Journal of Pharmacy And Bioallied Sciences

ORIGINAL ARTICLE
Year
: 2016  |  Volume : 8  |  Issue : 1  |  Page : 52--57

Usage of complementary and alternative medicine among patients with chronic kidney disease on maintenance hemodialysis


Aravapalli S. M. Arjuna Rao1, D Phaneendra1, Ch. Divya Pavani1, P Soundararajan2, N Vanitha Rani1, P Thennarasu1, G Kannan3,  
1 Department of Pharmacy Practice, Faculty of Pharmacy, Sri Ramachandra University, Chennai, Tamil Nadu, India
2 Department of Nephrology, Sri Ramachandra Medical College, Sri Ramachandra University, Chennai, Tamil Nadu, India
3 Department of Pharmacy Practice, Saastra College of Pharmaceutical Education and Research, Nellore, India

Correspondence Address:
N Vanitha Rani
Department of Pharmacy Practice, Faculty of Pharmacy, Sri Ramachandra University, Chennai, Tamil Nadu
India

Abstract

Aim: To determine the prevalence and the type of complementary and alternative medicine (CAM) use among chronic kidney disease (CKD) patients on maintenance hemodialysis (MHD). Materials and Methods: The study was conducted in 200 CKD patients who were on MHD. The patients were subjected to a validated interviewer-administered questionnaire adopted from the National Health Interview Survey Adult CAM. The knowledge on CAM and its usage by the patients were assessed based on the responses given by the patients. Results: Of the 200 patients, 52 (26%) patients were identified to be using CAM therapy. The most commonly used CAM modality by these patients was Ayurveda both alone (30.4%) and in combination with other CAM modalities (23.2%), followed by acupuncture in 17.3% patients. CAM usage was high in the age range of 50–64 years (67%). Of the CAM users, 21% of patients were from a rural area; 16.5% of patients were from upper middle class, and 24% were on dialysis for 1–4 years. There was a statistically significant association between CAM usage and age, gender, place of living, socioeconomic status, and duration of dialysis (P < 0.01). Conclusion: The present survey provides the data on the usage of CAM among dialysis patients and adds to the increasing evidence about CAM use. Because many products are at risk to either accumulate or cause interactions with medication, a better education on the risks and benefits of the CAM therapy by the health care providers to the end stage renal disease patients is needed.



How to cite this article:
Arjuna Rao AS, Phaneendra D, Pavani C, Soundararajan P, Rani N V, Thennarasu P, Kannan G. Usage of complementary and alternative medicine among patients with chronic kidney disease on maintenance hemodialysis.J Pharm Bioall Sci 2016;8:52-57


How to cite this URL:
Arjuna Rao AS, Phaneendra D, Pavani C, Soundararajan P, Rani N V, Thennarasu P, Kannan G. Usage of complementary and alternative medicine among patients with chronic kidney disease on maintenance hemodialysis. J Pharm Bioall Sci [serial online] 2016 [cited 2019 Aug 21 ];8:52-57
Available from: http://www.jpbsonline.org/text.asp?2016/8/1/52/171692


Full Text



Chronic kidney disease (CKD) is a slowly progressive irreversible condition. The incidence and prevalence of CKD are increasing, posing it to be a worldwide public health problem leading to poor outcomes and high economic burden. The clinical complications of CKD include not only renal failure but also renal anemia, renal osteodystrophy, and cardiovascular diseases (CVDs).

Majority of the Indian population suffer from chronic diseases such as diabetes or hypertension, both of which if not being well-controlled may lead to renal impairment (nephropathy) slowly progressing to CKD.

According to the National Kidney Foundation classification, the stage at which the glomerular filtration rate is <15 ml/min is called the Stage V of CKD or end stage renal disease (ESRD) where the treatment option is dialysis or transplantation.[1],[2] In India, the prevalence of ESRD has increased in the past two decades, emerging as a global threat with significant morbidity and mortality and a significant decline in the patients' overall quality of life (QOL). Despite significant medical advances over several decades, the survival of patients on maintenance hemodialysis (MHD) remains drastically shorter than the general population.[3]

Complementary and alternative medicine (CAM) may provide new therapeutic options for the patients with CKD progressing to ESRD with the goal of improving symptoms and QOL. CAM, as defined by National Centre for CAM (NCCAM), is “a group of diverse medical and health care systems, practices, and products that are not generally considered to be a part of conventional medicine.” The most commonly used CAM modalities include biologically based products (herbs, dietary supplements, Siddha, Unani, Homeopathy, and Ayurveda).[4]

Complementary medicine

Complementary medicine is used together with conventional medicine. An example of a complementary therapy is using aromatherapy to help lessen a patient's discomfort following surgery.

Alternative medicine

Alternative medicine is used in place of conventional medicine. An example of an alternative therapy is using a special diet to treat cancer instead of undergoing surgery, radiation, or chemotherapy that has been recommended by a conventional doctor.

