DIFFERENCES IN RENAL DIET AND MEDICAL SYMPTOM KNOWLEDGE IN DIET ADHERENT AND DIET NONADHERENT ADULT HEMODIALYSIS PATIENTS A thesis submitted to the Kent State University College of Education, Health and Human Service in partial fulfillment of the requirements for the degree Master of Science in Nutrition and Dietetics By Kelsey Lynn Hagens May 2019 © Copyright, 2019 by Kelsey L. Hagens All Rights Reserved ii A thesis written by Kelsey Lynn Hagens B.S., Indiana University of Pennsylvania, 2017 M.S., Kent State University, 2019 Approved by ________________________, Director, Master’s Thesis Committee Natalie Caine-Bish ________________________, Member, Master’s Thesis Committee Eun-Jeong (Angie) Ha ________________________, Member, Master’s Thesis Committee Tanya Falcone Accepted by ________________________, Director, School of Health Sciences Ellen Glickman ________________________, Dean, College of Education, Health, and Human Services James C. Hannon iii HAGENS, KELSEY LYNN, M.S., May 2019 Nutrition and Dietetics THE EFFECT OF RENAL DIET AND RENAL SYMPTOM KNOWLEDGE ON DIETARY ADHERENCE IN ADULT HEMODIALYSIS PATIENTS Director of Thesis: Natalie Caine-Bish, Ph.D, R.D., L.D. pp 111 Most end stage renal disease patients utilize hemodialysis as a treatment to sustain kidney function. Hemodialysis requires adherence to a complex diet that restricts nutrients in order to reduce complications and improve quality of life. However, dietary nonadherence is extremely prevalent in this population with many etiologies considered. The purpose of this study was to determine if renal nutrition knowledge differed between patients who are adherent and nonadherent to a renal diet. Participants were adult hemodialysis patients with a diagnosis of end stage renal disease who completed a questionnaire that tested their knowledge of renal diet components and the medical complications associated with nonadherence. A series of laboratory results consisting of serum phosphorus, serum potassium, and interdialytic weight gain divided the population as adherent or nonadherent. Data analysis showed no significant difference in renal knowledge scores between adherent and nonadherent participants (p<0.05). This indicates that education is not a significant factor in dietary nonadherence. Methods of behavior change should be explored to improve adherence. ACKNOWLEDGEMENTS I would first like to express my appreciation to Dr. Natalie Caine-Bish for advising me through this process that initially seemed so intimidating and unattainable. Her persistent help and support kept me motivated through all of the bumps in the road. I would like to thank my committee members, Dr. Eun-Jeong Ha and Tanya Falcone, who took time to provide crucial advice and knowledge that improved my research drastically. Additionally, I would like to thank Judy Nagy for her passion to the field of renal nutrition that inspired this study. I truly appreciate the time and effort you put into helping me throughout this process. I would also like to thank the entire staff at CDC that allowed this research to happen and the patients who participated. You made my first research experience more enjoyable than I ever could have imagined. iv TABLE OF CONTENTS Page ACKNOWLEDGEMENTS………………………………………………………………………iv CHAPTER I. INTRODUCTION…………………………………….…...….……………….......1 Statement of the Problem…………………………………………………….….....3 Purpose Statement………………………………………………………...............4 Hypothesis………………………………………………………………………...4 Operational Definitions…………………………………………………………....5 II. REVIEW OF LITERATURE……………………………………………....…….7 The Kidney………………...................................................................................7 Physiology…………………….……………………………………..…...7 Glomerular Filtration Rate..………..……………………….…..8 Chronic Kidney Disease...…….……………...…………………………….…..9 Etiology..…………….…………………………………………….......10 Glomerulonephritis.….……………………………………...…10 Diabetes Mellitus….……………………………………..……11 Hypertension…………….......……………………………..…12 Polycystic Kidney Disease……….……………………...…....12 Acute Kidney Injury..………….………………………...…....14 Stages of CKD…..…………..……..………………………….…..…15 Stage 1..…..…………………………….…………….……....15 Stage 2……………….……………………..……..…....…….16 Stage 3……………....…….………………………………….17 Stage 4………….………………………….…………….…...18 Stage 5…………………....…………………………….….…18 End Stage Renal Disease……….……….....……………………………....….19 Epidemiology…….……………..………………………………...…19 Dietary Assessment…...………...……...……………….…………...19 v Laboratory Assessment.…..…..…..……...……………………..…..21 Treatment……………........…...……………………………………24 Medications…….….…………………….........………..….24 Phosphorus binders..……………………………....24 Erythropoietin...……………………….…………..25 Active vitamin D………………..………..………..25 Dialysis…….………….….……………..…………..……26 Kt/V.........…...