Beruflich Dokumente
Kultur Dokumente
Engagement with Fluid and Dietary Restriction among Chronic Kidney Disease
(CKD) Patients in Selected Public Hospitals of KwaZulu-Natal (KZN) Province,
South Africa
Geldine Chironda*, Busisiwe Bhengu
University of KwaZulu- Natal School of Nursing and Public Health, Howard College Campus, Durban, South Africa
*Correspondence: Geldine Chironda, University of KwaZulu- Natal School of Nursing and Public Health, 5th floor, Desmond Clarence Building,
which include intradialytic cramping and hypotensive programme as 2000 which was infinite [4]. Therefore, the
episodes, treatment related fatigue and dizziness, lower- necessary Sample Size (SS) was calculated according to the
extremity oedema, ascites, left ventricular hypertrophy and approximate number of CKD patients on the programme using
congestive heart failure, hypertension, shortness of breath, the standard formula and the finite population adjustment
and pulmonary vascular congestion or acute pulmonary model as illustrated in Katzenellenbogen et al. [14].
oedema [9,11]. Excessive fluid overload contributes to an
increased morbidity [12] and high mortality [9] in CKD Inclusion and exclusion criteria
patients. Similarly, dietary restriction in CKD forms part of the
management of the condition and its goal is to minimize All male and female CKD patients who could communicate
uremic and anaemia symptoms, reduce the incidence of fluid, verbally and attending the renal unit or renal clinic were
electrolyte and acid base imbalances, decrease patient’s eligible for selection into the study. The patients had to have
vulnerability to infections and limit catabolism [13]. Again, been on CKD programme for at least three months in order to
documented poor adherence to dietary restriction has been be able to estimate a realistic engagement with their fluid and
documented to be in the ranges of 2% to 81% [7] among CKD dietary restriction. All CKD patients aged 18 years and over
patients. In this regard, fluid and diet engagement plays a were eligible for selection and this ensured coverage of all
pivotal role in the effective management of CKD as it lowers ages in which CKD occurs. Excluded were all critically ill
morbidity, improve rehabilitation, survival and clinical patients, minors, and all those who have been attending renal
outcomes [5]. unit or clinic for less than three months. Critically ill patients
were excluded because they lacked the ability to comprehend
Despite evidence that has been compiled to date of the information about a study, to make decisions regarding
importance of patient engagement, more research is needed participation or withdrawal from the study and to
to determine best practices for engaging patients with their communicate effectively. Minors were excluded because they
fluid and dietary restrictions. Furthermore, there are no were not capable of giving informed consent.
studies that examined the concept of fluid and dietary
restriction engagement among CKD patients in KwaZulu-Natal,
province, South Africa. Therefore, the investigator sought to
Data collection instruments
determine the level of engagement with fluid and dietary The tool used for this study was the structured interview
restriction among CKD patients. Findings from this study may guide which was developed from in depth literature review
add important information to the literature regarding patients’ [15,16]. The interview schedule consisted of 3 sections
engagement with fluid and dietary restriction. The results can namely: Demographics (Section A), Engagement with fluid
be used to inform future interventions that promote highest restriction (Section B), Engagement with dietary restriction
positive adherent behaviours among CKD population. (Section C) of the CKD participants. The instrument for
engagement with fluid restriction consisted of ten items.
Purpose of the Study Respondents were asked on how often the health care worker
talked to them about the importance of fluid restriction,
The aim of the study was determine the level of amount of daily expected fluid intake, how often they have
engagement with fluid and dietary restriction among Chronic followed fluid restriction in the past week, the level of
Kidney Disease (CKD) patients in KZN province, South Africa. importance to follow fluid restriction, importance of limiting
fluid restriction, difficulties with fluid restriction and types of
Methodology difficulties, level of difficulties with fluid restriction, number of
times weighed at home, level of importance on weighing and
reasons for missing and weight gain or loss.
