The Effects Of A Self Management Support Program On The People With Hypertension Undergoing Maintenance Hemodialysis

Background Hypertension in maintenance hemodialysis patients is very common,with a reported prevalence as high as 70%-90%,and is controlled adequately only in 30%patients.Evidence showed that one of the factors which are associated with the low rate of control is the poor self management of hypertension.This study emerged from a need to explore an effective strategy to provide self-management support for these people.Objectives To explore the people’s experiences and views of self management who were undergoing hemodialysis with hypertension;To describe the current status of self management among these people and to analysis the association between the level of blood pressure control and self management;To assess the effects of self management support strategy on hypertensive hemodialysis patients;To explore the associations among renin-angiotensin system(RAS),volume control and blood pressure.Methods This study consisted of two parts.The first part was a qualitative research which used depth interview to collect data and analyzed the experiences of self management on hypertension.The second part of the study had three sections.In the first section,90 hypertensive hemodialysis patients were enrolled.The status of self management and the the level of blood pressure control were assessed.The predialysis blood pressure within two weeks and the home blood pressure in one week demonstrated the level of blood pressure control.Effective self management of hypertension in hemodialysis patients consisted of volume control,medication adherence and home blood pressure monitoring.The volume control was evaluated by the fluid intake indicated by the mean of interdialytic weight gain(IDWG),and the salt intake,which was measured using Body Composition Monitor and variations of serum sodium levels in between dialysis.Medication adherence was assessed using Morisky medication adherence scale,and home blood pressure monitoring was evaluated by self-administered questions.The association between the self management and blood pressure control was analyzed by SPSS 17.0.In the second section,the patients were allocated to either a nurse administered self-management support intervention(self-management education and motivational interviewing)or ordinary intervention.The duration of the intervention was one month.The level of blood pressure control and the status of self-management were assessed at the time point of 1,3 and 6 months after the intervention.In the third section,the plasma levels of RAS were measured in part of the patients to describe the changes of RAS between dialysis and to analyze the effect of volume control on RAS.Results Part one:14 patients accepted the interview.Four key themes were identified after the analysis of the qualitative data;these were:cognition is the key to self management;emotion and will are the guarantee of self management;motivation is the drive source of self management;and behavior is the externalization of self management capabilities.Part two:(1)The average salt intake of the subjects was 9.6±4.3g/d.47.7%of the patients demonstrated poor medication adherence in various degrees and only 31.1%of the patients performed standard home blood pressure monitoring.The results of correlation analysis showed that the level of blood pressure control was related with the self management of volume control and home blood pressure monitoring.(2)83 patients completed the intervention and the 6-month follow-up.The results showed that self-management support improved the status of self management and the standard of blood pressure control.It manifested that,to compare with the baseline,the patients in the self-management support group had lower salt and fluid intake(P<0.05),higher medication adherence rate(P<0.001),higher rate of home blood pressure monitoring;and lower level of blood pressure(P<0.001).The patients in the usual care group improved the rate of medication adherence rate.(3)46 patients completed the measurement of plasma renin activity and angiotensin Ⅱ.The results showed that part of the patients had significant volume-dependent hypertension(n=22)and another part of the patients had abnormal rennin activation between dialysis which demonstrated non volume-dependent hypertension(n=24).25 patients were remeasured the above indicators after 1 month of the intervention.The results illustrated that the salt restriction did not activate the renin activity.Conclusions(1)Due to lack of relevant knowledge,skills,and motivation of self management,the maintenance hemodialysis patients had various problems in self management of hypertension.(2)The standard of blood pressure control in hemodialysis patients is significantly correlated with self management and these patients have poor self management which needs further intervention.(3)Self-management support improved the status of self-management and the blood pressure control.(4)RAS was in disorder in the hemodialysis patients with hypertension.Salt restriction was safe for the hypertensive hemodialysis patients and it does not affect the rennin activity.