……………………………………26 Hemodialysis..………………….........………..….27 Peritoneal dialysis…..…………………………....28 Kidney Transplantation..…………………….…………..29 Medical Nutrition Therapy..…………..………..………..30 Energy.……….….……………..…………..……30 Protein....…...……………………………………31 Phosphorus…………………….........………..….31 Potassium………..……………………………....32 Sodium……...……………………….…………..32 Fluid…………………………..………..………..33 Vitamin D…....….……………..…………..……33 Calcium…....……………………………………33 Comorbidities of ESRD patients…...…………….........………..….34 Diabetes………………..…..…………………………....35 Cardiovascular Disease..…………………….…………..35 Malnutrition……………....…………..………..………..36 Infection Concerns of ESRD Patients..…………..…………..……36 Factors Affecting Nonadherence in Hemodialysis Patients…….…………….…..38 Psychological Factors.…………………………………………......39 Social Factors…………….……………………………………......40 Education Factors…..….……………………………………..……42 Self-efficacy………………….......………………………………44 III. METHODOLOGY……………………………………………………………....47 Overview….……………………………………………………………………..47 Participants.……………………………………………………………………...47 Laboratory Results………..……………………………………………………...48 Instrumentation…….………………………………………………………….…48 Questionnaire Development……………………………………………...48 Questionnaire Components……………..………………………………..49 Part I: Nutrition Knowledge and Medical Symptom Quiz………49 Part II: Demographics and Health Information.…..……….…….50 vi Data Collection Procedures….………………………………………………….50 Data Analysis Procedures…….…………………………………………………51 IV. JOURNAL ARTICLE…………………………………………………………....53 Introduction…….………………………………………………………………..53 Methodology...…………………………………………………………………..55 Participants………………………………………………………………...55 Review of Laboratory Results……………………………………………..56 Instrumentation…..………………………………………………………...56 Data Collection Procedures…...…………………………………………...58 Data Analysis Procedures...………………………………………………..58 Results…....……………………………………………………………………….59 Demographics……..………….…………………………………………...59 Laboratory Results…………….…………………………………………..60 Knowledge Questionnaire…….…………………………………………...60 Discussion………..………..……………………………………………………...64 Characteristics of Study Population..……………………………………..64 Laboratory Results...……………………………………………………...65 Renal Nutrition and Medical Symptom Knowledge……………………...66 Limitations………………………………………………………………………..68 Applications.……………………………………………………………………...69 Conclusion………..……….……………………………………………………...70 APPENDICES………………………..………………………………………………………….71 APPENDIX A. LABORATORY STANDARDS…………………………………………72 APPENDIX B. RENAL NUTIRITION KNOWLEDGE QUESTIONNAIRE……..….....74 Part I: Renal Nutrition Knowledge Questionnaire……...….……..… …………..75 Part II: Demographics……….….……..……..…………..………...………….....78 APPENDIX C. QUESTIONNAIRE BY DUROSE ET AL………………………………80 APPENDIX D. STUDY CONSENT FORM….…………………………………………..88 APPENDIX E. HIPAA FORM………………..…………………………………………..91 REFERENCES……………………………………………………………………………..……94 vii CHAPTER I INTRODUCTION Chronic kidney disease (CKD) is a steady decline in renal function (Mahan, Escott-Stump, & Raymond, 2012). This decline can be stable and last many months or can rapidly progress to kidney failure. CKD is categorized into stages that are determined by glomerular filtration rate (GFR) and other factors that show evidence of kidney disease (Mahan, Escott-Stump, & Raymond, 2012). CKD affects nearly 1 in 8 adults globally, with approximately 2% of these individuals progressing to stage 5, also known as end stage renal disease (ESRD) (Lambert, Mullan, & Mansfield, 2017). Renal replacement therapy, or dialysis, is required to sustain life once a patient reaches ESRD (Barnett, Li Yoong, Pinikahana, & Si-Yen, 2008). Hemodialysis is the most common treatment for ESRD patients and requires attendance three times a week to remove uremic toxins and excess water that the kidneys no longer can. Although hemodialysis is performing the main function of the kidneys, a proper diet is necessary to minimize the accumulation of toxins, electrolytes, and fluid in the body between treatments (Barnett, Li Yoong, Pinikahana, & Si-Yen, 2008). The renal diet is extremely complex and involves potential restrictions of phosphorus, potassium, sodium, and fluid (Durose, Holdsworth, Watson, and Przygrodzka, 2004). Phosphorus is crucial for the formation of bone and other tissues (Nutrition and Hemodialysis, 2013). Phosphorus is a mineral that is abundant in dairy products, beans, nuts, colas, and processed foods, and often needs to be limited by dietary 1 2 restriction and/or phosphorus binders. Potassium helps the muscles and heart work properly and is found in certain fruits and vegetables, milk, and meats. Sodium, found in many snack foods, canned and frozen foods, sauces, and soups, can cause our body to hold on to extra fluid when consumed in excess amounts. Fluid is considered anything that is liquid at room temperature. Excess