Study design
The instrument for engagement with dietary restriction
A cross sectional descriptive study to determine the level of consisted of seven items. Respondents were asked on how
engagement with fluid and dietary restriction of CKD patients’ often the health care worker talked to them about dietary
was carried out at two major referral hospitals in KZN, South restriction, expected renal diet, the level of importance to
Africa. These referral hospitals serve the population of the follow dietary restriction, importance of following dietary
whole KwaZulu-Natal province including neighbouring restrictions, difficulties with dietary restriction and types of
provinces like Eastern Cape and Mpumalanga. Therefore difficulties, level of difficulties with fluid restriction and
focusing on these centres posed the likelihood of capturing all number of times of missed dietary restriction in the past week.
CKD patients from all three provinces of South Africa.
Face-to-face interview was used to collect data. The content
validity of the structured interview schedule was ensured by
Sample size submitting the tool to the experts in the field of nephrology
A sample of 90 consenting CKD participants was drawn namely experts in school of nursing and public health,
using simple random sampling method. The exact number of nephrologist and renal specialists in the clinical area. A pilot
patients with CKD in KwaZulu-Natal province was unknown study was conducted on adult CKD patients who met the
due to lack of renal registries. However, Assounga et al inclusion criteria at a major referral hospital and no changes
revealed the approximate population of CKD patients on CKD were made to the instrument after expert review and pilot
study. Cronbach’s alpha was the psychometric test applied to Albert Luthuli Hospitals (Ethical clearance reference number
measure the internal consistency of the instrument. The BE377/14). Patient’s rights namely rights to self-
reliability of the instrument was 0.77 (Cronbach's α=0.77). determination, right to privacy, right to confidentiality, right to
fair treatment and right to protection from discomfort and
Data analysis harm were observed. Informed consent and participant
authorization were sought from the study participants.
Data analysis was performed using the Statistical Package Assessing research benefit was also part of the ethical process
for Social Sciences (SPSS) version 23, 2015. Responses to for balancing benefits and risks for this study.
individual dietary and fluid restriction plan was analysed using
descriptive statistics namely frequencies and percentages.
Engagement with dietary and fluid restriction was analysed Results
using descriptive statistics namely frequencies and
percentages. Engagement with fluid and dietary restriction of Demographic data
90% to 100% was classified as high, 80% to 89% was classified
as moderate and engagement of below 80% was considered as Table 1 reveals the distribution of demographic variables for
low. The investigator developed the scale because no scale CKD participants. The age of participants was from a minimum
was found in literature. The Chi square test was used to test of 21 years to a maximum of 61 years with an age range of 40.
whether a statistically significant relationship existed between The sample comprised of more males [53 (59%)] than females
two categorical variables. The selected independent [33 (47%)]. The majority, [56 (62%)] of the CKD participants
biographical categorical variables were gender, marital status, were married though some were divorced and widowed.
and level of income, level of education, duration of CKD, Highest [58 (64%)] and lowest [9 (10%)] number of CKD
support systems, occupation and CKD class. The dependent participants were found in grade 10-12 and tertiary education
categorical variable in this study was level of engagement with respectively. The majority, [66 (73%)] were unemployed, on
dietary and fluid restriction. government medical grant and about a quarter of the
population had jobs with no medical grant from the
government. Duration of CKD ranged from three months to
Ethical considerations over 5 years among the population.
Permission to carry out the study was sought from the
Department of health, KZN, CEO, King Edwards and Inkosi
21-30 8 9
31-40 12 13
41-50 41 46
51-60 28 31
Greater than 60 1 1
Gender
Male 53 59
Female 37 41
Level of Education
Grade 8 to 9 3 26
Grade 10 to 12 58 64
Tertiary level 9 10
Marital status
Married 56 62
Single 27 30
Divorced 3 3
© Copyright iMedPub 3
Health Science Journal 2016
ISSN 1791-809X Vol.10 No.5:4
Widowed 4 5
Occupation
Self-employed 1 1
Professional 23 26
Non employed 66 93
Income
R3000 to R6000 18 20
R6001 to R10000 6 7
Support System
Family only 24 17
Duration of CKD
3 months to 1 year 22 24
Table 2 displays results for engagement with fluid among 701 to 800 9 10
CKD participants. Concerning health education by health 801 to 900 3 3
professional on the importance of fluid restriction, 2 (2%) had
health education that week, 5 (6%) last week, the majority, [76 Over 901 53 59
(84%)] on monthly basis, 6 (7%) a month ago and 1 (1%) never How often have you followed fluid restriction?
had health education on the importance of fluid restriction.
