these evaluation methods have been used in combination in the absence of a generally recognized phosphate binder compliance evaluation standard. 40

KDIGO Phosphate Binder Usage Guide

Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guidelines for the Diagnosis, Evaluation, Prevention and Treatment of Chronic Kidney Disease-Mineral and Bone Disorders (CKD-MBD) was updated in 2017. The current recommendations for serum phosphorus control should be based on the gradual increase or continuous increase of serum phosphorus (not graded) for dialysis patients, and the elevated serum phosphorus level should be reduced to the normal range (3.5-5.5 mg/dL) (Level 2C recommendation). However, due to the laboratory variability of the normal range of phosphorus and the diurnal changes in serum phosphorus levels, the implementation of this recommendation is challenging. In addition, the KDIGO guidelines recommend limiting the dosage of calcium-based phosphate binders (level 2B recommendation)41.

Economical use of phosphate binder

In the United States, the use of phosphate binders for American dialysis patients and non-dialysis patients with chronic kidney disease who participated in Medicare Part D in 2015 exceeded US$1.5 billion. 42 Phosphate binder related costs exceed all other related costs covered under Part D. 42 By 2013, compared with calcium acetate, the cost of sevelamer carbonate and lanthanum carbonate was 5 times that of Medicare, which can be achieved in the patient's body The same degree of phosphate control. 42 After adjusting the cost of the adhesive, the monthly medical insurance cost for each member of the calcium bond is lower. 43 Recent systematic review data indicate that calcium acetate is the most cost-effective first-line treatment for dialysis patients, although these conclusions are of limited quality due to the heterogeneity of the research.44

In the absence of conclusive evidence to prove its impact on the endpoint, the use of phosphate binders in dialysis patients will incur huge costs, which has always been a source of controversy. 42 There is controversy regarding the best method for determining the most cost-effective phosphate binder treatment, and most of the controversy is due to the quality of the available data. One way might be to look at the overall cost. It has been suggested that sevelamer is associated with a lower stroke risk45 and reduced medical insurance hospitalization and total costs compared to calcium-based adhesives, which makes it more cost-effective overall. 43 This is still a source of controversy and may help convey to patients a mixed message about the risks/benefits of various options.

Factors Affecting the Adhesion of Phosphate Binder

Many factors are related to non-compliance with phosphate binders (Table 2). The drug-related factors that lead to non-compliance with phosphate binders have been well studied, the most common being pill burden. Phosphate binders are usually the biggest cause of overburden of pills for dialysis patients, accounting for half of their daily pill burden. 35 Dialysis patients take an average of 11 ± 4 drugs, and the median daily pill intake is 19 (interquartile range: 12) .11 The total number of prescriptions for phosphorus binders 46 and the total burden of pills for other chronic diseases combined with paraphosphorus The non-compliance of the agent is related. 35,47,43 The frequency of administration of phosphorus binders in all food intake, including meals, beverages and snacks, increases its complexity and reduces compliance. 12,47 Unfortunately, non-compliance leads to poor phosphate control and an increase in the number of prescription pills. 10 In addition to the pill burden, the form, taste, and side effects-as mentioned before-are also related to non-compliance with these drugs. 46

Table 2 Summary of factors and correlations related to non-compliance (N=38) Note: a The level of significance (p <0.05, p <0.01, and p <0.001) varies from study to study. b Defined as having a high expectation that there is a causal relationship between one's own actions and the consequences. Copyright © 2015. public Library. Reprinted from Ghimire S, Castelino RL, Lioufas NM, Peterson GM, Zaidi ST. Non-compliance with medication in hemodialysis patients: a systematic review. Public Science Library One. 2015;10(12):e0144119.12 Abbreviations: DM, diabetes; HD, hemodialysis; HTN, hypertension; PB, phosphate binder.

Patient-related factors associated with phosphorus binder non-compliance include 1) sociodemographics and 2) sociopsychological variables. The younger ages 10, 12, 31-33, 46-49 are most consistent with phosphate binder non-compliance. Perhaps, young people value other activities more than their health50, or they may be more willing to report non-compliance than older patients. 10

Non-Caucasian races 12, 23, 32, 36, 37, 49 are associated with phosphate binder non-compliance (odds ratio [OR 0.76]; p <0.05)49 and may be confused by lower socioeconomic status. 50 Adhesive non-compliance with other sociodemographic variables related to phosphate includes lack of marital support 12,52,53 (OR 1.21; p <0.05) 49 and unemployment 12,52 (OR 1.21; p <0.05) 49, Although the results across studies are not consistent.

Psychosocial factors have been identified as the most influential and potentially changeable determinants of phosphorus binder non-compliance (Figure 1). These include 1) the patient’s health beliefs and 2) social support related to the treatment of hyperphosphatemia. 10 These health beliefs include concerns about the potential side effects of phosphorus binders (OR = 3.17; 95% CI: 1.87–5.37; p <0.001); 32 beliefs that reduce personal demand for phosphorus binders (OR = 0.34; 95%) CI: 0.14–0.83; p <0.05); 32 and low self-efficacy or perception of taking phosphorus binders (t (71) = 2.55, p <0.02). 54 It has been found that knowledge about the use of phosphorus binders is an influence Important factors for compliance (r = 0.22; p <0.05). 55 However, the knowledge of treatment instructions has nothing to do with compliance, which suggests that knowledge alone is not sufficient to promote compliance with phosphate binders. 10

Figure 1. Psychosocial predictors of non-compliance with phosphate-bound drugs evaluated in two or more studies. Note: ©2008. BioMed Central Ltd. is adapted from Karamanidou et al.; the licensees are BioMed Central Ltd. Karamanidou C, Clatworthy J, Weinman J, Horne R. A systematic review of the prevalence and determinants of non-compliance with phosphate-binding drugs in patients with end-stage renal disease. BMC kidney. 2008;9:2.10

Although marriage support may be related to compliance, the support of other family members and friends has not been shown to have a significant impact on phosphorus binder non-compliance. 55 In contrast, the patient’s perception of the disease and its damage to family life has a significant impact on phosphate binding and adhesive non-adhesion (r = -0.35; p <0.05).55

In addition, depressive symptoms were associated with non-compliance with phosphate binder treatment (OR = 1.11; 95% CI, 1.04–1.18; p = 0.001). 52,56,57 Factors such as forgetfulness, lack of interest, and monotony have been confirmed as causing non-compliance. 12 Intentional phosphate binder non-compliance behavior exists in dialysis patients58. In order to understand this, it is important to understand the patient's personal values ​​and motivation level. This satisfies the call for patient-centered care in dialysis management, which integrates the patient's values ​​with their treatment while taking into account the patient's side effects and tolerability. 59

