INTRODUCTION:

Chronic kidney disease (CKD) results in numerous illnesses and fatalities. CKD increase prevalence of End-Stage Kidney Disease (ESKD) is a growing global health problem. Many CKD patients reach ESKD and require hemodialysis.¹ Albuminuria contributes to a major nutritional deficit in CKD.² Toxic substances build up in the body, causing nutritional issues. Hemodialysis results in additional nutritional burden. Many ESKD patients are also diabetic, complicating metabolic disadvantages in them.^3,4

Clinical pharmacist is a member of healthcare professionals in the dialysis unit in some parts of the world.^5,6 The high number of prescriptions, complex instructions, and frequent changes may make it challenging for patients to manage their medication schedules. Pharmacy services were associated with better diet and clinical outcomes in hemodialysis patients has been demonstrated by several studies worldwide.^7-9

Due to financial constraints, anorexia, and dietary restrictions, many patients do not follow these guidelines. Patients on HD usually lack proper nourishment. Dietary deficiencies may negatively impact the QOL. Presence of many drugs and nutritional restrictions complicate malnutrition in ESKD patients. Nutritional interventional and ideal nutritional status are positive prognosis factors, and it is a multidisciplinary approach.^10-15

A pharmacy professional counsel the patients in addition to the nutritionist might add value to ideal nutritional habits of patients on hemodialysis. This integrated approach of building on nutritionist services could potentially lead to improved medication adherence, better management of drug-related problems, enhanced nutritional status, and overall better health outcomes for hemodialysis patients. Thus the objective of this study was to evaluate the impact of clinical pharmacy researcher counseling of hemodialysis patients.

MATERIALS AND METHODS:

Research design:

The research was a pre-post intervention study. Patients undergoing maintenance hemodialysis at a tertiary-level care hospital in the United Arab Emirates was the study population. Counseling was performed by clinical pharmacy researcher in consultation with nutritionist, following nutritional recommendations at the study site.

Nutritional behaviors were assessed based on ideal or not ideal practice by interviewing the patients. Patients were counselled to improve their nutritional behaviors. Drug-drug and food-drug interactions were assessed in the study population with other pertinent parameters. Nutritionist guidelines at the study site was used as a framework for the counseling. Though the study was aiming to find impact of clinical pharmacist researcher, it was a real-life interventional study in addition to the existing care by nutritionist and other healthcare professionals on routine care of the study population.

Study population:

This is a population-based study. All hemodialysis patients at the study site were screened and enrolled based on inclusion and exclusion criteria. So, sampling or sample size calculation was not done. Patients with maintenance hemodialysis and willing to participate in the study were included.

Study settings:

The study was conducted among patients attending the Hemodialysis Unit at a University Hospital Ajman, United Arab Emirates (UAE). This unit in considered as one of the largest hemodialysis unites among the UAE in the private sector hospitals. The University Hospital is the largest private academic hospital in the country, with a capacity of 350 beds. Number of HD machines for patient care at the HD unit was 9, plus one machine reserved of patients with active infections.

Ethical issues:

Patient confidentiality and privacy were maintained. No patient identifiers were processed further in the data analysis. The study was approved by the Institutional Review Board approval from the University in Ajman, UAE. The approval was dated November 19, 2020, Ref No. IRB/COP/STD/07/Nov-2020. The principles of the Helsinki Declaration were followed in this research.

Data collection:

The data collection and counseling interventions happened between February to June 2023, in the first month nutrition intake data with regard to the research was collected from the participants. Next two month were spent for counseling the patients one or two times as needed for individual case. Each counseling session was typically 15-20 minutes. The post-intervention data were collected on fifth month giving a gap of fourth month with no counseling. Simultaneously, drug interactions were also checked and informed to the treating physician.

