Date of publication: May 16, 2012

News & Views

What are the causes of patient non-adherence to hyperphosphatemia treatment? (Part I)

Non-adherence to treatment regimens in hyperphosphatemia is a significant treatment challenge, with over 50% of patients non-compliant by some measures. In this series of articles we examine the factors that contribute to this low adherence, including:

  • patient demographics;
  • patient education and guidance;
  • psychosocial factors, such as a patient’s perception of medications; and
  • drug preference, with a focus on high pill burdens and GI side effects.

Patient demographics

Clear relationships have not been found [1] between adherence and socio-demographic variables, with the exception of age: younger patients are less likely to adhere to their treatment regimens.

Suggested reasons for this finding are that younger patients may have less structured lives in which to accommodate the demands of the treatment regimen, may have more difficulty in coping with the diagnosis of a chronic condition or that they are simply more willing to report non-adherence than older patients.

Patient education and guidance

There is a growing body of evidence that supports the role of patient education and guidance in improving phosphorous control, including:

  • a structured education program [2] that led to a decrease in plasma phosphate levels at both 2 months and 12 months;
  • a randomized controlled trial [3] of an educational intervention that resulted in significantly reduced phosphate levels at 1, 2 & 3 months post-intervention compared with the control group; and
  • intensified patient education [4] resulting in a reduction in serum phosphorous at 3 months in 72% of patients.

While there are studies that correlate enhanced patient education with improved outcomes, there is limited available evidence that directly analyses the association between educational programs and hyperphosphatemia treatment adherence.

However, if we broaden our scope to dialysis patients in general, a 2010 study showed that dialysis patients appear to benefit in general from receiving comprehensive guidance about their medications. After providing patients with more detailed information on their treatments, they identified benefits in terms of compliance with the regimen and blood chemistry and hematology measures.

Given the positive association between patient education and outcomes, what level of understanding do patients currently have regarding their treatment goals and how best to achieve them? Frustratingly, data is again scarce, but a 2010 study [5] of 136 Australian hemodialysis patients showed that only 84% of patients had previously heard of phosphate, almost half were unsure of high phosphate foods and the consequences of elevated phosphate, and nearly three quarters wanted to know more about CKD-MBD, preferably through written materials.

From the available data it would be difficult to argue against the hypothesis that improving patient education has a positive impact on serum phosphorous. However, further research is needed to support the association between education and adherence as the root cause of this improvement in outcomes.

Furthermore, it would also be useful to identify which types of patient education have the most impact in improving hyperphosphatemia outcomes.

See also the previous adherence article:
May 9th 2012, “How significant an issue is non-adherence to hyperphosphatemia tretament regimes?”


1. Karamanidou C, Clatworthy J, Weinman J, Horne R. A systematic review of the prevalence and determinants of nonadherence to phosphate binding medication in patients with end-stage renal disease. BMC Nephrology. 2008;9(1):2.

2. Gardulf A, Pålsson M, Nicolay U. Education for dialysis patients lowers long-term phosphate levels and maintains health-related quality of life. Clin. Nephrol. 2011 Apr;75(4):319–27.

3. de Brito Ashurst I, Dobbie H. A randomized controlled trial of an educational intervention to improve phosphate levels in hemodialysis patients. Journal of Renal Nutrition. 2003 Oct;13(4):267–74.

4. Shaw-Stuart NJ, Stuart A. The effect of an educational patient compliance program on serum phosphate levels in patients receiving hemodialysis. J Ren Nutr. 2000 Apr;10(2):80–4.

5. Toussaint ND, Pedagogos E, Beavis J, Becker GJ, Polkinghorne KR, Kerr PG. Improving CKD-MBD Management in Haemodialysis Patients: Barrier Analysis for Implementing Better Practice. Nephrol. Dial. Transplant. [Internet]. 2010 Oct 8

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