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James A, Mannon RB. The Cost of Transplant Immunosuppressant Therapy: Is This Sustainable? CURRENT TRANSPLANTATION REPORTS 2015; 2:113-121. [PMID: 26236578 PMCID: PMC4520417 DOI: 10.1007/s40472-015-0052-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
A solid organ transplant is life-saving therapy that engenders the use of immunosuppressive medications for the lifetime of the transplanted organ and its recipient. Conventional therapy includes both induction therapy (a biologic that is infused peri-operatively) followed by maintenance therapy. The cost of these medications is a constant concern and the advent of generics has brought this cost down modestly. For those lacking long term insurance coverage, this may be a significant out of pocket expense that is not affordable. Moreover, transplant Centers are managing higher risk transplant recipients that require more complex induction regimens and longer term use of such biologic agents in the context of desensitization or abrogation of de novo antibody mediated injury. While in kidney transplantation, Medicare part B covers three years of medication, there is frequent non-adherence due to cost after that time-point. The impact of the Affordable Care Act remains uncertain at this time. Finally the pipeline of new therapies is limited due to the cost of development of a drug, the inherent cost of clinical studies, and lack of defined endpoints for newer therapies in high risk patients. These new therapies are of high value to the community but will contribute additional burden to current drug costs.
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Affiliation(s)
- Alexandra James
- Department of Pharmacy, University of Alabama at Birmingham, Birmingham, AL
| | - Roslyn B. Mannon
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
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Ward FL, O'Kelly P, Donohue F, ÓhAiseadha C, Haase T, Pratschke J, deFreitas DG, Johnson H, Conlon PJ, O'Seaghdha CM. Influence of socioeconomic status on allograft and patient survival following kidney transplantation. Nephrology (Carlton) 2015; 20:426-33. [DOI: 10.1111/nep.12410] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Frank L Ward
- Department of Transplantation and Renal Medicine; Beaumont Hospital; Dublin Ireland
| | - Patrick O'Kelly
- Department of Transplantation and Renal Medicine; Beaumont Hospital; Dublin Ireland
| | - Fionnuala Donohue
- Health Intelligence Unit; Health & Wellbeing Directorate; Health Service Executive; Dublin Ireland
| | - Coilin ÓhAiseadha
- Health Intelligence Unit; Health & Wellbeing Directorate; Health Service Executive; Dublin Ireland
| | - Trutz Haase
- Social and Economic Consultant; Health Service Executive; Dublin Ireland
| | - Jonathan Pratschke
- Social and Economic Consultant; Health Service Executive; Dublin Ireland
| | - Declan G deFreitas
- Department of Transplantation and Renal Medicine; Beaumont Hospital; Dublin Ireland
| | - Howard Johnson
- Health Intelligence Unit; Health & Wellbeing Directorate; Health Service Executive; Dublin Ireland
| | - Peter J Conlon
- Department of Transplantation and Renal Medicine; Beaumont Hospital; Dublin Ireland
| | - Conall M O'Seaghdha
- Department of Transplantation and Renal Medicine; Beaumont Hospital; Dublin Ireland
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Ortega F, Díaz-Corte C, Valdés C. Adherence to immunosuppressor medication in renal transplanted patients. World J Clin Urol 2015; 4:27-37. [DOI: 10.5410/wjcu.v4.i1.27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 05/27/2014] [Accepted: 12/17/2014] [Indexed: 02/06/2023] Open
Abstract
Non-adherence is a priority public health concern. Non-adherence means not taking medications, missing medications, taking too much, not taking enough, wrong timing, wrong dose and/or wrong pill, but may also refer to missing appointments, not booking appointments, not doing blood work, not returning calls and/or refusal to follow the treatment regimen. In renal transplantation, adherence to immunosuppressive medication is a fundamental requisite in order to preserve graft function, since non-adherence is one of the main causes for late acute rejection, incomplete recovery after rejection treatment, chronic graft dysfunction, graft loss, and death. Transplantation failure due to treatment non-adherence is economically, socially, ethically and morally unjustifiable. This is a very prevalent issue: in some studies, its incidence is as high as 70% of patients. The self-reported nonadherence levels found in certain studies, including those performed immediately after transplantation show the need for early and continued intervention after kidney transplantation in order to maximise adherence and consequently clinical outcomes. There is not a single method to assess non adherence, thus combining several measures increases diagnostic accuracy. Electronic monitoring with a microdevice that records each time a pill bottle is opened is considered the “gold standard” for measuring adherence, but self-report at a confidential interview was the best measure of adherence. Thus non-adherence risk can be effectively assessed using clinically available assessment tools. Medication Adherence Scale, Brief Medical Questionnaire, Immunosuppressant Therapy Adherence Scale, Immunosuppressant Therapy Barrier Scale, Long-Term Medication