Data were collected before and after nutritional counseling sessions. The counseling sessions focused on improving dietary habits and behaviors, adhering to ideal and non-ideal practices for specific categories such as fluid intake, egg consumption, fish and meat preferences, and employing proper cooking techniques. In fluid intake the ideal use for most people on hemodialysis are limited to approximately 1 to 1.5 milliliters of fluids per day. In egg intake the ideal use for patients on hemodialysis is taking only egg white not the whole egg and should be boiled. In fish and meat the ideal use for patients if they are taking high protein fish like salmon or tuna and for the meat if they are eating red meat so that’s ideal. In following good cooking methods patients should include boiling in water. After nutrition education and counselling, Assessing the Food-Drug, Drug-Drug interactions and malnutrition symptoms was done for each patient to compare before and after counselling. For example, in food-drug interactions Concurrent use of iron and dairy foods may result in decreased iron bioavailability and absorption, concurrent use of clopidogrel and grapefruit juice may result in reduced exposure of the active clopidogrel metabolite and concurrent use of calcium and phytic acid foods may result in decreased calcium effectiveness. Regarding malnutrition symptoms, factors like nausea, vomiting, muscle twitches, cramps, fatigue, and weakness were collected and documented.

Data analysis:

Raw data were processed on a Microsoft Excel file for numbers percentages and graphs. Multiple tests were planned and conducted to find association or difference between different variables. SPSS version 26 was used in data analysis. P-value was set less than 0.05 for significance.

RESULTS:

The study flow diagram is shown in Figure 1 from number of patients screened to those who were included and followed-up in the study.

Figure 1. Study flow diagram

When examining hemodialysis duration among participant’s data showed that one sixth (17.0%) had been undergoing hemodialysis for than a year roughly one fifth (19.1) had been doing so for between one and two years, and nearly two thirds (63.8) had undergone hemodialysis for over two years (Table 1).

Table 1. Demographic Characteristics of the Participants (n=47)

Demographic Characteristics		N (%)
Gender	Female	13 (28.0)
Gender	Male	34 (72.0)
Mean age (±SD) years	54.3 (±12.7)
Age (years)	Less than 40	8 (17.0)
	40-59	18 (38.3)
	60 and above	21 (44.7)
Mean BMI (±SD)	27.8 (±5.8)
BMI kg/m2	Underweight Less than 18.4	2 (4.3)
	Normal 18.5 - 24.9	15 (31.9)
	Overweight 25 - 29.9	13 (27.7)
	Obese 30 and above	17 (36.2)
Number of Medications	Five or less	15 (31.9)
	6-10	21 (44.7)
	More than ten	11 (23.4)
Duration of hemodialysis patients	Less than one year	8 (17.0)
	1-2 years	9 (19.1)
	More than two years	30 (63.8)
Number of Malnutrition Symptoms	Two symptoms or less	23 (48.9)
Number of Malnutrition Symptoms	Three and more	24 (51.1)

Among the participants, 21 patients (45%) exhibited comorbid hypertension without diabetes, while 26 patients (55%) presented the combined comorbidity of hypertension with diabetes. About 30 participants (64%) undergo two dialysis sessions per week while the remaining 17 participants (36%) have three sessions weekly.

The study participants were experiencing more numbers of food-drug interactions than drug-drug Interactions with P 0.001. More numbers of food-drug interactions were observed in the participants with more malnutrition symptoms and longer duration of dialysis years P 0.001 and P 0.004 respectively. All these patterns were associated based on Pearson’s Chi-Square test.

Table 2 presents an analysis of food type usage before and after the counseling intervention aimed at promoting ideal nutritional practices among 47 study participants. The food types assessed include Fluid, Egg, Fish and Meat, and Fruits and Vegetables. The data is divided into two categories: "Not ideal use" and "Ideal use," indicating participants' perceptions on their use of recommended nutritional practices. The data shows significant improvements in food type usage after the intervention, with a noticeable shift towards the ideal use across all food categories. The P-values show the statistical significance of these changes with <0.001.

Table 2. Ideal diet before and after intervention

Food Type	Before the intervention N (%)		After the intervention N (%)		P value
Food Type	Not ideal use	Ideal use	Not ideal use	Ideal use	P value
Fluid	34 (72.0)	13 (28.0)	14 (30.0)	33 (70.0)	<0.001*
Egg	24 (51.0)	23 (54.0)	9 (19.0)	38 (81.0)	<0.001*
Fish and Meat	32 (68.0)	15 (32.0)	8 (17.0)	39 (83.0)	<0.001*
Fruits and Vegetable	34 (72.0)	13 (28.0)	8 (17.0)	39 (83.0)	<0.001*

*McNemar’s test

DISCUSSION:

The study population was obviously malnourished and were in need of additional nutritional counseling. The counseling intervention by the pharmacy professional was impactful in shifting not ideal diet to ideal diet in the study participants’ perception. Malnutrition is a common and critical issue in CKD, associated with poor clinical outcomes, increased mortality, and impaired quality of life. Nutritional counseling and intervention are critical components of CKD management to address malnutrition and improve patient well-being.^16-21

Comorbidities like diabetes mellitus and hypertension interfere with early detection, regular monitoring, and lifestyle modifications in CKD. Patients with ESKD suffer from malnutrition aggravated by their comorbidities and multiple medications required. Personalized treatment and nutritional plans tailored to each patient's condition.^22,23

Additionally, the presence of food-drug interactions highlights the complexity of managing drug therapy in hemodialysis patients. These interactions may be linked to dietary restrictions common in CKD management, such as restrictions on potassium, phosphorus, and sodium intake. Therefore, a holistic approach to patient care should encompass not only medication reconciliation but also dietary guidance to optimize treatment outcomes. Thus, pharmacists need to care for hemodialysis patients, considering not only their medications but also their nutritional status and individual characteristics. Tailored interventions, regular assessments, and interdisciplinary collaboration by pharmacists joining healthcare providers are essential to optimize patient care.^24-30

Majority of participants displayed non-ideal usage patterns, with a high percentage of them not meeting recommended dietary guidelines. Patients in ESKD might need multiple reinforcements in their nutritional support.^31,32 The positive changes in food type usage by patients were identified in studies. More research is required on how to sustain ideal nutritional habits in patients on maintenance hemodialysis.

This study has several limitations: The study findings are to be read in consideration to its limitations. Hawthorne effect is possible patients reporting ideal practices when asked multiple times (pre, while, and post counseling). The study was useful only to explore the potential as we did not use standard counseling protocols, making the study and interview questions semi-structured for the intervention being more real life and natural to the patients in study. Though some credits were attributed to clinical pharmacy researcher’s counseling, it in addition to the existing care patients receive from other healthcare professionals.

CONCLUSION:

Nutritional patient counseling by a pharmacy professional was found to be impactful in improving ideal nutritional practices among patients studied. Along with the care provided by healthcare professionals, an addition of a nutritional clinical pharmacy service was found to be useful. Food-drug interactions were found more than drug-drug interactions, there was also association between more numbers of patients food-drug interactions having more malnutrition symptoms. The study recommends regular pharmacy services for nutritional counseling services among maintenance hemodialysis patients and find ways to sustain ideal nutritional behaviors.

REFERENCES:

1. Murton M, Goff-Leggett D, Bobrowska A, Garcia Sanchez JJ, James G, Wittbrodt E, Nolan S, Sörstadius E, Pecoits-Filho R, Tuttle K. Burden of chronic kidney disease by KDIGO categories of glomerular filtration rate and albuminuria: a systematic review. Advances in Therapy. 2021; Jan; 38: 180-200. doi: 10.1007/s12325-020-01568-8.

2. Ayav C, Beuscart JB, Briançon S, Duhamel A, Frimat L, Kessler M. Competing risk of death and end-stage renal disease in incident chronic kidney disease (stages 3 to 5): the EPIRAN community-based study. BMC Nephrology. 2016; Dec; 17: 1-3. doi: 10.1186/s12882-016-0379-3

3. Cunillera-Puértolas O, Vizcaya D, Cerain-Herrero MJ, Gil-Terrón N, Cobo-Guerrero S, Salvador-González B. Cardiovascular events and mortality in chronic kidney disease in primary care patients with previous type 2 diabetes and/or hypertension. A population-based epidemiological study (KIDNEES). BMC Nephrology. 2022; Nov 23; 23(1): 376. doi: 10.1186/s12882-022-02966-6.

4. Afghahi H, Nasic S, Rydell H, Svensson J, Peters B. The association between long-term glycemic control and all-cause mortality is different among older versus younger patients with diabetes mellitus and maintenance hemodialysis treatment. Diabetes Research and Clinical Practice. 2022; Sep 1; 191: 110033. doi: 10.1016/j.diabres.2022.110033.

5. Dyer SA, Nguyen V, Rafie S, Awdishu L. Impact of medication reconciliation by a dialysis pharmacist. Kidney360. 2022; May 26; 3(5): 922-5. doi: 10.34067/KID.0007182021.