With regards to expected fluid intake per day, 24 (27%) took All the time 18 20
500 ml to 600 ml per day, 1 (1%) had between 601 ml and 700 Most of the time 44 49
ml, 9 (10%) drank 701 ml to 800 ml, 3 (3%) took from 801mls
About half of the time 25 28
to 900mls and most, [53 (59%)] had over 901 ml per day.
Concerning following daily fluid restriction, 18(20%) followed Very seldom 3 3
all the time, 44 (50%) most of the time, 25 (28%) about half of
Level of importance to limit fluid intake
the time and only 3 (3%) occasionally.
Highly important 39 43
Table 2 Engagement with Fluid restriction for CKD participants
Very important 50 56
(n= 90).
Moderate important 1 1
Percentage
Variable Frequency (n) Why it’s important to follow fluid restriction
(%)
Fluid expected to drink per day How much difficulty with fluid intake
important. Concerning the reason for importance of following because they could not afford the prescribed diet and some of
diet restriction, more than half, [48 (53%)] said that their them were not willing to avoid certain recommended foods
kidney condition requires them to take required diet, 39 (43%) and control what they eat.
said that taking required diet keeps their body healthy and 3
(3%) revealed that they are taking required diet because a Engagement with dietary restriction scores
medical practitioner told them to do so.
among CKD participants
Table 4 Engagement with dietary restriction for CKD Engagement with dietary restriction scores was measured
participants (n=90). on a scoring system using Likert scale of the interview
scheduled guide. The minimum possible total score for
Variable Frequency (n) Percentage (%) engagement with dietary restriction was seven and the
Health education on diet maximum possible score, signifying perfect engagement with
dietary restriction was 28. Dividing the attained score on this
Last week 1 1
section by the maximum possible attainable score (28) and
One month ago 82 91 multiplying by a hundred to come up with a percentage
calculated engagement with dietary restriction. Engagement
More than a month ago 7 8
with dietary restriction of 90% to 100 % was classified as high,
Expected diet 80% to 89% as moderate and of below 80% was considered
Renal diet 90 100
low.
To keep my body healthy 39 44 Table 5 Engagement with dietary restriction scores for CKD
participants out of 28 (N= 90).
Medical practitioner told me to
3 3
do so
Engagement
Engagement Frequenc Percentage
Any difficulties with diet intake score in
score out of 28 y (n) frequency
percentage (%)
Yes 43 48
Eighteen 64 5 6
No 47 52
Nineteen 68 4 4
How much difficulty with diet intake
Twenty 71 5 6
Not difficulty 47 52
Twenty one 75 12 13
Little difficulty 32 36
Twenty two 79 12 13
Moderate difficulty 11 12
Twenty three 82 9 10
How often have you followed diet
Twenty four 86 17 19
All the time 29 32
Twenty- five 89 12 13
Most of the time 47 52
Twenty six 93 14 16
About half of the time 14 16
participants showed better engagement with dietary urine output. Based on evidence and best practice, the CKD
compared to fluid restriction. patient is advised a daily fluid allowance of 500 ml plus the
volume equal to daily urine output [9] and all the participants
Discussion were aware of the expected daily intake. Although patients
were aware of the need to follow fluid restriction, this created
an uncomfortable state of ambivalence regarding drinking [9].
Biographical characteristics As a result, CKD patients drank more than the expected per
Concerning age, the study showed that age ranged from 21 day as revealed by findings of this study.