Behavior Self-Efficacy Scale and Simplified Medication Adherence Questionnaire are some of the self-reported questionnaires. There are multiple factors associated with non-adherence in immunosuppressant therapy: Younger patients (adolescent, especially), poor health coverage, poor social support, unmarried, no family, non-Caucasian, immigrant, lower income, lower socioeconomic class, greater parental distress and lower family cohesion; complex medical regimens, higher number of drugs, longer time after transplant, toxicity, side effects, poor tolerance to medication, higher number of physicians involved, poor provider-patient rapport; psychological (dependency, high levels of anxiety and hostility, poorer behavioral functioning and greater distress in children) and psychiatric (depression) illnesses, low self-efficacy with medicine intake, perception of immunosuppressive therapy as not been necessary to preserve kidney function, forgetfulness, rebelliousness, poor perception of health, poor satisfaction, low Health-related Quality of life, addictions, lack of coping strategies and avoidance behavior; patient morbidity: comorbidity, receiving a transplant from a live donor, retransplantation, and non-insulin-dependent diabetes. The most frequent strategies to promote medication-taking must focus on modifiable risk factors. Reasons for non-adherence are complex and diverse and any successful intervention aimed at improving adherence must be multidimensional. Although effective intervention strategies are needed to improve immunosuppressant therapy adherence, few intervention studies have been conducted in the adult renal transplant population. In this study, we perform an exhaustive review of the different strategies reported in the literature. A number of key reasons for non-adherence are also provided.
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Gentile G, Somma C, Gennarini A, Mastroluca D, Rota G, Lacanna F, Locatelli B, Remuzzi G, Ruggenenti P. Low-dose RATG with or without basiliximab in renal transplantation: a matched-cohort observational study. Am J Nephrol 2015; 41:16-27. [PMID: 25612603 DOI: 10.1159/000371728] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 12/18/2014] [Indexed: 01/11/2023]
Abstract
BACKGROUND/AIMS In renal transplantation, peri-operative low-dose rabbit-antithymocyte-globulin (RATG) plus basiliximab induction prevented acute allograft rejection more effectively than post-operative RATG plus basiliximab induction. We investigated the specific antirejection contribution of basiliximab in this context. METHODS This single-center, observational, matched-cohort study evaluated allograft rejections (primary outcome), steroid exposure and side effects, GFR (iohexol plasma clearance) and treatment costs in 16 deceased-donor renal transplant recipients induced with RATG (0.5 mg/kg/day) and 32 age-, gender- and treatment-matched reference-patients given RATG plus basiliximab (20 mg on days 0 and 4). RESULTS Induction was well tolerated. At 18 months, 8 patients (50%) vs. 3 reference-patients (9.4%) rejected the graft [HR (95% CI): 6.53 (1.73-24.70), p = 0.006]. Difference was significant (p < 0.01) even after adjusting for recipient/donor age and gender, cold ischemia time and HLA mismatches. There were 1 antibody-mediated rejection and 2 moderate cellular rejections in patients vs. none in reference-patients (p = 0.032). The median (interquartile range) prednisone cumulative dose was remarkably higher in patients than reference-patients [4.78 (1.12-6.10) vs. 0.19 (0.18-3.81) grams, p = 0.002]. Three patients vs. 24 reference-patients were off-steroid at study end (p < 0.001). Three patients vs. no reference-patient developed new-onset diabetes (p = 0.003). Both inductions similarly depleted B-cells. Outcomes of AZA- vs. MMF-treated participants were similar. GFR was similar in all groups. Compared to MMF, AZA therapy saved ≈ EUR 2,500/year and by month 14.3 post-transplant compensated basiliximab costs. CONCLUSION In renal transplantation, basiliximab plus peri-operative low-dose RATG more efficiently prevented allograft rejection than RATG monotherapy, and minimized steroid exposure and toxicity. AZA- vs MMF-based maintenance immunosuppression largely compensated the extra costs of basiliximab.
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Affiliation(s)
- Giorgio Gentile
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Bergamo, Italy
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Abstract
Poor adherence to immunosuppressive medications may be the most important barrier to long term graft survival. An understanding of medication adherence and its determinants is critical to addressing this important problem. In this paper, we will review the different ways in which adherence may be compromised, summarize the evidence that young people constitute a particularly high risk group, and consider the consequences and impact of poor adherence. We will also review the determinants of adherence, including characteristics of the patient and family, the treatment regimen, the healthcare team and its organization, and the healthcare system. We will highlight the most common barriers to adherence identified by young people, and consider different methods of measuring adherence, along with the advantages and limitations of each. Finally, we will consider possible intervention strategies to improve adherence in young people.