The CAM modalities are classified based on CAM classification of the NCCAM as following:

Alternative medical systems (acupuncture, Homeopathy, Ayurveda, Siddha, and Unani) Mind-body interventions (relaxation techniques, spiritual healing/prayer, hypnosis, meditation, yoga) Biologically based therapies (herbal therapy, dietary supplements) Manipulative and body-based methods (massage therapy, exercise, chiropractic, or osteopathy) Energy therapies (energy healing, Reiki).

Alternative medical systems

HomeopathyA system that used highly diluted doses of a substance that causes symptoms to enable the body's self-healing response.

Ayurveda medicineA medical system from India that originated in the 5th Century A.D. It focuses on a customized treatment based on the individual using practices such as yoga, meditation, massage, diet, and herbs.

NaturopathyA philosophy that utilizes noninvasive treatments to help the body heal itself. Practices utilized include massage, herbal remedies, exercise, and lifestyle counseling.

Ancient medicineThese included Chinese, Asian, Pacific Islander, and American Indian and Tibetan practices. Chinese medicine, for example, includes treatments such as acupuncture, qigong, herbal medicine, exercise, and breathing techniques.

Mind-body interventions

Mind-body medicine works to use the mind to affect the body and its physical symptoms. The premise is that the mind and body must be in harmony to stay healthy. Examples include psychotherapy, guided imagery, meditation, prayer and mental healing, hypnosis, dance, music, and art therapy. Some mind-body practices systems that were once considered CAM are now in mainstream including support groups and cognitive-behavioral therapy.

Biologically based treatments

These treatments utilize natural but unproven products such as herbs, minerals, and hormones to promote health. Examples include specialized diets (e.g., macrobiotics), dietary supplements, and herbal therapies. However, many of these treatments are scientifically unproven, and can be harmful, particularly from interactions with other medication.

Manipulative and body-based methods

These practices are based on manipulation: “The application of controlled force to a joint, moving it beyond the normal range of motion in an effort to aid in restoring health."

Examples include chiropractic care, osteopathic manipulation, massage therapy, pressure point therapies, rolfing, polarity therapy, and craniosacral therapy.[5]

Energy therapies

Energy medicine practitioners believe an invisible energy force flows through the body. When this force becomes blocked or unbalanced, it manifests physical illness. This force has been referred to as Chi, Prana, and the life force. The goal of these therapies is to correct this blockage. The field is divided into two areas: Biofield and bioelectromagnetic-based therapy. Biofield therapies, work to “affect the energy fields that purportedly surround and penetrate the human body through applying pressure or manipulating the body by placing the hands in or through these fields.” Examples include Qigong, Reiki, and therapeutic touch therapy. Bioelectromagnetic therapies utilize magnetic, pulsed, or direct current fields for healing.[4]

Though patients with CKD turn to CAM for controlling the symptoms and coping with the disease to combat the chronic nature of the disease and the potential threat posed by renal failure on QOL, the data on the use of CAM among CKD patients remain insufficient.[6],[7],[8] The reason for this is to some extent, the usage of CAM modalities by the CKD patients without the knowledge of the health care team.[9]

Studies that have examined the prevalence of CAM use in patients with CKD revealed that 18% of dialysis patients had used or were using some form of alternative medicine and an additional 63% of patients were willing to use CAM.[10] A regular usage of CAM was reported by 57% of dialysis patients and 49% of transplant patients in another study.[11] In Turkey, 68.8% of the HD patients have insufficient knowledge of CAM even though 49.4% of them were using CAM.[12]

The health care team should play a vital role in identifying CAM use among their patients, the adverse effects of CAM and its possible complications. They should be aware of educational needs of their patients and be prepared for open communication regarding CAM by initiating open discussions and questioning the patients about the use of these products. In order to achieve this, a thorough knowledge of CAM modalities is needed for the health care providers to advise patients appropriately and to discuss safe and effective treatments with patients.[13],[14],[15],[16],[17],[18]

 Materials and Methods



A cross-sectional study was carried out in the dialysis unit of a tertiary care hospital for a period of 6 months. The sample size was determined based on the literature [10],[19],[20] and 200 CKD patients aged above 18 years, who were on MHD and consenting to participate in the study were included in the study. After obtaining the approval of Institutional Ethics Committee, the data on patient demographics (age, sex, socioeconomic status, educational status, and occupational status), disease-related information (past medical history, medication history, comorbidities, and duration of dialysis) were collected from the patients' case files and by direct history interview of the patients in a data collection form specially designed for this study. Based on the Kuppuswamy scale,[18] the socioeconomic status of the patients was categorized as Class I (upper), Class II (upper middle), Class III (lower middle), Class IV (lower/upper lower), and Class V (lower); the educational status was categorized as illiterates, with primary school education, high school education and graduates, and the occupational status of the patients was categorized as employed, self-employed, skilled, unskilled, professional, and unemployed.

