Compliance in hemodialysis patients: Multidimensional measures in search of a gold standard

The gold standard to assess the compliance of hemodialysis (HD) patients ha s not been established. Compliance parameters should be easily measured and verified, reproducible, clearly interpretable, and accurate. They should h ave meaning for the patient, clear pathophysiological significance unrelate d to other factors, and be related to important outcomes. There is poor cor relation of subjective and objective measures and poor correlation of labor atory compliance measures. Different factors have been associated with diff erential compliance in different patient populations, depending on the meas ures assessed. Recently, behavioral measures of compliance with dialysis pr escription, such as shortening or skipping HD treatments, have been develop ed. New data confirm that many compliance measures, including both laborato ry and behavioral compliance indices, are associated with patient outcomes. It is the duty of the nephrologist and staff to make the importance of com pliance understandable to patients, It is important for the health care tea m to understand patients' expectations end attitudes about their illness an d their beliefs about the efficacy and importance of the treatment, as well as patients' demographic, medical, psychological, familial, and socioecono mic status, before realistically evaluating compliance. Such knowledge and approaches may be critical in achieving mutually agreed on compliance goals . We suggest that although assessment of indirect indices is useful, behavi oral compliance measures that quantity shortening and skipping behaviors ge nerally should be used in HD patients. Hopefully, analyses of results that control for multiple potentially confounding factors and effective interven tions to improve compliance will be developed in the near future. (C) 2001 by the National Kidney Foundation, Inc.