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Mercado-Martínez FJ, Hernández-Ibarra E, Ascencio-Mera CD, Díaz-Medina BA, Padilla-Altamira C, Kierans C. Viviendo con trasplante renal, sin protección social en salud: ¿Qué dicen los enfermos sobre las dificultades económicas que enfrentan y sus efectos? CAD SAUDE PUBLICA 2014; 30:2092-100. [DOI: 10.1590/0102-311x00150713] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 03/07/2014] [Indexed: 11/21/2022] Open
Abstract
El trasplante es el mejor tratamiento para la insuficiencia renal, de acuerdo con la biomedicina; sin embargo, es una tecnología cara. Este artículo examina las dificultades económicas y sus efectos en personas con trasplante renal, pero sin protección social en salud. Para el estudio se desarrolló una investigación cualitativa en México. Participaron 21 pacientes trasplantados; se aplicaron entrevistas semiestructuradas, y se realizó un análisis de contenido. Los resultados muestran que las personas enfermas enfrentan dificultades económicas, debido a los costes de las terapias renales, particularmente, de las medicinas. Todo ello tiene efectos negativos: las personas con pocos recursos dejan el tratamiento con medicamentos, abandonan el protocolo, no asisten a las consultas médicas y disminuyen los gastos domésticos, incluyendo el de alimentación; además de suponer una merma en los ingresos familiares. En conclusión, el trasplante renal empobrece a las personas enfermas sin protección social en salud; es urgente la implementación de un sistema de protección social para esta población.
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Kamran Hejazi Kenari S, Mirzakhani H, Saidi RF. Pediatric transplantation and tolerance: past, present, and future. Pediatr Transplant 2014; 18:435-45. [PMID: 24931282 DOI: 10.1111/petr.12301] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/06/2014] [Indexed: 12/13/2022]
Abstract
Solid organ transplantation is the treatment of choice in children with end-stage organ failure. With improving methods of transplant surgery and post-transplant care, transplantation is more frequently performed worldwide. However, lifelong and non-specific suppression of the recipient's immune system is a cause of significant morbidity in children, including infection, diabetes, and cancer. There is a great need to develop IS minimization/withdrawal and tolerance induction approaches.
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Affiliation(s)
- Seyed Kamran Hejazi Kenari
- Division of Organ Transplantation, Department of Surgery, Alpert Medical School of Brown University, Providence, RI, USA
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Améliorer l’adhésion au traitement en transplantation rénale : un enjeu majeur. Nephrol Ther 2014; 10:145-50. [DOI: 10.1016/j.nephro.2013.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 11/01/2013] [Accepted: 11/02/2013] [Indexed: 11/23/2022]
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Spivey CA, Chisholm-Burns MA, Garrett C, Duke KM. Serving underserved transplant recipients: experience of the Medication Access Program. Patient Prefer Adherence 2014; 8:613-9. [PMID: 24833895 PMCID: PMC4014366 DOI: 10.2147/ppa.s63133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Programs have been established to help underserved, solid-organ transplant recipients and other patient populations address the burden of medication regimen costs. The purpose of this study was to describe one such program, the Medication Access Program (MAP), and the population of solid-organ transplant recipients it serves. An additional objective was to compare characteristics of recipients whose MAP enrollment was continued versus those who were discontinued during the annual re-enrollment period. METHODS Enrollment into MAP is based on referral from a pharmacist or another health care professional/transplant team member. To enroll, a recipient must complete an application which includes information about demographics, health care coverage, income, and medication regimen. To maintain enrollment, patients must complete a renewal application on an annual basis. Data were collected from renewal applications for 2012 and 2011 (for those who did not return the 2012 renewal applications). Chi-square analyses and Student's t-test for independent samples were conducted to compare the characteristics of those who renewed their MAP enrollment in 2012 and those who were discontinued because they did not return the renewal application. Multivariate stepwise logistic regression was conducted to determine variables predictive of MAP continuation status. RESULTS In total, 246 recipients were included. The majority qualified for Medicare (67.9%), did not qualify for Medicaid (69.9%), and did not have private health care coverage (63.8%). Significantly more continued recipients qualified for Medicare compared to discontinued recipients (P=0.002). Discontinued recipients had a greater number of past discontinuations than continued recipients (P=0.01). In the logistic regression analysis, qualifying for Medicare was significantly associated with continuation status (P=0.001). CONCLUSION MAP is designed to increase medication access for low-income solid-organ transplant recipients through enrollment into medication assistance programs, education regarding medication therapy, and availability of medication assistance programs. Health care providers should use historical monitoring to identify high risk patients and implement programs that will facilitate continuity of care.