A validated interviewer-administered questionnaire adopted from the National Health Interview Survey Adult CAM Supplement (NHISAC) was used for the study, to assess the CAM use among study population after obtaining due permission from the author.[21]

The CAM modalities were described to the study population. The patients who acknowledged of using CAM were questioned about the CAM modalities used, the reason for using CAM, the duration and frequency of CAM usage, expectation from CAM modalities, and whether any side effects or toxicity related to the treatment occurred.

NHISAC questionnaire

It is a six-item questionnaire and the first section of the questionnaire consists of the patients' demographics and patients' disease-related information. The first question is regarding the usage of any CAM modalities, and it gives the information regarding any CAM usage in subjects. The second question is about the usage of any herbal products in specific. The third question gives the information on mind and body practices adopted by subjects. The fourth question is to know whether the subjects are interested in the usage of CAM. If the patients agree that they are interested, then the fifth question is asked to know the reason for their interest in CAM. The sixth question is to know the willingness of the patients to use CAM with the knowledge of the physician. Patients' responses to each question are obtained as “Yes” or “No."

The applicability of the questionnaire was assessed statistically using Cronbach's Alpha, and a value of 0.76 was obtained (0.5–0.6 was considered poor and above 0.6 was considered acceptable).

Statistical analysis

The collected data were tabulated and the baseline characteristics like patient demographics (age, gender, socio-economic status, educational status, occupational status, and place of living), severity of disease, duration of dialysis, and comorbidities were expressed as descriptive statistics. The duration and frequency of CAM usage were expressed as mean and standard deviation. The influence of age, gender, socioeconomic status, educational status, occupation, the disease conditions, duration of illness, and the comorbidities in the usage of CAM was assessed using Chi-square test. A P < 0.05 was considered statistically significant.

 Results



The study included 200 patients (120 males and 80 females) with the mean age of 48.92 ± 13.52 years. The age and gender distribution of the study population is depicted in [Table 1]. The majority of the patients were in the age range of 50–64 years (47.5%), followed by 35–49 years (25.5%).{Table 1}

Of 200 patients subjected to the NHISAC questionnaire, 52 (26%) patients reported of using some type of CAM and 148 (52%) patients did not report the usage of any type of CAM. [Table 2] depicts the response of the study population on the CAM usage questionnaire. Of 200 patients, 52 responded as “Yes” and 148 responded as “No” for question 1 (have you ever used any of the CAM modalities for your health?); 9 responded as “Yes” and 191 responded as “No” for question 2 (Have you ever used natural herbs or dietary supplements for your health?); 3 responded as “Yes” and 187 responded as “No” for question 3 (have you ever used any of the mind-body techniques for your health?); 149 responded as “Yes” and 51 responded as “No” for question 4 (Would you be interested in learning mind-body techniques at no cost to you?); 160 responded as “Yes” and 40 responded as “No” for question 6 (If your doctor agreed, would you be interested in a study that would teach you mind-body techniques that you would practice during dialysis?).{Table 2}

The types of CAM used by the 52 patients identified with CAM usage were as follows: 16 (30.4%) patients on Ayurveda, 9 (17.3%) patients on acupuncture, 7 (13.4%) on herbal therapy, 10 (19.2%) on Ayurveda + acupuncture, 2 (4%) patients each on a combination of Siddha and Homeopathy, one patient each on combination of Ayurveda + Siddha and Ayurveda + Homeopathy. There were 4 (7.6%) patients using mind-body practices. In our study, Ayurveda was found to be the most commonly used CAM type both alone and in combination with other systems of CAM [Table 3].{Table 3}

[Table 4] describes the duration of CAM usage. Of 52 patients using CAM, 17 (32%) patients were found to be using some type of CAM for 1–6 months, 19 (36.5%) patients were using for 6 months–1 year, 13 (25%) patients were using for 1–2 years, and 3 (5.7%) patients were using for 2–3 years. The majority of patients were using CAM for 6 months–1 year.{Table 4}

[Table 5] shows the influence of baseline characteristics of study population on the usage of CAM therapy. Of the 52 patients using CAM, the majority were found to be in the age range of 50–64 years. Age and gender had a statistically significant influence on CAM usage (P = 0.009 and 0.01, respectively). Similarly, duration of dialysis also had a significant influence on CAM usage (P = 0.009). CAM usage was found to be significantly higher among patients living in the rural area than in patients dwelling from an urban area (P = 0.046). Socioeconomic status of the patients also had a statistically significant influence on CAM usage (P = 0.01) whereas the occupational status, educational status, and marital status did not have any statistically significant impact on CAM usage (P = 0.526, 0.655, and 0.582, respectively).{Table 5}

 Discussion



The present study was conducted in 200 patients undergoing MHD in the dialysis unit. Of the 200 patients, 52 (26%) patients were identified to be using CAM therapy based on their responses toward the CAM questionnaire. The most common CAM modality used by these patients was Ayurveda both alone and in combination with other CAM modalities.