Emerging research shows that new motivations and autonomy-centered factors are related to non-compliance with phosphorus binders. These psychosocial factors are based on self-determination theory (SDT), which believes that autonomy is an important factor in achieving lasting positive change. 60 SDT distinguishes between autonomous or self-motivated behavior and controlled behavior. It includes three unique social and psychological factors: self-regulation, self-support and perception ability. 60 Higher autonomy in phosphate binder treatment or a more positive attitude towards the use of phosphate binders is associated with phosphate binder compliance. 47,61 Similarly, the perception of dialysis is related to the patient's compliance with the binding agent in terms of the provider's autonomy in the treatment of phosphorus binders and the support of patient empowerment. 62 In addition, perception or self-efficacy is related to compliance with phosphorus binder treatment. 63 These factors show great hope for a better understanding of non-compliance because they are related to self-reported phosphate binder compliance 61,62 and can be modified using patient-centered methods such as motivational interviews. 60,64

These new psychosocial factors, racial differences in the relationship between phosphorus binder compliance and phosphorus control suggest that they may be more important among non-whites. Compared with whites, non-white dialysis patients have a lower perception of provider support for phosphorus binder compliance. 62 In addition, the association between autonomous regulation of phosphorus binder therapy and serum phosphorus control was significant in non-whites (β 95% CI: -0.38 [-0.74 to -0.02]; p = 0.04) but not in whites ( β 95% CI: 0.49 [-0.00 to 0.99]; p = 0.05). 61

Compliance with phosphate binders in the elderly

Multidrug administration has been identified as an age-related syndrome associated with drug non-compliance,51 and is exacerbated when the regimen includes phosphate binders. There are currently no guidelines to achieve a balance between phosphate adherence and health-related quality of life in the elderly or others with low expected survival rates. Therefore, the primary principle of phosphorus control compliance is to provide patient-centered care and optimize the health-related quality of life of the elderly through individualized phosphorus control programs.

The World Health Organization (WHO) emphasizes that the provider factor is an important determinant of patients' compliance with prescription drugs, and emphasizes that 1) "Patients need to be supported by providers, not blamed", 2) Providers need to be able to assess compliance and influence patients Factors of compliance 3) The provider must receive adequate training in compliance management. 65 The provider factors associated with phosphate binder non-compliance have not been fully investigated. Interviews and focus group data from hemodialysis patients indicate that there is an adversarial interaction between dialysis patients and their providers, which can affect their compliance. 66 In particular, dialysis providers will not 1) personalize patient care, but provide “streamlined” treatment, 2) recognize the patient’s knowledge based on the patient’s unique expertise in their own body and experience gained from chronic diseases, or 3) Participate in joint decision-making. 66

The provider’s attitude has been shown to be correlated with the clinical outcome. For example, organizations whose providers have a more positive attitude towards transplantation have better alternate performance. 67 Dialysis providers’ phosphorus-binding agent prescription patterns vary greatly, and some dialysis units prescribe phosphorus-binding agent prescriptions for their dialysis patients much less. 5 This suggests that dialysis providers have different preferences or attitudes towards phosphate binders. 5 Positively describe that patients who interact with dialysis providers are less likely to be non-compliant with phosphate binders (OR = 0.52; 95% CI, 0.30–0.90). 33 In addition, support from dialysis staff is related to compliance with phosphate binders (R = 0.20; p <0.05). 55 Provider’s interventions have shown promise to have a positive and lasting impact on dialysis patients’ medication adherence.

Dialysis treatment and hospitalization affect drug compliance

The duration of hemodialysis treatment of 5 years or more has been found to be the most consistent ESRD factor associated with phosphate binder non-compliance. 17,47,68 Perhaps, the longer the duration of hemodialysis, the more bored and frustrated the need for continued compliance.17 Another important consideration is the relatively frequent acute illnesses that lead to hospitalization. This disrupts the strict routine of daily phosphate binder drugs and increases the perception of treatment burden. 47 Generally speaking, due to medication reconciliation errors69 and patients’ limited understanding of treatment, hospitalization can also adversely affect medication compliance. -Discharge treatment plan. 70,71

Interventions to improve compliance with phosphate binders

Understanding the basic principles of phosphate binders is related to improving patients' compliance with phosphate binder therapy. 33 Effective education of patients is needed to understand the risks associated with non-compliance with phosphorus binders, especially its association with increased morbidity and mortality. 14,19,72 Patient education about the appropriate time of administration at the end of each meal, as well as adjusting the dosage according to the phosphorus content of the food, are important to ensure the effectiveness of the adhesive. 14

An effective method for phosphorus binder education is to use tools such as brochures, posters, websites, and videos. 14 However, the readability of many available patient education materials is still an issue, the level of text writing is higher than the ninth grade level, and the format does not meet the best usability standards. 73,74 Provide various forms of education, including face-to-face individual consultations, group education, telephone consultations and practical demonstrations19, such as lobbying days in the dialysis room. Individual education courses that adhere to the adhesive have the benefit of providing personalized education, but require a lot of resources and time. Group education promotes interaction among peers of dialysis patients, and it has been proven that with the assistance of a nutritionist, it can improve the knowledge and compliance of phosphate binders. 19,75

The dosing schedule can be simplified by reducing the burden of pills and adjusting the phosphate binder prescription to suit the patient's dialysis preferences. 11 For example, some patients prefer calcium acetate capsules instead of tablets because it is easy to swallow76 while others prefer lanthanum because it requires 77. A personalized strategy that takes into account the patient’s preference for phosphate binders has significantly improved deliberate non-compliance. Performance, phosphorus control, and even costs associated with the use of phosphorus binders. 27 This strategy enables patients to request a change in the binding agent. If they have a problem with the prescribed phosphate binding agent, please type. It is recommended to provide alternative options for patients who oppose a specific method of administration. 14

Counseling interventions that include cognitive or behavioral components may be most effective in improving compliance with phosphate binders. 19,78 Cognitive behavioral intervention is a psychological strategy that focuses on the association between thoughts, feelings, and emotions, and helps patients identify and correct negative thoughts, and help cope with feelings and behaviors. They may include education or relaxation training provided in different environments and formats. In a small study, motivational interviews—a form of communication that promotes autonomy—have been shown to improve phosphorus binder compliance and phosphorus control. 79 This type of communication effectively allows patients to focus on behavior change; resolve conflicts; and develop specific, measurable, action-based, realistic, and time-based plans (Table 3). Motivational interviews use open-ended questions, affirmation, reflection, and summary strategies. 80 Similarly, self-affirmation—including reflection on personal values ​​to reduce resistance to health risk information—has been successfully used to increase compliance. 81 These patient-authorized technologies address the factors that have the greatest impact on phosphate binder compliance. Including beliefs and attitudes. 10

Table 3 Motivation Interview Note: Copyright © 2013. Pigeon Medical Press. Reprinted with permission from Kalantar-Zadeh K. Patient education for phosphorus management in chronic kidney disease. The patient's first choice is compliance. 2013;7:379–390.14 Abbreviation: CKD, chronic kidney disease.