6. Snoswell CL, Cossart AR, Chevalier B, Barras M. Benefits, challenges and contributors to the introduction of new hospital-based outpatient clinic pharmacist positions. Exploratory Research in Clinical and Social Pharmacy. 2022; Mar 1; 5: 100119. doi: 10.1016/j.rcsop.2022.100119.

7. Cardone KE, Maxson R, Cho KH, Davis JM, El Nekidy WS, Kane-Gill SL, McNamara A, Wazny L, Wong L, Battistella M. Pharmacy practice standards for outpatient nephrology settings. Kidney Medicine. 2022; Aug 1; 4(8): 100509. doi: 10.1016/j.xkme.2022.100509.

8. Ravi P, Pfaff K, Ralph J, Cruz E, Bellaire M, Fontanin G. Nurse-pharmacist collaborations for promoting medication safety among community-dwelling adults: A scoping review. International Journal of Nursing Studies Advances. 2022; Dec 1; 4: 100079. https://doi.org/10.1016/j.ijnsa.2022.100079

9. Hegazy IS, El Raghy HA, Abdel Aziz SB, Elhabashi EM. Study of the effect of dietary counselling on the improvement of end-stage renal disease patients. EMHJ-Eastern Mediterranean Health Journal. 2013; 19 (1); 45-51.

10. Dwyer JP, Kelepouris E. New directions in phosphorus management in dialysis. Journal of Renal Nutrition. 2023; Jan 1; 33(1): 12-6. doi: 10.1053/j.jrn.2022.04.006.

11. Lee MJ, Doh FM, Kim CH, Koo HM, Oh HJ, Park JT, Han SH, Yoo TH, Kim YL, Kim YS, Yang CW. Interdialytic weight gain and cardiovascular outcome in incident hemodialysis patients. American Journal of Nephrology. 2014; May 10; 39(5): 427-35. doi: 10.1159/000362743.

12. Visiedo L, Rey L, Rivas F, López F, Tortajada B, Giménez R, Abilés J. The impact of nutritional status on health-related quality of life in hemodialysis patients. Scientific Reports. 2022 Feb 22; 12(1): 3029. doi: 10.1038/s41598-022-07055-0.

13. D’Alessandro C, Benedetti A, Di Paolo A, Giannese D, Cupisti A. Interactions between food and drugs, and nutritional status in renal patients: a narrative review. Nutrients. 2022; Jan 4; 14(1): 212. doi: 10.3390/nu14010212.

14. Adhikari UR, Taraphder A, Hazra A, Das T. Is there an association between medication knowledge and medication compliance in renal transplant recipients?. Asian Journal of Nursing Education and Research. 2016; 6(1): 32-6. doi: 10.5958/2349-2996.2016.00007.0

15. Mary SA, Jaikumar M. Effectiveness of Structured Teaching Programme Regarding Risk Factors and Prevention of Renal Failure Among Adults in Selected Hospitals at Bangalore, Karnataka. Asian Journal of Nursing Education and Research. 2018; 8(1):149-51.doi: 10.5958/2349-2996.2018.00031.9

16. Patidar K, Patidar K. A Study to Assess the Effectiveness of Planned Teaching Programme on Knowledge regarding Dietary Awareness to reduce the risk of Renal Stones among the People of Mehsana City. Asian Journal of Nursing Education and Research. 2019;9(3):379-82.doi: 10.5958/2349-2996.2019.00081.8

17. Pandey N. A Study to assess the Knowledge and Attitude regarding risk factors and prevention of Renal calculi among patients admitted in the selected kidney Hospitals of Gujarat state with a view to Develop an Information Booklet. Asian Journal of Nursing Education and Research. 2019; 9(3): 445-8. doi: 10.5958/2349-2996.2019.00093.4

18. Aggarwal S, Kaur JP, Devi CG. A Study to assess the level of stress among significant family members of patients with end stage Renal Failure undergoing Hemodialysis in selected hospitals of Punjab. International Journal of Advances in Nursing Management. 2018; 6(3): 171-4. doi: 10.5958/2454-2652.2018.00039.2