In our study, the majority of the patients identified as CAM users were in the age range of 50–64 years (67%) and the prevalence of CAM usage was also high among this age range. This finding was similar to the reports of a study done by Birdee et al.[20] which showed that the usage of CAM was more among middle-aged (50–64 years) patients compared to other age groups. The prevalence of CKD is more in this age group due to a higher incidence of chronic diseases like diabetes and hypertension.[22]

Use of CAM varies by sex, race, geographic region, socioeconomic status, duration of disease, use of cigarettes or alcohol, and hospitalization, etc. In our study, we analyzed the usage of CAM according to age, gender, educational status, socioeconomic status, occupational status, place of living, marital status, and duration of dialysis. Demographic factors like age, gender, place of living, and socioeconomic status, and duration of dialysis were found to have significant influence on CAM usage whereas educational status, occupational status, and marital status had no impact on CAM usage. The most important reason for CAM usage among the users was found to be the socioeconomic constraints, duration of illness and the co-morbidities.

There may be a difference in results between different studies among CAM usage which could be attributed to the differences in the study population, the geographical location of the various studies, or to the fact that patients using CAM were hesitant to tell the fact to others, and mostly to the physicians. Two studies have reported the reasons for not disclosing to the physicians about CAM usage which included fear of physicians' disapproval and physicians not enquiring about their CAM usage.[23],[24]

In our study population, 26% of patients on MHD reported the use of CAM which was found to be similar as that found by Akyol et al.[19] in HD and/or transplantation patients. In India, there is a paucity of data on the use of CAM among MHD patients. While most of the studies conducted by the National Surveys of some countries to identify the patterns of CAM usage have focused only on chronic diseases like diabetes, arthritis, and CVDs,[24] very few surveys have reported CAM prevalence among patients with ESRD. A survey conducted in Cincinnati on 153 patients receiving both HD and peritoneal dialysis reported 18.3% of CAM usage and a survey on 356 renal transplant patients reported 12% prevalence of CAM usage. However, these studies did not focus on mind-body practices which are the most commonly used CAM therapy modalities by the Western population.[13],[25],[26],[27],[28]

Our study identified Ayurveda as the most commonly used CAM therapy. Mind-body practices were also identified in 7.6% of the study population, and there was a positive perception of and willingness among 30% patients to learn mind-body practices during HD, of which 21% was among CAM users. As the mind-body practices are known to produce relaxing effects and distinct physiological, functional, and psychological changes among patients on MHD, there is physical and mental involvement during such practices.

In our study, none of the 52 patients using CAM reported of any toxic effects due to CAM therapy during the study. Since the study patients were not followed up for a longer duration and the frequency of CAM usage by these patients was not obtained, long-term toxicities associated with CAM usage in these patients were not thoroughly assessed. The use of many herbal products in the treatment of CKD patients is not safe because of their possible side effects. The renal failure affects pharmacokinetics through changes in absorption, distribution, metabolism, and elimination of drugs. In addition, as CKD patients use many drugs for different complications at the same time, the interactions between drug–drug and drug–herb are more complex. The use of CAM (herbal products) in CKD patients seems to be especially harmful because of reasons such as nephrotoxicity, hemodynamic changes, and unpredictable effects on blood pressure, blood glucose, and coagulation parameters or because of electrolyte abnormalities.[14] The risk for undesirable effects of CAM usage is mainly due to the fact that most patients do not inform the health professionals of their use of CAM. The above-mentioned issues reveal that the health care professionals should be well-informed about the possible side effects of herbal treatments, and they in turn should alert the patients on these issues through proper patient education.

Our study has provided an insight for the health care providers into the CAM usage in CKD patients. An elaborate research on the usage of CAM therapies, their frequency of usage, the interactions between the CAM and the prescribed medications among patients with CKD on MHD patients is the need of the hour.

 Conclusion



The present study identified CAM usage in 26% of the CKD patients on MHD, and Ayurveda was found to be the CAM type most commonly used by these patients. Age and socioeconomic status of the patients were the significant influencing factors for CAM usage. The majority of the patients using CAM were found to be using it for around 1 year, and they were also very hesitant to disclose about CAM usage to their physicians. The health care team should take an active role in identifying CAM use among their patients, its adverse effect, and possible complications and should be aware of educational needs of their patients for open communication regarding CAM usage. A better education by the health care providers on the risks and benefits of the CAM therapy to the ESRD patients would encourage the patients to understand the importance of discussing about the CAM usage to their physicians.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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