Other potential new ways to empower patients in improving medication compliance include the use of electronic monitoring equipment. These can be used to remind patients to take medications at the prescribed time, and may help to enhance patients' compliance with phosphorus binder medications. 82 The Phosphate Education Program (PEP) is a new program that teaches patients how to estimate83. This program enables patients to "visualize" the phosphorus content of various foods to guide these real-time adjustments. It assigns similar phosphorus units to similar whole food groups, where 1 phosphorus unit is equivalent to 100 milligrams per serving. 84 Based on similar approaches in diabetes management, this approach seems promising; however, the additional complexity of dietary recommendations for phosphorus management must be acknowledged.

Dietary methods to control phosphorus

Epidemiology of adherence to a low-phosphorus diet

A comprehensive review of studies on kidney dietary compliance reports wide-ranging differences in dietary compliance. 16 This is related to differences in how dietary adherence is measured-from subjective methods involving self-reporting adherence to the use of serum phosphorus levels or a combination of methods. In 15 studies, 12,571 ESRD patients had low-phosphorus diet compliance ranging from 43% to 84%, and most of these studies used serum phosphorus levels to measure low-phosphate diet compliance. 16 Interestingly, a study that measured the rate of a low-phosphate diet used two different methods of compliance reporting. The self-reported compliance rate was 33%, while the compliance rate when using serum phosphorus levels was 44%. 85

Dietary phosphorus is obtained from three different sources: 1) Organic phosphorus in plant foods; 2) Organic phosphorus in animal protein; 3) Inorganic phosphorus in processed food additives. 14 The bioavailability of phosphorus in plant foods is only 20%–40%, while the bioavailability of phosphorus in animal protein is 40%–60%. 14 In sharp contrast, the bioavailability of food additives is 100%, which has the greatest impact on hyperphosphatemia. 14

The "hidden" phosphorus content in phosphate additives found in processed food 86,87 adds to the complexity of dietary phosphorus management. In addition to a large number of foods with high natural phosphorus content, there are unlabeled phosphorus content in many foods, causing people not to adhere to a low-phosphorus diet. Recently, emphasis has been placed on reducing phosphate additives by avoiding processed high-phosphorus protein sources. 14

Dietary phosphorus restrictions are complicated because there is a delicate balance between ensuring adequate protein intake and limiting phosphorus intake at the same time. 11,14 Achieving this balance is a top priority, because higher protein intake (up to 1.4 g/kg/day) increases the survival rate of dialysis patients regardless of the increase in serum phosphorus levels. 88 However, higher levels of dietary phosphorus intake and higher dietary phosphorus to protein ratios increase the 5-year mortality rate of hemodialysis. 89 Interestingly, previous studies did not prove that the prescribed dietary phosphorus restriction is beneficial for survival. 13 This may partly be explained by the fact that dietary phosphorus restriction is not sufficient to reduce serum phosphorus load. 90 The daily low-phosphorus diet includes approximately 371 mg of absorbed phosphorus. day. Therefore, in addition to dietary restrictions, phosphorus control itself requires other strategies. 11,14

Factors Affecting Compliance with Low Phosphorus Diet

Table 4 lists the factors that affect compliance with a low-phosphorus diet. A recent comprehensive review of dietary compliance during dialysis (including adherence to a low-phosphorus diet) provides a detailed overview of contributing factors. 16 Longer years of dialysis are related to non-adherence to a low-phosphorus diet. 16,17,49 may be due to the burden of long-term management of such complex dietary recommendations. 16 Insufficient dietary knowledge is related to non-compliance with a phosphorus-restricted diet. 17,91,92 In addition, dialysis patients admit that diet is difficult to integrate into social situations and dietary recommendations, preferably from a kidney nutritionist or nephrologist, is the most important. 93

Table 4 Factors related to dietary compliance of ESRD adult hemodialysis patients classified according to WHO standards. Note: Adapted from Lambert K, Mullan J, Mansfield K. Comprehensive evaluation of methodology and research results on dietary compliance in end-stage renal disease. BMC kidney. 2017; 18:318. The Creative Commons license and disclaimer are available from: http://creativecommons.org/licenses/by/4.0/legalcode.14 Abbreviations: BMI, body mass index; ESRD, end-stage renal disease; World Health Organization, World Health Organization.

Patient factors related to non-adherence to a low-phosphorus diet include age, gender, race, and education level. 16 Younger age (r = 0.19; p <0.05) and men are more likely to predict diet non-compliance (r = 0.25; p <0.05). It has been found that non-whites have higher dietary non-compliance,85,92 This may be caused by lower socioeconomic status. Employment status is related to the dietary non-compliance of dialysis patients (r = -0.36; p <0.01), which may be due to the challenge of taking into account dietary requirements under strict employment conditions. Lower education levels have always been associated with diet non-compliance. 17,94-98

Some psychosocial factors have been related to non-compliance with diet during dialysis. Negative beliefs and attitudes are closely related to diet non-compliance. 92,96 In addition, patients with low self-efficacy or depressive symptoms experience dietary non-compliance. 17,85,99,100 Poor coping skills are associated with non-compliance with a low-phosphorus diet. 68 Negative peer pressure or family or friends not accepting the prescribed diet 93 can aggravate diet non-compliance.

The adverse interaction between the patient and the dialysis provider is related to dietary non-compliance, 16 conflicting dietary recommendations from different dialysis clinicians are also related to non-compliance. 17 The limited dietary education and support of kidney dietitians 49,91,101 is related to dietary non-compliance, which is largely due to unsatisfactory staffing ratios. 49,91

Intervention measures to improve compliance with low-phosphorus diet

Effective education on dietary phosphorus restrictions should include specific recommendations for foods with the lowest inorganic phosphorus content, foods without phosphorus additives, low phosphorus to protein ratios, and adequate protein content (Table 5). 14 Patients need to understand the phosphorus bioavailability of plant foods, animal food-derived foods, and food additives from low to high. 14 Food choices with the lowest phosphorus to protein ratio include non-dairy products and animal foods with high protein content, such as egg whites. 89 These food choices can effectively reduce serum phosphorus levels while increasing albumin levels. 102 In addition, education should include cooking methods that preserve protein content while reducing phosphorus content (such as boiled chicken) to promote a low-phosphorus diet. 14,103

Table 5 Strategies to improve dietary phosphorus intake control and phosphorus binder compliance in ESRD Note: Copyright © 2013. ©Covic and Rastogi; reproduced by licensee BioMed Central Ltd. from Covic A, Rastogi A. Hyperphosphatemia in ESRD patients: assessment of current evidence linking results to treatment adherence. BMC kidney. 2013;14(1):153.11 Abbreviation: ESRD, end-stage renal disease.