19. Hapipa HU, Bhuvaneswari S. Effectiveness of self-Instructional module on knowledge regarding post dialysis home care among care givers of chronic renal failure patients undergoing Haemodialysis in Karthik Hospital at Sivagangai. International Journal of Advances in Nursing Management. 2020; 8(3): 191-3. doi: 10.5958/2454-2652.2020.00045.1

20. Duzalan ÖB, Cosar AA, Sarikaya S. Hemodialysis Patients' experiences of diet and fluid restriction: A qualitative study. Progress in Nutrition. 2021; 23: e2021254. doi 10.23751/pn.v23iS2.11985

21. Rahman T, Ahmed S, Kabir MR, Akhtaruzzaman M, Mitali EJ, Rashid HU, Daud ZM, Khor BH, Kaur D, Khosla P. Provision of renal-specific nutrition knowledge for changing dietary practice in Bangladeshi hemodialysis patients. PEC Innovation. 2022; 1: 100028. doi: 10.1016/j.pecinn.2022.100028.

22. Joshi S, Kalantar-Zadeh K, Chauveau P, Carrero JJ. Risks and Benefits of Different Dietary Patterns in CKD. Am J Kidney Dis. 2023; 81(3): 352-360. doi: 10.1053/j.ajkd.2022.08.013.

23. D'Alessandro C, Benedetti A, Di Paolo A, Giannese D, Cupisti A. Interactions between Food and Drugs, and Nutritional Status in Renal Patients: A Narrative Review. Nutrients. 2022; 14(1): 212. doi: 10.3390/nu14010212.

24. Srinivassan K. A descriptive study to assess the knowledge on dietary management among chronic renal failure patients undergoing hemodialysis at selected hospital, Kanchipuram. International Journal of Nursing Education and Research. 2014; 2(3): 241-4.

25. Jesna JK, Resmi SP, Gnanadurai A, Anand MK. Effect of Video assisted teaching on knowledge and practice for prevention of Hypertensive renal diseases among patients with hypertension. International Journal of Advances in Nursing Management. 2021; 9(2): 216-21. doi: 10.5958/2454-2652.2021.00049.4

26. John L. A Study to assess the Renal Dietary Adherence among Patients undergoing Hemodialysis in selected Hospital, Bangalore with a view to develop Informational Pamphlet. International Journal of Nursing Education and Research. 2017; 5(4): 356-8. doi: 10.5958/2454-2660.2017.00074.6

27. Al-Baghdadi DD, Rajha A. Quality of life for hemodialysis patients with chronic renal failure. Research Journal of Pharmacy and Technology. 2018; 11(6): 2398-403. doi: 10.5958/0974-360X.2018.00443.2

28. Hammar T, Hamqvist S, Zetterholm M, Jokela P, Ferati M. Current Knowledge about Providing Drug-Drug Interaction Services for Patients-A Scoping Review. Pharmacy (Basel). 2021; 9(2): 69. doi: 10.3390/pharmacy9020069

29. Olumuyiwa JF, Akinwumi AA, Ademola OA, Oluwole BA, Ibiene EO. Prevalence and pattern of potential drug-drug interactions among chronic kidney disease patients in southwestern Nigeria. Niger Postgrad Med J. 2017; 24(2): 88-92. doi: 10.4103/npmj.npmj_64_17.

30. Fasipe OJ, Akhideno PE, Nwaiwu O, Adelosoye AA. Assessment of prescribed medications and pattern of distribution for potential drug-drug interactions among chronic kidney disease patients attending the Nephrology Clinic of Lagos University Teaching Hospital in Sub-Saharan West Africa. Clin Pharmacol. 2017; 9: 125-132. doi: 10.2147/CPAA.S147835.

31. Slee A, Reid J. Disease-related malnutrition in chronic kidney disease. Curr Opin Clin Nutr Metab Care. 2022; 25(3): 136-141. doi: 10.1097/MCO.0000000000000830.

32. Palmer SC, Maggo JK, Campbell KL, Craig JC, Johnson DW, Sutanto B, Ruospo M, Tong A, Strippoli GF. Dietary interventions for adults with chronic kidney disease. Cochrane Database Syst Rev. 2017; 4(4): CD011998. doi: 10.1002/14651858.CD011998.pub2.

Received on 21.03.2024 Modified on 11.06.2024

Research J. Pharm. and Tech 2024; 17(10):4856-4860.

DOI: 10.52711/0974-360X.2024.00747