Hemodialysis Therapy Adherence and Contributing Factors among End-Stage Renal Disease Patients at Muhimbili National Hospital, Dar es Salaam, Tanzania

Round 1

Reviewer 1 Report

In the manuscript entitled “Hemodialysis Therapy and associated factors among End-Stage Renal Disease Patients at Muhimbili National Hospital, Dar es Salaam, Tanzania” the authors examined the adherence to hemodialysis (HD) therapy in one National hospital in Dar es Salaam, Tanzania and the factors associated with the HD adherence. There is not much data on HD treatment in this region, so this work is interesting and significant. The study is well done and I have only a few comments.

1. In the Method section, it is not clear what the criteria were for selecting 265 patients out of 620 patients receiving HD.
2. All three figures provide little information. The data can be given in the appropriate table or the data from all three figures can be presented as a column chart in one figure.
3. The authors nicely described the limitations of the study, but it should be pointed out what the strength of the study is.
4. It is not necessary to explain the abbreviation more than once. It is enough to explain it when it first appears in the text.

Author Response

Thank you for your constructive comments, I have addressed the comments

Author Response File: Author Response.pdf

Reviewer 2 Report

This is a meaningful manuscript, with the authors focusing on Hemodialysis Therapy in End-Stage Renal Disease Patients. Authors should strongly justify the necessity to conduct the described research. This part of the introduction is insufficient. Both, in the introduction and in the discussion, the following paragraphs are often thematically unrelated. Authors should take care of the quality of the text. The English language needs to be greatly modified.

Author Response

Dear reviewer, thank you very much for your constructive comments which aim at improving our manuscript. We have addressed all comments. Thank you!

Author Response File: Author Response.pdf

Reviewer 3 Report

1. The article title mentioned to be: Hemodialysis Therapy and associated factors among End-Stage Renal Disease Patients at Muhimbili National Hospital, Dar es 3
   Salaam, Tanzania. The associated factors are not quite representative of the aim of the paper and need to be revised. It seems that the "contributing factors to the adherence to the hemodialysis treatment" were planned to discuss. Therefore, an appropriate title is required to be replaced.
2. Line 39, only should be removed. 
3. Lines 42, and 46, the underlying causality of the ESRD patients' residential status major shift from 80 to 70% in the developing countries, is recommended to be discussed. 
4. The paragraph from lines 63 to 67: the mechanism of dialysis and the significance of that have been tortured and the concept is not well organized. 
5. Lines 77 to 79 are required to be dragged before line 68. In that case, the internal guidelines followed by the regional and local modification would make more sense.
6. line 83, needs to be revised to : regimen. Lack of appropriate adherence to the dialysis schedules, or skipping hemodialysis sessions is related to an increased risk of morbidity and mortality.
7. Line 88, religion is recommended to be revised to faith. 
8. Line 93, increased admission chance, is recommended to be revised to increase the rate of hospitalization.
9. Line 118, attending, needs to be revised to attended
10. The exclusion criteria need to be discussed. Were the incomplete forms excluded? What were the objective criteria used to assess the appropriate understanding and relevant answers?
11. The data collection situation needs to be discussed more comprehensively. According to lines 146, and 147, the patients were approached while waiting for their turn for hemodialysis. How did the team optimize the situation in the sense of unforceful and liberal participation in the study? Were the patients supposed to fill out the questionnaires under the hemodialysis condition, and how did the team ablate the confounding factors of the fear to be withdrawn from the maximal treatment in case of refusing to participate? On the other hand, if they accepted to enroll, were they supposed to complete the questionnaire during the hemodialysis session, and how did the team evaluate the possibly less than a favorable condition of responding to the questions?
12. line 163 mentioned the restricted access to the collected data by PI. How the data were analyzed afterward? What specific coding was used to keep the data anonymous during the analysis?
13. Line 168 mentioned the missed sessions? Is there any registry system to reach out to the patients while missing their schedule to follow up?
14. Line 169 mentioned shortening the hemodialysis sessions in 7.9% of the respondents. What was the causality of the aborted sessions? Did the registry mention the decreased blood pressure or any kind of events during the dialysis sessions? 
15. line 174, non-adherence needs to be revised to non-adherent 
16. Figures 2, and 3, are quite simple and not appropriate for the level of a review. It would rather work on the conference presentations.
17. Line 187 discussed the knowledge of ESRD patients on the importance of hemodialysis adherence. The questionnaire details and more-quantitative criteria need to be discussed here. 
18. Several points were discussed in the discussion section and need to be in a more integrated style. Referring to the insurance systems, religion, and income hold a huge bias and might torture the understanding. It seems to be far beyond a cross-sectional study and is recommended to cautiously judge the details.

Author Response

Dear Reviewer, 

Thank you very much for your helpful comments. We have addressed all comments. Thank you  very much. 

Author Response File: Author Response.pdf

Round 2

Reviewer 3 Report

1. A cross-section of time the study was performed should be mentioned, including starting and ending months and years.
2. Line 21 should be revised and clarified. Binomial is concerned with an observed proportion between 0 and 1. The analysis has variable denominators compared to the Bernoulli, and it's an aggregation of individual data that seems not relevant in the current study. Therefore, as the factors affecting the non-adherence situations are more significant than 2, at least the analysis method should be revised to multinomial logistic regression. Therefore, if the authors plan to discuss just the two occasions of adherence and non-adherence to keep the concept of binomial, the cutoff should be clearly discussed. That said, even one missed attendance would be categorized as non-adherence?
3. Lines 23 and 24, incomplete sentence, do the author plan to make a range of adherence?
4. Lines 32, and 33, providing such recommendations, are beyond the scope of a single-center cross-section review and should be discussed in a multidisciplinary panel. That said, the authors could mention the type of insurance and whether the whole dialysis and complications are covered, but the details need to be discussed in further studies. 
5. Line 39, only hemodialysis,...to be revised to whereby hemodialysis, peritoneal dialysis, or transplantation are life-saving. When the authors mentioned only, it would reflect inappropriately that down-sizing the life-threatening situation.
6. Line 49, add Hyphen for income; low-income.
7. Line 54, CDK should be edited to CKD.
8. Line 59, Malaria or bacteria, to be revised to infectious disease with parasitic or bacterial organisms, the authors categorized the incomparable groups.
9. Line 60, million of population.
10. Lines 79, and 80, to be revised to the International guideline, recommend 3 to 4 hours of hemodialysis session, three times weekly.
11. Line 86, add the before recommended hemodialysis
12. Line 95, people to be revised to patients
13. Starting line 79 to line 104, there are triplicates of the sentence that tries to mention poor adherence.
14. Line 114, including but not limited to, to be revised to includes but is not limited to.
15. Line 115, units and machines, to be revised to facilities
16. Lines 361 to 366, the factors (age, sex, and educational level ) discussed in the discussion section according to the current study, are different from the factors (occupation, and monthly income) discussed in the Cameron and Rwanda studies, therefore they are not comparable

Author Response

See attachment 

Author Response File: Author Response.pdf