In the dietary management of chronic kidney disease (including ESRD), food fatigue or tiredness of eating the same permitted food has been determined to be a greater problem than food intolerance or allergies. 14 Food fatigue can be improved by diversifying the diet to include additional low-phosphorus, high-protein food choices such as poultry. 14 Phosphate binder medication, if taken effectively, can also reduce food fatigue by allowing the patient’s preferred mainstream food while controlling their serum phosphorus levels. 14

Ideal patient education tools include information on estimating the phosphorus content of foods and a glossary of additives to guide the interpretation of food labels; comprehensive labeling of phosphorus additives; and using a "traffic light" program to classify foods based on low, medium, or high phosphorus content. 104 Educational interventions to improve phosphorus control by restricting diet indicate patient knowledge, compliance with low-phosphorus diets, and serum phosphorus levels. 19,91,105 Recent education programs, such as the phosphate education program described above, enable patients to adjust the phosphorus content of food according to the amount of phosphorus binders used in each meal, thereby improving the control of hyperphosphatemia. 14,83, 84

The interventions led by dietitians have been successful. 75,106,107 The use of nursing instruction manuals, pictures and reminder cards to systematically provide low-phosphorus diet care instructions has also been shown to improve compliance, reduce serum phosphorus levels and improve itching. 108 Although the comprehensive low-phosphorus diet-phosphorus diet education developed and provided by dialysis nurses and doctors can effectively improve serum phosphorus levels, the participation of 109 dietitians was found to be more effective. 109

Behavioral interventions to improve dietary phosphate compliance also usually use counseling provided by a dietitian. 19 Some interventions are based on theoretical frameworks, such as self-regulation theory91 and self-efficacy theory. 110 Personalized self-managed diet counseling—especially combined with patient education—to improve patient knowledge, dietary compliance, and serum phosphorus levels. 91 The use of phosphate management programs, including diet counseling and patient education and medication provided by dialysis dietitians and dialysis pharmacists, respectively, led to greater improvements in serum phosphorus 111 An incentive interview pilot on diet, medication, and dialysis attendance Studies have shown that it has a positive effect on serum phosphorus control. 79

Patients expressed frustration with the lack of psychosocial support and information from providers that affected their self-care. 112 The provider’s communication skills and the relationship and interaction between the provider and the patient may affect compliance with the prescribed low-phosphorus diet. 16 Providers need to recognize that patients’ limited self-efficacy17,85 and suboptimal attitudes92,93 lead to poor compliance with low-phosphorus diets and are potentially changeable targets. The staffing ratio of the dialysis unit is related to the compliance index and needs to be optimized. For example, the ratio of each nutritionist who consults no more than 60 dialysis patients per month has been shown to be more effective in improving phosphate binder compliance and serum phosphate control. 14 Provider-level strategies may complement ongoing interventions that are important patient-centered opportunities to improve dietary compliance of dialysis patients. All members of the multidisciplinary team should have the ability to provide phosphate binder compliance education and counseling . 14

Traditional four-hour hemodialysis three times a week has limited ability to reduce phosphorus levels associated with average dietary phosphorus intake. 19,113 The removal of phosphorus by traditional hemodialysis mainly occurs in the first half of the treatment, after which the serum phosphorus level either stabilizes or even increases again due to the rebound effect (up to 30%-40%). 114 The average daily phosphorus intake of dialysis patients is 1,500 mg/day or 10,500 mg/week. If 50% of this is absorbed, the excess phosphorus may be more than 5,000 mg removed by dialysis. 15 However, traditional hemodialysis removes an average of 1,800-3,600 mg of phosphorus per week. Therefore, conventional hemodialysis alone is usually not enough to control phosphorus. 19 The optimal dialysis removal rate of phosphorus depends on the slow flow rate and the longer dialysis time. Compared with traditional hemodialysis three times a week, daily or extended nighttime hemodialysis results in a higher phosphorus clearance rate. 115

Non-compliance with dialysis treatment is a major problem. 49 As many as 35% of patients missed treatment completely, while another 32% shortened their treatment time. 20 In addition to the direct impact on the management of hyperphosphatemia, non-compliance with dialysis treatment is associated with an increase in the hospitalization rate 116,117 23,49 This high treatment non-compliance rate has always existed, and is related to age, 23, 36 gender, 118 marital status, 118 Race, 23,119 and education 118 as well as comorbidities and logistical barriers (such as changing the vacation of the dialysis unit) are related to 116 As with other chronic diseases that require self-management, autonomy-centered psychosocial factors may be important and changeable dialysis adherence determining factors. 120 A deliberate multidisciplinary strategy designed to increase patient participation in dialysis59,121,122 is increasingly recognized as a high-value opportunity to influence compliance behavior and outcomes.

Phosphate control compliance is an essential part of dialysis care. The compliance rate for phosphate binder treatment, low-phosphorus diet and dialysis attendance is still not ideal. Factors that lead to non-compliance include treatment-related factors (for example, medication, diet, dialysis); patient-specific factors, including demographic, clinical, and psychosocial determinants, and provider-level factors. Psychosocial factors are the most influential determinants of compliance, because strategies that include cognitive behavioral interventions can be used to effectively modify them to change negative beliefs, attitudes, and behaviors in the treatment method, thereby optimizing phosphorus control. Provider-level factors are a key determinant of compliance with phosphate control in dialysis patients. Therefore, the relationship between providers and patients must be strengthened by ensuring a positive provider attitude, adequate staffing ratio, and improving employee efficiency through role clarification and training. All dialysis providers must be proficient in using novel combinations of effective strategies and protocols to provide culturally sensitive, patient-centered care. Optimal phosphate control compliance requires multi-level intervention to identify and address the preferences and unique attitudes of dialysis patients, enhance their self-regulating behavior, and enable them to achieve sustained phosphate binder compliance.

The author would like to thank Heather Laferriere, Health Sciences Library Liaison, Escinder Biomedical Library, Vanderbilt University, MLIS for supporting the detailed literature review of the selected database.

Dr. Umeukeje was supported by the BIRCWH K12 Award (K12HDO43483-17 – PI: Katherine Hartmann). Dr. Cavanaugh was supported by NIH R01DK03935-01A1. Dr. Mixon is supported by the Geriatric Research Education and Clinical Center (GRECC) of the Tennessee Valley Health Care System in Virginia. The authors report no other conflicts of interest in this work.

Malberti F. Hyperphosphatemia: treatment options. drug. 2013; 73(7): 673–688.

Slatopolsky E, Gonzalez E, Martin K. The pathogenesis and treatment of renal osteodystrophy. Blood purifier. 2003;21(4–5):318–326.

Tentori F, Blayney MJ, Albert JM, etc. Mortality risk in dialysis patients with different serum calcium, phosphorus, and PTH levels: Dialysis Outcome and Practice Model Study (DOPPS). I am J kidney disease. 2008; 52(3): 519–530.

Ketterer M, Bigger PH. The application of phosphate binders in chronic kidney disease. Curr Opin nephropathy hypertension. 2013;22(4):413–420.