years to 61 years with the mean age of 45.6 years. The findings Concerning following daily fluid restriction, 80% did not
are partly supported by Venkateswararao et al. where the follow it all the time and the majority, (63%) experienced
mean age of CKD participants was 46.7 years [17]. Overall, the difficulties. These results are confirmed by the findings by
results revealed that CKD is affecting a wide range of patients Venkateswararao et al. where they revealed CKD patients
in terms of age groups in South African population. The sample experiencing difficulties with fluid restrictions [17]. Difficulties
comprised of more males [53 (58.89%)] than females [37 experienced with fluid restriction included thirst as a result of
(41.11%)]. In South African population, studies have shown hot weather and high temperatures in the study area. Also
that more males suffer from risk factors for CKD hence more of inability to control fluid intake was cited as a difficulty by the
them with the disease [4]. Highest 37 (62%) and lowest 4 (6%) participants. These results are affirmed by the study done by
number of CKD participants were found in grade 10-12 and Venkateswara et al. where most commonly reported reason
tertiary education respectively. There was a significant for non-adherence to fluid restriction was inability to control
association between educational level (Chi square value=28 their desire for fluid followed by seasonal variation and wrong
219, df=74, p<0.013 and engagement with dietary restriction. perception of the patient that dialysis will help in the removal
Low education has been found to have poor correlation with of total fluid consumed [17]. Although Lindberg indicated that
knowledge of disease and treatment [18]. Most, [66 (73.33%)] the season of the year may affect fluid consumption [9], winter
were unemployed and received less than R3000 as they were season was highlighted with higher intake of fluid than in
on government medical grant. Generally, there was low summer. This is in contrast with the study results where higher
socioeconomic status in the study sample. The results intake of fluid was reported in summer.
reinforce the study by Assounga where majority of the CKD
patients were unemployed [4]. There was a significant Concerning the weight of the participants on review, the
association between monthly income (Chi square majority (60%) had excessive weight gain meaning their weight
value=25.916, df=74, p<0.027) and engagement with dietary was more than 3.5% of dry body weight on assessment as
restriction. In this study, the source of source of income for the operationalised in the study. These results are supported by
unemployed was from medical grant which government give Lindberg and Charra where they revealed that associated fluid
to chronic CKD patients on monthly basis to aid in expenses surplus is a major clinical problem in individuals with CKD
related to CKD. However, the medical grant is minimal and this [9,11]. Removal and control of excess fluid is the cornerstone
affected engagement with dietary restriction among CKD of volume management in CKD patients [10]. Dietary sodium
patients. intake and other treatment-related use of sodium have a
negative impact on fluid overload. A more frequent dialysis
would reduce the fluid overload but with effective patient
Engagement with fluid restriction engagement with fluid restriction. Although effective fluid
Engagement with fluid restriction scores among CKD management in CKD population encompasses dialysis
participants ranged from 46% to 86% out of a total possible adequacy, medication and dietary restriction, it is the most
score of 100% and the mean score was 63%. Although 40% difficult to achieve in CKD patients as confirmed by previous
scored above the mean score, none of the participants studies [9]. The results of this study confirm the findings in
achieved high levels of engagement with fluid restriction. literature as they revealed least scores of engagement with
There were 11% with moderate levels and the majority, (89%) fluid restriction.
had low levels of engagement with fluid restriction. Adherence
to fluid restrictions is considered the most difficult to Engagement with dietary restriction
accomplish [9] as evidenced by none of the patients achieving
higher scores of engagement in this study. The study results Total engagement with diet restriction scores among CKD
are also reinforced by Chan et al. where low rates of participants ranged from 18 (64%) to 26 (93%) out of total
adherence have been observed [8]. Drinking considerably possible score of 28 (100%) and the mean score was 23 (82%).
more fluid than recommended is known in many CKD patients. Over half [52 (58%)] of the participants scored above the
Fluid retention and associated fluid surplus is a major clinical mean. However, 14 (16%) of the participants achieved high
problem in individuals with CKD [11] as shown by the study levels of engagement and equal numbers, [38 (42%)] had
findings. moderate and low levels of engagement with diet restriction.
These results reflect significant problems of engagement with
With regards to expected fluid intake per day, most (73%) dietary restrictions among CKD patients. This is further
had over 600mls per day. The expected fluid intake in this supported by findings in literature [8] where non adherence to
study was 500mls to 600 mls in addition to the volume of daily diet ranges from 2% to 81.4%. All 90 (100%) had knowledge of
© Copyright iMedPub 7
Health Science Journal 2016
ISSN 1791-809X Vol.10 No.5:4
the expected renal diet. The results of the study are reinforced
with findings by Shailendranath et al. where they found
References
adequate knowledge among CKD patients regarding protein 1. Vivekanand JHA, Guillermo G, Kunitoshi I, Zou l, Saraladev N
rich, sodium rich, potassium rich and fluid contributing food (2013) Chronic kidney disease: Global dimension and
sources [18,19]. Nevertheless, people with good basic literacy perspectives The lancet Publication.
and numeracy skills may struggle to understand and interpret 2. Singh S (2013) Hypertension in chronic kidney disease. Clinical
health information in a way that prompts them to act Queries: Nephrology 2: 15-22.
appropriately to protect or enhance their health [20].