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Affiliation(s)
| | - Marie A Chisholm-Burns
- University of Tennessee College of Pharmacy, Memphis, TN, USA
- Correspondence: Marie A Chisholm-Burns, University of Tennessee College of Pharmacy, 881 Madison Ave, Ste 264, Memphis, TN 38163, USA, Tel +1 901 448-7141, Fax +1 901 448-7053, Email
| | | | - Kenneth M Duke
- University of Georgia College of Pharmacy, Athens, GA, USA
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Saidi RF, Hejazii Kenari SK. Clinical transplantation and tolerance: are we there yet? Int J Organ Transplant Med 2014; 5:137-45. [PMID: 25426282 PMCID: PMC4243045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Organ transplantation is not only considered as the last resort therapy but also as the treatment of choice for many patients with end-stage organ damage. Recipient-mediated acute or chronic immune response is the main challenge after transplant surgery. Nonspecific suppression of host immune system is currently the only method used to prevent organ rejection. Lifelong immunosuppression will cause significant side effects such as infections, malignancies, chronic kidney disease, hypertension and diabetes. This is more relevant in children who have a longer life expectancy so may receive longer period of immunosuppressive medications. Efforts to minimize or complete withdrawal of immunosuppression would improve the quality of life and long-term outcome of pediatric transplant recipients.
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Affiliation(s)
- R. F. Saidi
- Correspondence: Reza F. Saidi, MD, FICS, FACS, Assistant Professor of Surgery, Division of Organ Transplantation, Department of Surgery, Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI 02903, USA, Tel: +1-401-334-2023, Fax: +1-401-856-1102, E-mail:
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Prevalence and correlates of medication non-adherence among kidney transplant recipients more than 6 months post-transplant: a cross-sectional study. BMC Nephrol 2013; 14:261. [PMID: 24289809 PMCID: PMC4219432 DOI: 10.1186/1471-2369-14-261] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 11/25/2013] [Indexed: 01/24/2023] Open
Abstract
Background Among kidney transplant recipients, non-adherence with immunosuppressive medications frequently precedes allograft loss. We sought to determine the prevalence and correlates of medication non-adherence among kidney transplant recipients. Methods We performed a single-center, cross-sectional study of kidney transplant recipients who were at least 6 months post-transplant. We measured self-reported adherence using the Immunosuppressive Therapy Adherence Scale (ITAS, which is scored from 0 to 12, where higher scores indicate increased adherence) and barriers to adherence using the Immunosuppressive Therapy Barriers Scale (ITBS). We also used validated scales to measure perceived stress, health literacy, anxiety, depression, and interpersonal support. Results The 252 patients included in the study were 59.9% male, 27.0% Black, and at a median of 2.9 years post-transplant (interquartile range [IQR] 1.4-5.8). On the ITAS, 59.1% scored a perfect 12, 26.6% scored 10–11, and 14.3% scored 0–9. In univariate models, non-adherence (defined as ITAS score ≤9) was significantly associated with increased scores on scales for perceived stress (OR 1.12, 95% CI 1.01-1.25) and depression (OR 1.14, 95% CI 1.02-1.28), and with more self-reported barriers to adherence on the ITBS (OR 1.15, 95% CI 1.08-1.22). After adjusting for sociodemographic factors, stress and depression were not associated with non-adherence. Higher scores on the ITBS (corresponding to more self-described barriers to adherence) were associated with lower scores on the ITAS (P < 0.001). Several individual barriers were associated with non-adherence. Conclusions Among prevalent kidney transplant recipients, a minority is non-adherent. Practical barriers to adherence may serve as promising targets for future interventions.
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Tanriover B, Stone PW, Mohan S, Cohen DJ, Gaston RS. Future of Medicare immunosuppressive drug coverage for kidney transplant recipients in the United States. Clin J Am Soc Nephrol 2013; 8:1258-66. [PMID: 23559679 DOI: 10.2215/cjn.09440912] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Kidney transplantation is the preferred treatment for patients with ESRD. It improves the quality of life in recipients, increases patient survival, and is also substantially less costly than maintenance dialysis. Long-term transplant success requires immunosuppressant drug therapy for the life of the allograft. Under current law, Medicare coverage for most recipients (except for those recipients over 65 years of age or with nonkidney-related disabilities) lasts only 3 years, leaving many recipients unable to afford these medications. Lack of drug therapy often leads to allograft rejection, resulting in premature graft failure, return to dialysis, or death. This article reviews the current policy for Medicare immunosuppressive drug coverage and analyzes the potential impact of pending legislative proposals H.R. 2969 and S. 1454 and the Patient Protection and Affordable Care Act.