Lopes AA, Tong L, Thumba J, etc. Dialysis Outcome and Practice Model Study (DOPPS) Phosphate Adhesive Use and Mortality in Hemodialysis Patients: Assessment of possible confounding factors caused by nutritional status. I am J kidney disease. 2012;60(1):90–101.

de Boer IH, Kovesdy CP, Navaneethan SD, etc.; Chronic Kidney Disease Advisory Group of the American Society of Nephrology. Practical clinical trials of CKD: opportunities and challenges. J Am Soc Nephrol. 2016;27(10):2948-2954.

Arenas MD, Malek T, Alvarez-Ude F, Gil MT, Moledous A, Reig-Ferrer A. Captores del fósforo: preferencias de los pacientes en hehedialisis y su repercusión sobre el cumplimiento del tratamiento y el control del fósforo. [Phosphorus binders: patients' preference for hemodialysis and its influence on treatment compliance and phosphorus control]. Nefrologia. 2010;30(5):522–530. Spanish [with English abstract].

Isakova T, Nickolas TL, Denburg M, etc. KDOQI US comment on the 2017 update of the KDIGO clinical practice guidelines for the diagnosis, evaluation, prevention and treatment of chronic kidney disease-mineral and bone disease (CKD-MBD). I am J kidney disease. 2017;70(6):737–751.

Schmid H, Hartmann B, Schiffl H. Adherence to oral prescription drugs in adult patients undergoing chronic hemodialysis: a critical review of the literature. Eur J Med Res. 2009;14(5):185–190.

Karamanidou C, Clatworthy J, Weinman J, Horne R. A systematic review of the prevalence and determinants of non-compliance with phosphate-binding drugs in patients with end-stage renal disease. BMC kidney. 2008; 9:2.

Covic A, Rastogi A. Hyperphosphatemia in ESRD patients: assessment of current evidence linking results to treatment adherence. BMC kidney. 2013;14(1):153.

Ghimire S, Castelino RL, Lioufas NM, Peterson GM, Zaidi ST. Non-compliance with medication in hemodialysis patients: a systematic review. Public Science Library One. 2015;10(12):e0144119.

Lynch KE, Lynch R, Curhan GC, Brunelli SM. The prescribed dietary phosphate restriction and survival rate in hemodialysis patients. Clinical J Am Soc Nephrol. 2011; 6(3): 620–629.

Kalantar-Zadeh K. Patient education for phosphorus management in chronic kidney disease. The patient's first choice is compliance. 2013; 7: 379-390.

Waheed AA, Pedraza F, Lenz O, Isakova T. Phosphate control in end-stage renal disease: obstacles and opportunities. Renin dial transplantation. 2013;28(12):2961–2968.

Lambert K, Mullan J, Mansfield K. Comprehensive evaluation of methodology and research results on dietary compliance in end-stage renal disease. BMC kidney. 2017; 18:318.

Chan YM, Zalilah MS, Hii ​​SZ. Determinants of compliance with sexual behavior of hemodialysis patients in Malaysia. Public Science Library One. 2012; 7(8): e41362.

Hou SH, Zhao Jie, Elman CF, etc. Calcium and phosphorus flux during hemodialysis using low calcium dialysate. I am J kidney disease. 1991;18(2):217-224.

Milazi M, Bonner A, Douglas C. The effectiveness of educational or behavioral interventions in adhering to phosphate control in adults undergoing hemodialysis: a systematic review. JBI database system revision implementation report 2017; 15(4): 971-1010.

Denhaerynck K, Manhaeve D, Dobbels F, Garzoni D, Nolte C, De Geest S. The prevalence and consequences of non-compliance with the hemodialysis regimen. It is J Crit Care. 2007;16(3):222–235; Quiz 236.

Tohme F, Mor MK, Pena-Polanco J, etc. Predictors and outcomes of non-compliance in patients receiving maintenance hemodialysis. Int Urol Nephrol. 2017;49(8):1471–1479.

Kutner NG, Zhang R, McClellan WM, Cole SA. Psychosocial predictors of non-compliance in hemodialysis and peritoneal dialysis patients. Renin dial transplantation. 2002;17(1):93-99.

Leggat JE Jr, Orzol SM, Hulbert-Shearon TE, etc. Non-compliance in hemodialysis: predictive factors and survival analysis. I am J kidney disease. 1998;32(1):139-145.

O'Brien me. Compliance behavior and long-term maintenance of dialysis. I am J kidney disease. 1990;15(3):209-214.

Sekercioglu N, Thabane L, Diaz Martinez JP, etc. The comparative effectiveness of phosphate binders in patients with chronic kidney disease: a systematic review and a network meta-analysis. Public Science Library One. 2016;11(6):e0156891.

Locatelli F, Del Vecchio L, Violo L, Pontoriero G. Phosphate binders for the treatment of hyperphosphatemia in patients with chronic kidney disease on dialysis: safety comparison. Expert Opin Drug Saf. 2014; 13(5): 551–561.

Arenas Jiménez MD, Parra Moncasi E, Álvarez-Ude Cotera F. Strategies based on patient preference can improve the compliance and outcome of phosphate binders in hemodialysis. Clinical nephropathy. 2017;88(1):1-11.

Negri AL, Urena Torres PA. Iron-based phosphate binders: do they have any advantages compared to currently available phosphate binders? Journal of Clinical Kidney. 2015; 8(2): 161-167.

Liu X, Yang R, Dai B, Zhang H, Wang J, Ma N. Niacin and related compounds: a meta-analysis of the use of hyperphosphatemia in dialysis patients. Medicine (Baltimore). 2018;97(12):e0117.

Wang S, Anum EA, Ramakrishnan K, Alfieri T, Braunhofer P, Newsome B. The reasons for the discontinuation of phosphate binders vary depending on the type of binder. J Ren nutrition. 2014;24(2):105–109.

Wileman V, Farrington K, Wellsted D, Almond M, Davenport A, Chilcot J. Drug beliefs are related to non-compliance of phosphate binders in patients with hyperphosphatemia hemodialysis. Br J Health psychologist. 2015;20(3):563–578.

Chater AM, Parham R, Riley S, Hutchison AJ, Horne R. Analyze patients’ attitudes towards phosphate-binding drugs: approaches to personalized treatment and compliance support. Mental health. 2014;29(12):1407–1420.

Martins MT, Silva LF, Kraychete A, etc. Potentially modifiable factors related to the non-persistent use of phosphate binders in hemodialysis patients. BMC kidney. 2013; 14:208.

Lindberg M, Prütz KG, Lindberg P, Wikström B. Interdialysis weight gain and ultrafiltration rate in hemodialysis: lessons from the National Clinical Practice Registry for fluid compliance. Hemodialysis 2009;13(2):181–188.

Chiu YW, Teitelbaum I, Misra M, de Leon EM, Adzize T, Mehrotra R. Maintain the pill burden, compliance, hyperphosphatemia and quality of life of dialysis patients. Clinical J Am Soc Nephrol. 2009; 4(6): 1089-1096.

