Background:
Adherence is the key to long-term disease control in patients with chronic kidney disease and decreasing the progression of this condition is important in the management of patients during the early stages. Furthermore, several behavioral recommendations have been offered in the asymptomatic stage to maintain health status, healthy lifestyles, and prevent deterioration of kidney function. A healthy lifestyle is attained by following the behavioral recommendations of the Chronic Kidney Disease Guidelines that improve quality of life. Limited research study investigates how patients with chronic kidney disease adopt those health behavior recommendations in their daily life, and to what extent it impacts their quality of life. The evaluation of trajectory and relationship among adherence to behavior recommendations, healthy lifestyle, and quality of life is thus required.

Purpose:
This study aims to identify the longitudinal trends and the longitudinal relationship of adherence to behavior recommendations, healthy lifestyle, and quality of life among patients with chronic kidney disease.

Methods:
In this study, a longitudinal design was conducted using 250 CKD patients from two medical center in southern Taiwan. Self-reported questionnaires were used to examine the following variables: Adherence to Healthy Behaviors (AHBs), Health Promoting Lifestyle (HPLP-II) and Quality of Life (WHOQOL-BREF). Furthermore, measurement was conducted four times in a row at the start of the study, after 6, 12 and 18 months. The descriptive and exploratory longitudinal analysis were used in analyzing data. Meanwhile, individual growth curve (IGC) of mixed model analysis was used to assess Trajectory of Behavior Recommendations' Adherence, Health Promoting Lifestyle and Quality of Life. Hierarchical Linear Mixed Model was used to investigate the longitudinal effect of Adherence to Behavior Recommendation and Healthy Lifestyle on Quality of life. In addition, mixed model assumption of normality, homoscedasticity and linearity were tested graphically for the best fit model.

Result: A total of 250 patients were recruited, and in the 18th month, only 200 completed the final measurements due to rejection, death and receiving RRT. The attrition rate was 20% and the list-wise deletion was used in handling missing data. A total of 200 participants included for further longitudinal analysis. Trajectory of Adherence to behavior recommendation showed positive linear trends, while health promoting lifestyle indicated higher order cubic growth curve with acceleration in the rate of change. Among the dimensions of quality of life, the general health status has positive linear trend. The physical, psychological, social and environment dimension of quality of life present quadratic growth rate with deceleration in the rate of change. Meanwhile, patients that adopt healthier lifestyle, report high status of all dimensions of quality of life overtime. Advances stages of chronic kidney disease result in poor status of quality of life.

Conclusion:
During the 18 months period, pre-dialysis CKD patients continuously improve their adherence to behavior recommendations. The non-linear trend towards a healthy lifestyle requisite further attention, the fluctuation of curve indicates the needs of re-evaluation every six months. Changes in all dimensions of quality of life showed a curvilinear decrease with decelerations, an increasing trend occurred during 12 to 18 months follow up, indicate the patients’ adaptations towards disease and potential improvements. The adaptation of adherence to behavior recommendations and health promoting behaviors diminishes the decline rate of quality of life.

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