Medication burden in CKD-5D: impact of dialysis modality and setting

Abstract

Background: Medication adherence is thought to be around 50% in the general and dialysis population. Reducing the pill burden (PB) reduces regime complexity and can improve adherence. Increased adherence should lead to improvement in treatment outcomes and patient quality of life. There is currently little published data on PB in CKD-5D across dialysis modalities.

Methods: This is a retrospective, single renal network study. All in-centre HD (MHD), peritoneal dialysis (PD) and home HD (HHD) patients were identified in the Greater Manchester East sector renal network. Information collected included age, sex, comorbidities, daily PB, dialysis vintage and adequacy. Data were retrieved from a customized renal database, clinic and discharge letters with cross validation from the general practitioner when needed.

Results: Two hundred and thirty-six prevalent dialysis patients were studied. HHD patients had a significantly lower PB (11 ± 7 pills/day) compared with PD and MHD (16 ± 7 pills/day). The HHD patients required fewer BP medications to meet the recommended target. HD setting was the only significant factor for reducing PB. For home therapies (HHD versus PD), weekly Kt/v and serum phosphate were significant factors influencing PB. When comparing all modalities, OR of PB ≥ 15/day for MHD versus HHD was 3.9 and PD versus HHD was 4.9. The influence of HHD is dominant above factors such as comorbidities or clinical variables in reducing PB for MHD. Higher clearances achieved by HHD could explain differences in PB with PD.

Conclusion: This is the first comparative study of PB across all dialysis modalities and factors that influence it. The PB advantage in HHD may result in greater adherence and might contribute to the outcome benefit often seen with this modality. Higher clearances achieved by HHD could explain differences in PB with PD but the precise reasons for lower PB remain speculative and deserve further research in larger settings.

Keywords: comparison; dialysis; home dialysis; pill burden.

Fig. 1.

Graph showing pill burden of different classes of medications across modalities. sHPT, secondary hyperparathyroidism medications including alfacalcidol and cinacalcet; BP, blood pressure medication including alpha-blockers, ACE Inhibitors, beta-blockers, calcium channel blockers and diuretics; CV, cardiovascular medication including anticoagulants, antiplatelets, antiarrythmics and cholesterol-lowering drugs. Non-calcium binders include sevelamer and lanthanum. Calcium binders include calcium acetate and calcium carbonate. HHD, home haemodialysis; MHD, maintenance haemodialysis; PD, peritoneal dialysis.