3. Barsoum RS (2013) Burden of chronic kidney disease: North
Although there was adequate knowledge about renal diet in Africa. Kidney International Supplements 3: 164-166.
CKD patients, level of engagement with this management
modality was low in this study. On experiencing difficulties 4. Assounga A, Hariparshad S, Madala N (2012) Kidney Diseases in
an African setting. Reach Publishers.
with diet restrictions, 43 (48%) experienced difficulties such as
loss of appetite, nausea, vomiting, inability to control what 5. Carman KL, Dardess P, Maurer M, Sofaer S, Adams K, et al.
they eat and lack of funds to buy the required diet. (2013) Patient and Family Engagement: A Framework for
Understanding the Elements and Developing Interventions and
Additionally, more than half, 68% did not follow all the time
Policies. Health Affairs 32: 223-231.
because they could not afford the prescribed diet and some of
them were not willing avoid certain recommended foods and 6. Skolasky RL, Mackenzie EJ, Wegener ST, Riley LHIII (2008) Patient
control what they eat. These results are reinforced by the Activation and Adherence to Physical Therapy in Persons
Undergoing Spine Surgery. Spine 33: E784-E791.
studies done by Sayed et al. where 50% of CKD patients
reported having difficulties in following dietary restrictions all 7. Theofilou P (2012) The effect of sociodemographic features and
the time [21-23]. In this study, these side effects limited beliefs about medicines on adherence to chronic kidney disease
engagement of CKD patients with their dietary restrictions. treatment. J Clin Res Bioethics 3: 1-5.
Socio economic status was also cited to have a great influence 8. Chan YM, Zalilah MS, Hii SZ (2012) Determinants of compliance
on following dietary restrictions as most patients verbalised behaviours. J Clin Nurs 19: 649–657.
that they cannot afford it. As a result, there was limited 9. Lindberg M (2010) Excessive Fluid Overload among
engagement with dietary restrictions among CKD participants Haemodialysis Patients: Prevalence, Individual Characteristics
due to low socioeconomic status. and Self-regulation of Fluid Intake. Haemodialysis international
13: 181-188.
Dietary restriction in CKD forms part of the management of
the condition and its goal is to minimize uremic and anaemia 10. Machek P, Jirka T, Moissl U, Chamney P, Wabel (2009) Guided
symptoms, reduce the incidence of fluid, electrolyte and acid optimization of fluid status in haemodialysis patients.
Nephrology Dialysis Transplantation.
base imbalances, decrease patient’s vulnerability to infections
and limit catabolism [13]. Low level of patient engagement 11. Charra B (2007) Fluid balance, dry weight, and blood pressure in
with diet has been revealed by the study results. Yet diet plays dialysis. Haemodialysis International 11: 21-31.
a pivotal role in the effective management of CKD as it lowers 12. Holmberg B, Stegmayr BG (2009) Cardiovascular conditions in
morbidity, improve survival and clinical outcomes [5]. haemodialysis patients may be worsened by extensive
intradialytic weight gain. Haemodialysis International 13: 27-31.
20. Coulter A (2012) Patient engagement—what works? The Journal 22. Lam LW, Twinn SF, Chan SWC (2010) Self-reported adherence to
of ambulatory care management 35: 80-89. a therapeutic regimen among patients undergoing continuous
ambulatory peritoneal dialysis. J Adv Nurs 66: 763–773.
21. Shailendranath B, Ushadevi C, Prashant G, Kedlaya (2014)
Impact of Knowledge, Attitude and Behaviour among 23. Sayed M, Abdelatty M, Elrawy B, Yasser M, Salman H, et al.
Maintenance Haemodialysis Patients for Adherence to Dietary (2014) Assessment of socioeconomic burden of haemodialysis
Regimen – A Single Centre Experience. International Journal of on ESRD patients in Suez canal cities and ELArisH. American
Humanities and Social Science 4: 12. Journal of Research Communication.
© Copyright iMedPub 9