Dietary prescription adherence among adults with chronic kidney disease on Hemodialysis(CARTA)

Chronic kidney disease (CKD) is a global public health problem and is now on the rise gradually [1]. About 850 million people are affected worldwide. This represents 11 to 13% of the total global population [2,3,4]. In Sub-Saharan Africa, currently, about 16% of the population is affected [5], a rise from 14% reported in 2014 [6]. The prevalence of CKD in Eastern Africa is also high, currently reported at 14% [7]. Kidney disease is now ranked as the sixth fastest growing cause of mortality globally, with over 2.4 million deaths per year [8].

In CKD, the kidney functions progressively decline, leading to a decrease in glomerular filtration rate, slowdown in removal of waste from the bloodstream, and accumulation of waste in the blood as well as changes in requirements and utilization of various nutrients [9]. Dietary adaptations for key nutrients, particularly carbohydrates, proteins, sodium, potassium, phosphorus, and fluid intake, are necessary to reduce the risk for morbidity and mortality in patients with CKD [10]. For patients on hemodialysis, limiting the intake of certain foods is important in order to reduce the accumulation of these metabolic wastes in the blood and to reduce the development of comorbidities such as hypertension, proteinuria, and other health complications of the heart and bones [11]. The dietary restrictions are recommended to prevent deterioration of kidney functions and thus slowing down the risk for morbidity and mortality [10]. However, most CKD patients encounter difficulties in adjusting to the recommended diet for their disease condition. Importantly, more than 50% of the dialysis patients consumed inadequate dietary intake for most nutrients [12, 13] on one hand and excess intake of phosphorus, sodium, calcium, and potassium on the other [12]. Evidence on dietary restrictions shows that adherence is a challenge for many patients with CKD [10, 14,15,16], with more than half of adult patients with CKD not adhering to their dietary prescriptions.

The World Health Organization defines adherence as the extent to which a person’s behavior in taking medication, following a diet, and/or executing lifestyle changes corresponds with agreed recommendations for their disease condition [17]. Clark-Cutaia and colleagues in the USA [18] observed that young females had more difficulties adhering to their hemodialysis dietary regimens. In Australia, dietary change among CKD patients involves several factors including cooking skills, ability to read and comprehend food labels, and cost and availability of fresh food [14]. Adherence appears to be a multidimensional phenomenon where patient-related, condition-related, socio-economic, therapy-related, and health care-related factors [17, 19] all exert their forces on the CKD patient, contributing to non-adherence to both dietary and medication guidelines. Yet, often, it is the patient who is blamed for non-adherence. The patient-related factors, health perceptions, and psychosocial factors have also been associated with no adherence to diet and fluid recommendations among patients with end-stage renal disease in Jordan [20]. Chironda and Bhengu [21] also observed that non-adherence to dietary prescription among CKD patients in South Africa was due to inability to afford the prescribed diet and unwillingness to avoid some of the recommended foods.

Most accessible studies reporting on adherence to dietary restrictions among patients with CKD are outside the African continent [7, 22,23,24]. In Kenya, documented research on adherence to dietary prescriptions among adults with CKD on hemodialysis is either non-existent or, if there is, non-accessible. Yet, currently, over 10,000 cases are diagnosed annually with CKD in Kenya, and it is estimated that 4.8 million Kenyans will be suffering from kidney disease by 2030 [25]. According to the Kenya Renal Association, the number of patients with kidney disease undergoing chronic hemodialysis increased from 300 in the year 2006 to 2400 in 2018 [26] in Kenya. Since nutrition is the most modifiable lifestyle factor in the management of CKD, it is important that adherence to dietary prescription and the food environment factors that affect accessibility, availability, acquisition, and preparation of food in the Kenyan context are well understood in order to prescribe the most appropriate modified diet for these patients. The Kenyan food environment may not be similar to what is found in other parts of the world; hence, the proposed solutions to non-adherence problem from existing studies may not be applicable in Kenya. The aim of this study was therefore to determine factors associated with adherence to dietary prescription among adult patients with chronic kidney disease on hemodialysis in national referral and teaching hospitals in Kenya. This will guide intervention strategies during nutrition counseling.