Curtin RB, Svarstad BL, Andress D, Keller T, Sacksteder P. The difference between elderly and young hemodialysis patients not complying with oral medications. Geriatr Nephrol Urol. 1997; 7(1): 35-44.

Curtin RB, Swastad BL, Keller TH. Hemodialysis patients do not comply with oral medications. Anna J. 1999;26(3):307-316; Discussion 317,335.

Park H, Rascati KL, Lawson KA, Barner JC, Richards KM, Malone DC. The compliance and adherence to prescription drug treatment of dialysis beneficiaries in part D of the medical insurance: a comparison of the types of benefits and the stages of benefits. J Manag Care Spec Pharm. 2014;20(8):862–876.

Dolores Arenas M, Perez-Garcia R, Ben Nuna M, etc.; studio COMQUELFOS. Improving treatment compliance in hemodialysis patients with poor phosphorus control and adherence to adhesive therapy: the COMQUELFOS study. Nefrologia. 2013;33(2):196-203.

Ghimire S, Peterson GM, Castelino RL, Jose MD, Zaidi STR. The complexity and compliance of medication regimens for hemodialysis patients: an exploratory study. This is J Nephrol. 2016;43(5):318-324.

Ketterer M, Block GA, Evenepoel P, etc. Chronic Kidney Disease-Diagnosis, Evaluation, Prevention and Treatment of Mineral and Skeletal Diseases: Summary of Kidney Diseases: Improving Global Outcomes 2017 Clinical Practice Guidelines Update. An intern doctor. 2018;168(6):422–430.

St Peter WL, Wazny LD, Weinhandl ED. The use of phosphate binders in dialysis patients in the United States: prevalence, cost, evidence, and policy. I am J kidney disease. 2018;71(2):246-253.

St Peter WL, Fan Q, Weinhandl E, Liu J. Economic evaluation of sevelamer and calcium-based phosphate binders in hemodialysis patients: a secondary analysis using data from the Medicare and Medicaid Service Centers. Clinical J Am Soc Nephrol. 2009; 4(12): 1954–1961.

Rizk R, Hiligsmann M, Karavetian M, Evers SM. Economic evaluation of interventions for hyperphosphatemia in adult hemodialysis patients: a systematic review. Nephrology (Carleton). 2016;21(3):178-187.

Panichi V, Rosati A, Di Giorgio A, etc. A pharmacoeconomic analysis of the cost-effectiveness of phosphate binders in the RISCAVID study. Blood purifier. 2015;39(1–3):174–180.

Arenas MD, Malek T, Gil MT, Moledous A, Alvarez-Ude F, Reig-Ferrer A. The challenge of phosphorus control in hemodialysis patients: compliance issues? J kidney disease. 2010;23(5):525–534.

Neri L, Martini A, Andreucci VE, Gallieni M, Rey LA, Branchaccio D; MigliorDialisi research group. The complexity of the protocol and compliance with prescriptions for dialysis patients. This is J Nephrol. 2011;34(1):71–76.

Wileman V, Chilcot J, Norton S, Hughes L, Wellsted D, Farrington K. Choosing not to take phosphate binders: the effect of medication beliefs in dialysis patients. Clinical practice of renal function. 2011;119(3):c205–c213.

Saran R, Bragg-Gresham JL, Rayner HC, etc. Hemodialysis non-compliance: association with mortality, hospitalization, and practice patterns in DOPPS. Kidney International 2003;64(1):254–262.

Jin J, Sklar GE, Min Sen Oh V, Chuen Li S. Factors affecting treatment compliance: review from the perspective of the patient. Clinical risk management. 2008;4(1):269–286.

CT Zhao, Jianwei Huang; COGENT (NTUH Cohort of Geriatric Nephrology) Research Group. Geriatric syndrome is a potential determinant of drug compliance status in general dialysis patients. Pell J. 2016; 4: e2122.

Theofilou P. Medication compliance in hemodialysis patients in Greece: Contributions to depression and health awareness. International J Behavioral Medicine. 2013;20(2):311–318.

Alkatheri AM, Alyousif SM, Alshabanah N, etc. Medication compliance in adult hemodialysis patients. Saudi Arabia J Kidney Dis Transpl. 2014;25(4):762–768.

Christensen AJ, Wiebe JS, Benotsch EG, Lawton WJ. Perceive health ability, health control points and compliance of kidney dialysis patients. Cognitive therapy. 1996;20(4):411–421.

Cummings KM, Becker MH, Kirscht JP, Levin NW. Psychosocial factors that affect the compliance of a group of hemodialysis patients to the medical team. medical insurance. 1982; 20(6): 567-580.

Ossareh S, Tabrizian S, Zebarjadi M, Joodat RS. The prevalence of depression in maintenance hemodialysis patients and its correlation with medication compliance. Iran J kidney disease. 2014; 8(6): 467–474.

Rosenthal Asher D, Ver Halen N, Cukor D. Depression and non-compliance predict mortality in end-stage renal disease patients treated with hemodialysis. Hemodialysis 2012;16(3):387-393.

Patel P, Antonou S, Popat R. Inadvertently not complying with the phosphate binder. Eur J Hosp Pharm. 2015;22(1):18-22.

Kavanaugh KL. Give priority to the implementation and research of patient-centered care for patients with kidney disease. Dial smartly. 2015;28(2):131–140.

Desi EL, Ryan RM. Self-determination theory in healthcare and its relationship to motivational interviews: some comments. Int J Behav Nutr Phys Act. 2012; 9:24.

Umeukeje EM, Merigi JR, Browne T, etc. Self-motivation is related to phosphorus control in end-stage renal disease. J Ren nutrition. 2015;25(5):433–439.

Umeukeje EM, Merigi JR, Browne T, etc. Health care providers’ support for end-stage renal disease patients’ autonomy, phosphate medication compliance, race, and gender. J Behavioral Medicine. 2016;39(6):1104–1114.

Umeukeje E et al. Sensing ability is related to phosphorus control in end-stage renal disease. NIDDK Minority Research Investigator Conference Network; April 20-22, 2016; Bethesda, Massachusetts.

Miller WR, Rollnick S. Intermediate meeting: motivational interviews and self-determination theory. Int Behav Nutr Phys Act. 2012; 9:25.

Sabate E. Persist in long-term treatment: evidence of action. Geneva: World Health Organization; 2003.

Allen D, Wainwright M, Hutchinson T. "Non-compliance" as disease management: a description of hemodialysis patients versus hostile patient-clinician interactions. Social science medicine. 2011;73(1):129–134.

Gander J, Browne T, Plantinga L, etc. Dialysis facility transplant concept and acquisition of kidney transplant in the southeast. This is J Nephrol. 2015;41(6):504-511.

O'Connor SM, Jardine AG, Millar K. Use Leventhal's self-regulating model to predict the self-care behavior of patients with end-stage renal disease. J Psychological Research. 2008;65(2):191–200.

