A Mindfulness Experiment in Dialysis Patients Offers a Subtle Lesson About Chronic-Care Adherence
For people with end-stage kidney disease, staying alive often means organizing life around a demanding medical routine: several hours connected to a hemodialysis machine, usually multiple times each week, while also managing medications, fluid intake, diet and other symptoms of kidney failure. A randomized controlled trial in Iran has now tested whether mindfulness training can make that regimen easier to follow. The answer is more complicated than a simple success story. Researchers found that patients who received eight brief mindfulness sessions showed a greater improvement in some adherence measures at a one-month follow-up, especially dietary adherence. Yet when the investigators analyzed changes across all assessment points and the overall treatment-adherence score, the intervention did not produce a statistically significant overall effect. The findings suggest that mindfulness may help with selected self-management challenges, but it is unlikely to be a standalone solution for every difficulty faced by people receiving dialysis.
The study, published in BMC Complementary Medicine and Therapies, was conducted at Bu-Ali Sina Educational Medical Center in Qazvin, Iran, between November 2024 and January 2025. The researchers enrolled 78 adults undergoing maintenance hemodialysis and assigned them to an intervention group or a routine-care control group using block randomization, with 39 participants initially placed in each group. Randomization is designed to distribute known and unknown characteristics—such as age, illness burden, motivation or previous experience with psychological treatment—more evenly between groups, strengthening the credibility of comparisons. Participants in the intervention arm received eight weekly sessions, each lasting 30 to 45 minutes. The training took place during dialysis sessions, an approach that may reduce the practical burden of attending additional appointments. The program was adapted from the mindfulness-based protocol associated with Jon Kabat-Zinn, which generally emphasizes deliberate attention to present-moment experiences, awareness of thoughts and bodily sensations, and a less reactive attitude toward discomfort.
Mindfulness is not intended to remove the medical demands of dialysis. Instead, it is a behavioral and psychological technique that may alter how patients respond to stress, fatigue, unpleasant sensations and recurring treatment decisions. During hemodialysis, a machine circulates blood through a filter called a dialyzer, removing excess water and waste products that damaged kidneys can no longer clear effectively. Between sessions, however, patients must carefully regulate how much fluid and certain nutrients they consume. Excessive fluid intake can contribute to interdialytic weight gain—the increase in body weight between dialysis treatments—raising the risk of swelling, high blood pressure and cardiovascular strain. Dietary and medication decisions also accumulate over time, and missed dialysis sessions can have serious consequences. Mindfulness could theoretically support adherence by improving attention, reducing automatic or impulsive responses, and helping patients tolerate distress. But the technique cannot substitute for individualized nutritional guidance, medication management, transportation support or clinical care.
Treatment adherence in dialysis is also difficult to measure, which helps explain why published estimates of non-adherence vary widely. The researchers note that studies in Iranian populations have reported non-adherence rates ranging from 2 percent to 87 percent. Such a broad range does not necessarily mean that patient behavior is changing dramatically from one study to another. It can reflect differences in definitions, questionnaires, clinical settings and the specific behaviors being measured. One investigation may focus on missed dialysis appointments, while another may emphasize fluid restriction, medication use or dietary recommendations. In this trial, adherence was assessed with the End-Stage Renal Disease Adherence Questionnaire, or ESRD-AQ, at three points: before treatment, immediately after the eight-week intervention and one month later. A composite questionnaire can capture a broader picture of self-management, but it may also obscure improvements in one domain when other domains remain unchanged.
Of the 78 people randomized, 70 completed the study: 36 in the mindfulness group and 34 in the control group. At baseline, the groups were broadly comparable in their adherence scores. The intervention group had a mean score of 862.83, with a standard deviation of 166.29, while the control group had a mean of 842.82 and a standard deviation of 187.80. The difference was not statistically significant, with a p-value of 0.638, indicating no clear evidence that one group began with better adherence than the other. At the one-month follow-up, however, the mindfulness group showed a significantly greater improvement in adherence change scores than the control group, with p = 0.005. That result is the most attention-grabbing finding in the study, but it should not be interpreted as proof that mindfulness broadly transformed treatment behavior. A statistically significant comparison at one time point is different from demonstrating a consistent treatment effect across the entire follow-up period.
The more comprehensive repeated-measures analysis did not find a significant group-by-time interaction. This interaction asks whether the pattern of change over time differed between the mindfulness and routine-care groups. In the trial, the interaction had a p-value of 0.223 and a partial eta squared of 0.022, a small effect-size estimate. In practical terms, the data did not establish that the intervention group followed a reliably different trajectory from the control group across baseline, post-intervention and follow-up assessments. The apparent advantage at one month may therefore reflect improvement concentrated in a particular adherence domain, natural fluctuations in behavior, measurement variability or the limited statistical power of a small trial. The distinction matters because repeated assessments can reveal whether an intervention produces durable and consistently different change, rather than an isolated difference. The authors consequently conclude that mindfulness did not show a significant overall effect on treatment adherence in the primary repeated-measures analysis.
Exploratory results offered a possible explanation for the mixed picture: dietary adherence appeared to improve more than other components of self-management. Mindfulness may be especially relevant when eating decisions are shaped by habit, emotion, boredom or momentary urges. A brief pause between craving and action could help some patients notice what they are experiencing and make a choice more consistent with their dietary plan. That possibility remains hypothetical in this study, however, because the trial was not large enough to establish a definitive domain-specific mechanism. The intervention did not demonstrate broad, statistically confirmed improvements in fluid restriction, medication adherence or attendance at dialysis sessions. Each of those behaviors is influenced by different barriers. Fluid control can be affected by thirst, dry mouth, heat and social routines; medication adherence may depend on side effects, cost, complicated schedules or memory; and dialysis attendance can be limited by transportation, work, caregiving responsibilities or severe illness. A single psychological strategy may not address all of them.
The study has several features that make the intervention clinically interesting, particularly its delivery during treatment rather than in separate clinic visits. Dialysis sessions already require patients to spend substantial time in a medical setting, so integrating a 30-to-45-minute activity into that period could make mindfulness more accessible. It may also allow nurses or other trained staff to incorporate behavioral support into routine care without adding travel requirements. At the same time, the trial’s scale and short follow-up limit what can be concluded about long-term benefits. Eight sessions and one additional month of observation cannot show whether any improvement persists for six months or a year, when treatment fatigue and changing health circumstances may become more important. The source material also does not report that the intervention was blinded—an inherently difficult condition for behavioral training—or provide evidence that the results would generalize to other hospitals, healthcare systems or cultural settings. Larger trials with longer follow-up, objective measures such as interdialytic weight gain and attendance records, and analyses of specific adherence barriers could provide a clearer test.
The researchers frame mindfulness as a feasible adjunct to nursing care, not as a replacement for medical treatment. That restrained conclusion is important because adherence problems are rarely caused by attention or motivation alone. Patients on hemodialysis may be coping with depression, anxiety, pain, sleep disruption, cognitive symptoms, financial stress and the relentless schedule of chronic illness. Effective support may therefore need to combine mindfulness with motivational interviewing, cognitive-behavioral therapy, dietitian-led education, medication simplification, family involvement and practical assistance with transport or appointments. The trial’s result is best understood as a signal rather than a breakthrough: a low-cost, non-pharmacological intervention may help some patients—possibly particularly with dietary decisions—but the evidence does not yet show that it can reliably improve every aspect of dialysis adherence. For a treatment regimen in which small daily choices can have major physiological consequences, the next scientific challenge is determining which patients benefit, which behaviors are most responsive and how psychological training can be combined with concrete clinical and social support.