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Affiliation(s)
- Bekir Tanriover
- Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA.
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Spence MM, Nguyen LM, Hui RL, Chan J. Evaluation of Clinical and Safety Outcomes Associated with Conversion from Brand-Name to Generic Tacrolimus in Transplant Recipients Enrolled in an Integrated Health Care System. Pharmacotherapy 2012; 32:981-7. [DOI: 10.1002/phar.1130] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Michele M. Spence
- Pharmacy Outcomes Research Group; Kaiser Permanente; Downey; California
| | - Lynda M. Nguyen
- Department of Pharmacy; San Francisco Veterans Affairs Medical Center; San Francisco; California
| | - Rita L. Hui
- Pharmacy Outcomes Research Group; Kaiser Permanente; Oakland; California
| | - James Chan
- Pharmacy Outcomes Research Group; Kaiser Permanente; Oakland; California
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Grubbs V, Plantinga LC, Vittinghoff E, O'Hare AM, Dudley RA. Medicare immunosuppressant coverage and access to kidney transplantation: a retrospective national cohort study. BMC Health Serv Res 2012; 12:254. [PMID: 22894737 PMCID: PMC3470983 DOI: 10.1186/1472-6963-12-254] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 08/12/2012] [Indexed: 11/10/2022] Open
Abstract
Background In December 2000, Medicare eliminated time limitations in immunosuppressant coverage after kidney transplant for beneficiaries age ≥65 and those who were disabled. This change did not apply to younger non-disabled beneficiaries who qualified for Medicare only because of their end-stage renal disease (ESRD). We sought to examine access to waitlisting for kidney transplantation in a cohort spanning this policy change. Methods This was a retrospective cohort analysis of 241,150 Medicare beneficiaries in the United States Renal Data System who initiated chronic dialysis between 1/1/96 and 11/30/03. We fit interrupted time series Cox proportional hazard models to compare access to kidney transplant waitlist within 12 months of initiating chronic dialysis by age/disability status, accounting for secular trends. Results Beneficiaries age <65 who were not disabled were less likely to be waitlisted after the policy change (hazard ratio (HR) for the later vs. earlier period, 0.93, p = 0.002), after adjusting for sociodemographic factors, co-morbid conditions, income, and ESRD network. There was no evidence of secular trend in this group (HR per year, 1.00, p = 0.989). Likelihood of being waitlisted among those age ≥65 or disabled increased steadily throughout the study period (HR per year, 1.04, p < 0.001), but was not clearly affected by the policy change (HR for the immediate effect of policy change, 0.93, p = 0.135). Conclusions The most recent extension in Medicare immunosuppressant coverage appears to have had little impact on the already increasing access to waitlisting among ≥65/ disabled beneficiaries eligible for the benefit but may have decreased access for younger, non-disabled beneficiaries who were not. The potential ramifications of policies on candidacy appeal for access to kidney transplantation should be considered.
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Affiliation(s)
- Vanessa Grubbs
- Division of Nephrology, University of California San Francisco, San Francisco General Hospital, San Francisco, CA, USA.
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Patzer RE, Pearson TC. Racial disparities in kidney graft survival: does donor quality explain the difference? Am J Transplant 2012; 12:1670-1. [PMID: 22741752 PMCID: PMC3950901 DOI: 10.1111/j.1600-6143.2012.04093.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- R. E. Patzer
- Emory Transplant Center, Emory University, Atlanta, GA,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA,Department of Surgery, Emory University School of Medicine, Emory University, Atlanta, GA,Corresponding author: Rachel E. Patzer,
| | - T. C. Pearson
- Emory Transplant Center, Emory University, Atlanta, GA,Department of Surgery, Emory University School of Medicine, Emory University, Atlanta, GA
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Gill JS, Tonelli M. Penny wise, pound foolish? Coverage limits on immunosuppression after kidney transplantation. N Engl J Med 2012; 366:586-9. [PMID: 22296029 DOI: 10.1056/nejmp1114394] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- John S Gill
- Division of Nephrology, University of British Columbia, Vancouver, Canada
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