Omori DM, Potyk RP, Kroenke K. The adverse effect of hospitalization on drug treatment. Arch intern doctor. 1991;151(8):1562-1564.

Calkins DR, Davis RB, Reiley P, etc. Doctor-patient communication at discharge and the patient's understanding of the treatment plan after discharge. Arch intern doctor. 1997;157(9):1026-1030.

Ziaeian B, Araujo KL, Van Ness PH, Horwitz LI. Accuracy of medication reconciliation at discharge and patient’s understanding of expected medication changes. J Gen intern doctor. 2012;27(11):1513–1520.

de Araujo LP, Figueiredo AE, d'Avila DO. Avaliação de programa de ensino-aprendizagem sobreMetaliseo de cálcio e fósforo para pacientes em hehedialise. [Evaluation of an education program for calcium and phosphorus metabolism in hemodialysis patients]. Rev Esc Enferm USP. 2010;44(4):928-932. Portuguese [with English abstract].

Tuot DS, Cavano KL. Assess the advantages of CKD patient education materials: readability is necessary, but not enough. I am J kidney disease. 2015;65(6):814–816.

Tuot DS, Davis E, Velasquez A, Banerjee T, Powe NR. Evaluation of printed educational materials for patients with chronic kidney disease. This is J Nephrol. 2013;38(3):184–194.

Reddy V, Symes F, Sethi N, etc. Nutritionist-led education program to improve phosphate control in single-center hemodialysis population. J Ren nutrition. 2009;19(4):314–320.

Kaplan MR, Stashenko CL, Bledsoe AL, McGowan J. A preference study: calcium acetate tablets and gel capsules for hemodialysis patients. Nephrol Nurs J. 2002;29(4):363-365.

Mehrotra R, Martin KJ, Fishbane S, Sprague SM, Zeig S, Anger M. High-strength lanthanum carbonate provides serum phosphorus control, with a low tablet load, and is the first choice for patients and doctors: a multicenter study. Clinical J Am Soc Nephrol. 2008; 3(5): 1437-1445.

Matteson ML, Russell C. Interventions to improve hemodialysis compliance: a systematic review of randomized controlled trials. Hemodialysis 2010;14(4):370–382.

Russell CL, Cronk NJ, Herron M, etc. Dialysis of Motivational Interviews in Compliance Studies (MIDAS). Kidney Disease Nurse J. 2011;38(3):229-236.

Levensky ER, Forcehimes A, O'Donohue WT, Beitz K. Motivational interviews: evidence-based counseling methods can help patients follow treatment recommendations. I am nurse J. 2007;107(10):50–58; Quiz 58-59.

Wileman V, Farrington K, Chilcot J, etc. Evidence that self-affirmation improves phosphate control in hemodialysis patients: a pilot cluster randomized controlled trial. Ann Behavioral Medicine. 2014;48(2):275–281.

Obrero Churillo T. Drug Reminder System: An assistive technology to improve compliance with phosphate binders. J Ren nutrition. 2012;22(1):e3-e9.

Cullman MK. Management of hyperphosphatemia. Hemodialysis 2006;10(4):338-345.

Kuhlmann MK, Hoechst S, Landthaler I. Patient authorization in the management of hyperphosphatemia. Int J Artif Organs. 2007;30(11):1008-1013.

Elliott JO, Ortman C, Almaani S, Lee YH, Jordan K. Understand the relationship between changing factors, personal health beliefs, and adherence to low-phosphorus diets in hemodialysis patients. J Ren nutrition. 2015;25(2):111–120.

Uribarri J. Phosphorus additives in food and its effect on dialysis patients. Clinical J Am Soc Nephrol. 2009;4(8):1290–1292.

Benini O, D'Alessandro C, Gianfaldoni D, Cupisti A. Additional phosphate load of food additives in common foods: the real and potential risks to patients with kidney disease. J Ren nutrition. 2011;21(4):303-308.

Shinaberger CS, Greenland S, Kopple JD, etc. Is it beneficial or harmful for patients with chronic kidney disease to control phosphorus by reducing dietary protein intake? This is J Clin Nutr. 2008;88(6):1511–1518.

Noori N, Kalantar-Zadeh K, Kovesdy CP, Bross R, Benner D, Kopple JD. The relationship between dietary phosphorus intake and phosphoprotein ratio and mortality in hemodialysis patients. Clinical J Am Soc Nephrol. 2010; 5(4): 683–692.

Martin KJ, Gonzalez EA. Prevention and treatment of CKD-MBD phosphate retention/hyperphosphatemia: what is normal, when to start, and how to treat? Clinical J Am Soc Nephrol. 2011; 6(2): 440–446.

Karavetian M, Ghaddar S. Nutritional education in the management of osteodystrophy (nemo) in hemodialysis patients: a randomized controlled trial. J takes care of it. 2013;39(1):19-30.

Thomas LK, Sargent RG, Michels PC, Richter DL, Valois RF, Moore CG. Identify the factors related to the dietary compliance of the elderly with end-stage renal disease. J Ren nutrition. 2001;11(2):80–89.

Hollingdale R, Sutton D, Hart K. Promoting dietary changes in kidney disease: investigating patients' perspectives. J takes care of it. 2008;34(3):136-142.

Kara B, Caglar K, Kilic S. Patients on hemodialysis do not comply with diet and fluid restrictions and perceived social support. J Nurse Scholar. 2007;39(3):243-248.

Kugler C, Vlaminck H, Haverich A, Maes B. Adults on hemodialysis did not comply with diet and fluid restrictions. J Nurse Scholar. 2005;37(1):25-29.

Mellon L, Regan D, Curtis R. Factors affecting the compliance of Irish hemodialysis patients. Patient Education Committee. 2013;92(1):88-93.

Ford JC, Pope JF, Hunt AE, Gerald B. The influence of diet education on the laboratory value and knowledge of patients with hyperphosphatemia hemodialysis. J Ren nutrition. 2004;14(1):36-44.

Park KA, Choi Kwon S, Sim YM, Kim SB. Comparison of dietary compliance and dietary knowledge among Korean hemodialysis patients. J Ren nutrition. 2008;18(5):415–423.

Zrinyi M, Juhasz M, Balla J, etc. Diet self-efficacy: a determinant of compliance behavior and biochemical results of hemodialysis patients. Renin dial transplantation. 2003;18(9):1869–1873.

Khalil AA, Frazier SK, Lennie TA, Sawaya BP. Depressive symptoms and dietary compliance in patients with end-stage renal disease. J takes care of it. 2011;37(1):30–39.

Morales López C, Burrowes JD, Gizis F, Brommage D. Dietary compliance of Hispanic patients undergoing hemodialysis. J Ren nutrition. 2007;17(2):138-147.

Taylor LM, Kalantar-Zadeh K, Markewich T, etc. Dietary protein for phosphorus control in maintenance hemodialysis patients: a preliminary study. J takes care of it. 2011;37(1):16-24.

Cupisti A, D'Alessandro C, Baldi R, Barsotti G. Eating habits and counseling focused on the phosphate intake of patients with hyperphosphatemia on hemodialysis. J Ren nutrition. 2004;14(4):220-225.

Ritz E, Hahn K, Ketteler M, Kuhlmann MK, Mann J. Phosphate additives in food-health risks. Dtsch Arztebl Int. 2012;109(4):49–55.

Brogdon RM. Self-care education intervention to improve the knowledge of dietary phosphorus control in patients requiring hemodialysis: a preliminary study. Kidney Disease Nurse J. 2013; 40(4): 313–318; Quiz 319.

Mayne TJ, Benner D, Ricketts K, etc. Results of a pilot program to improve phosphorus results in hemodialysis patients. J Ren nutrition. 2012;22(5):472–479.

Campbell KL, Ash S, Zabel R, McFarlane C, Juffs P, Bauer JD. The implementation of standardized nutrition guidelines by kidney nutritionists is related to improving nutritional status. J Ren nutrition. 2009;19(2):136–144.

Cheng TY, Tarng DC, Liao YM, Lin PC. The effect of systemic nursing guidance on low-phosphorus diet, blood phosphorus levels and pruritus in hemodialysis patients. J clinical nurse. 2017; 26(3–4):485–494.

Tsai WC, Yang JY, Luan CC, et al. The additional benefits of dietician participation in dialysis staff-led dietary education about uncontrolled hyperphosphatemia in hemodialysis patients. Clinical experimental nephropathy. 2016;20(5):815–821.

Yin KS, Cui Jingyan. The effect of diet plan based on self-efficacy theory on dietary compliance, physical indicators and quality of life of hemodialysis patients[J]. J Nurse Acad, Korea. 2016;46(4):598-609. Korean [with English abstract].

Yokum D, Glass G, Cheung CF, Cunningham J, Fan S, Madden AM. Evaluate phosphate management options to achieve optimal serum phosphate levels in hemodialysis patients. J Ren nutrition. 2008;18(6):521–529.

Tong A, Sainsbury P, Chadban S, etc. The patient's experience and perspective on life with CKD. I am J kidney disease. 2009;53(4):689–700.

Lorenzo Sellares V, Torres Ramírez A. Management of hyperphosphatemia in dialysis patients: the role of phosphate binders in the elderly. Drug aging. 2004;21(3):153-165.

Leporte JK. The dynamics of β2-microglobulin and phosphate during hemodialysis: the effect of treatment frequency and duration. Dial smartly. 2005;18(5):401–408.

Walsh M, Manns BJ, Klarenbach S, Tonelli M, Hemmelgarn B, Culleton B. The effect of night on mineral metabolism compared with traditional hemodialysis: a randomized controlled trial. Hemodialysis 2010;14(2):174–181.

Chan KE, Thadhani RI, Maddux FW. Compliance barriers for chronic dialysis in the United States. J Am Soc Nephrol. 2014;25(11):2642–2648.

Vaiciuniene R, Kuzminskis V, Ziginskiene E, Skarupskiene I, Bumblyte IA. Treatment compliance and hospitalization risk of hemodialysis patients. J kidney disease. 2012;25(5):672–678.

Kugler C, Maeding I, Russell CL. Non-compliance in chronic hemodialysis patients: an international comparative study. J kidney disease. 2011;24(3):366–375.

Christensen AJ, Benotsch EG, Wiebe JS, Lawton WJ. Coping with treatment-related stress: the impact on compliance of hemodialysis patients. J Consult a clinical psychologist. 1995; 63(3): 454–459.

Clark-Cutaia MN, Ren D, Hoffman LA, Burke LE, Sevick MA. Follow hemodialysis dietary sodium recommendations: the impact of patient characteristics, self-efficacy, and perception disorders. J Ren nutrition. 2014;24(2):92–99.

Bear RA, Stockie S. Patient participation and patient-centered care in the management of advanced chronic kidney disease and chronic renal failure. Can J kidney health problems. 2014; 1:24.

O'Hare AM, Armistead N, Schrag WL, Diamond L, Moss AH. Patient-centered care: an opportunity to achieve the "three goals" of the national quality strategy in the health insurance ESRD program. Clinical J Am Soc Nephrol. 2014;9(12):2189–2194.

Agondi Rde F, Gallani MC, Rodrigues RC, Cornelio ME. The relationship between low-salt diet beliefs in patients with chronic renal failure on dialysis. J Ren nutrition. 2011;21(2):160–168.

Ahrari S, Moshki M, Bahrami M. The relationship between social support for Iranian hemodialysis patients and compliance with diet and fluid restrictions. J cares about science. 2014;3(1):11-19.

Dowell SA, Welch JL. Using electronic self-monitoring of food and fluid intake: a pilot study. Nephrol Nurs J. 2006;33(3):271-277.

Durose CL, Holdsworth M, Watson V, Przygrodzka F. Knowledge about dietary restrictions and the medical consequences of non-compliance in hemodialysis patients cannot predict dietary compliance. J Am Diet Association. 2004;104(1):35–41.

Lee SH, Molassiotis A. Diet and fluid compliance of Chinese hemodialysis patients. Int J Nurs Stud. 2002;39(7):695–704.

Morrison EF, Adrick MK. The changing stages and fluid intake of dialysis patients. Patient Education Committee. 2003;49(1):5-12.

Mok E, Tam B. Stressors and coping methods of chronic hemodialysis patients in Hong Kong. J clinical nurse. 2001;10(4):503–511.

Pang SK, Ip WY, Chang AM. Psychosocial relevance of fluid compliance in Chinese hemodialysis patients. J senior nurse. 2001; 35(5): 691-698.

Poduval RD, Wolgemuth C, Ferrell J, Hammes MS. Hyperphosphatemia in dialysis patients: does key counseling work? J Ren nutrition. 2003;13(3):219-223.

Sagawa M, Oka M, Chaboyer W. The effect of cognitive behavioral therapy on fluid intake in chronic hemodialysis patients: a preliminary examination. Int J Nurs Stud. 2003;40(4):367–373.

Sharp J, Wild MR, Gumley AI, Deighan CJ. Cognitive behavior group approach to improve compliance with hemodialysis fluid restriction: a randomized controlled trial. I am J kidney disease. 2005;45(6):1046-1057.

Cai SL. Self-efficacy training for patients with end-stage renal disease. J senior nurse. 2003;43(4):370–375.

Welch JL. Hemodialysis patients' beliefs about the fluid compliance stage. Res Nurse is healthy. 2001; 24: 105-112.

Yokoyama Y, Suzuka Y, Hotta O, etc. The dialysis staff of hemodialysis patients encourage and fluid control compliance. Nephrol Nurs J. 2009;36(3):289-297.

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