A retrospective analysis of immunosuppression compliance, dose reduction and discontinuation in kidney transplant recipients

Adherence to immunosuppression in adult lung transplant recipients: prevalence and risk factors

BACKGROUND

Adherence to medication is a favourable with regard to survival after kidney, heart and liver transplantation. Little is known about adherence to medication in lung transplant recipients. To determine the prevalence of adherence and identify risk factors of non-adherence (NA) we evaluated adherence to tacrolimus in adult lung transplant recipients who were at least 1 year after transplantation.

METHODS

Tacrolimus intake was prospectively monitored using the Medication Event Monitoring System (MEMS). Recipients qualified as adherent if a timing-adherence score of ≥ 80% was reached. Patients' characteristics and possible risk factors for NA were collected using the Karnofsky Performance Index, Self-Care Agency ASA Scale, State-Trait Anxiety Inventory, Zung Self-Rating Depression Scale, and the Long-Term Medication Behavior Self-Efficacy Scale.

RESULTS

Ninety-one recipients used MEMS for a median of 95 days (range 50 to 124 days) and were included. They showed a median timing-adherence score of 98.1% (range 31.2% to 100%). A timing-adherence score of ≥ 80% was seen in 92.3% of the recipients. Multiple logistic regression showed an association of lower timing-adherence scores with younger age and lower ability of self-care.

CONCLUSIONS

Adherence to immunosuppressive therapy was very high in lung transplant recipients. Only 7.7% of the recipients were non-adherent. Younger recipients and recipients with lower ability of self-care appeared to be at risk for NA. Follow-up of clinical data is needed to determine whether NA is associated with poorer outcome, specifically bronchiolitis obliterans syndrome.

Extended-release tacrolimus therapy in de novo kidney transplant recipients: single-center experience

BACKGROUND

Available data for extended-release tacrolimus (Tac) except in clinical trials are limited.

OBJECTIVE

To describe our initial experience with once-daily Tac in combination with corticosteroids and mycophenolate mofetil therapy in patients undergoing de novo renal transplantation.

PATIENTS AND METHODS

In this retrospective, observational, single-center study, data were obtained for 49 adult recipients treated with extended-release Tac and 30 patients treated with standard-release Tac (control group). Mean (SD) follow-up in the 2 groups was 3.5 (2.5) months and 4.0 (2.6) months, respectively. The primary characteristics were comparable between the groups.

RESULTS

The acute rejection rate in the extended-release group was 10%, and 13% in the standard-release group. Patient and graft survival rates were 98% and 96% vs 100% and 90%, respectively. Renal function in the 2 groups was comparable: serum creatinine concentration 1.3 (0.2) mg/dL vs 1.45 (0.4) mg/dL. At day 14 posttransplantation, Tac doses were 0.17 mg/kg/d vs 0.14 mg/kg/d, and blood concentrations were 9.0 ng/mL vs 14.0 ng/mL. In recipients older than 60 years, lower dosages of Tac resulted in blood concentrations similar to those in younger patients, with less variation in dosage.

CONCLUSIONS

Short-term experience with extended-release Tac therapy in de novo renal recipients confirms its efficacy and safety. Adjusting blood concentrations in the immediate posttransplantation period is less difficult with extended-release Tac compared with the twice-daily formulation.

Long-acting injectable antipsychotics in the treatment of schizophrenia: their role in relapse prevention

IMPORTANCE OF THE FIELD

Antipsychotic medications are the cornerstone of treatment in schizophrenia, and a large body of data confirms the value of ongoing and continuous antipsychotic pharmacotherapy in controlling symptoms and preventing relapse. However, nonadherence with antipsychotic treatment is a significant issue, with estimates as high as 90%.

AREAS COVERED IN THIS REVIEW

This review focuses on long-acting injectable (LAI) antipsychotics and their role in the treatment of schizophrenia. The existing literature, with an emphasis on clinical evidence, is assessed. This includes both reviews and specific trials that examine LAIs and compare them with oral agents, with measures ranging from relapse and rehospitalization to adherence. Both advantages and limitations (e.g., challenges in terms of dose titration and time to steady state) are examined.

WHAT THE READER WILL GAIN

This overview serves as an update for clinicians wishing to understand LAIs better, including the newer second-generation antipsychotics (SGAs) with this formulation available, and their potential role in the long-term treatment of individuals with schizophrenia.

TAKE HOME MESSAGE

Despite identified advantages, LAIs are not used as widely as might be expected. It would seem that clinicians are at least partly responsible for this, influenced by our own misperceptions (e.g., that LAIs are not acceptable to patients) and, perhaps, misinformation (e.g., increased side effect risk). As clinicians, we may well be shortchanging LAIs if we position them as a treatment of last resort for the multi-episode, nonadherent, 'revolving door' patient, especially given recent evidence underscoring their potential benefits in first-episode patients. The search for new and more effective antipsychotics will continue, but we are reminded that suboptimal outcomes may have as much to do with nonadherence as inadequate treatments. Evidence has established that LAI antipsychotics demonstrate distinct benefits in this regard, and we would be remiss if we did not exploit this already available strategy. As well as additional research, we need to rethink how we position these agents in our treatment algorithms if we are to maximize their potential.

Tacrolimus once daily (ADVAGRAF) versus twice daily (PROGRAF) in de novo renal transplantation: a randomized phase III study

This multicenter, 1:1-randomized, parallel-group, noninferiority study compared the efficacy and safety of twice-daily tacrolimus (Tacrolimus BID; Prograf) and once-daily tacrolimus prolonged release (Tacrolimus QD; Advagraf), combined with steroids and low-dose mycophenolate mofetil without antibody induction, in 667 de novo kidney transplant recipients. A double-blind, double-dummy 24-week period was followed by an open extension of up to 12 months posttransplant. Biopsy-proven acute rejection rate at 24 weeks (primary endpoint, per-protocol analysis) was 15.8% for Tacrolimus BID versus 20.4% for Tacrolimus QD (p = 0.182; treatment difference 4.5%, 95% confidence interval-1.8%, 10.9%, just outside the prespecified 10% noninferiority margin). Kaplan-Meier 12-month patient and graft survival rates were 97.5% and 92.8% for Tacrolimus BID and 96.9% and 91.5% for QD. Both treatment groups showed equally well-maintained renal function at 12 months (mean creatinine clearance approximately 67 mL/min) and similar adverse event profiles. Overall results obtained with either Tacrolimus QD or BID, without antibody induction, were good, supporting use of the once-daily formulation as an effective alternative to the established twice-daily formulation.

Once daily everolimus is safe and effective in de novo renal transplant recipients: six-month results of a pilot study

INTRODUCTION

The half-life of everolimus is approximately 28 hours, but everolimus is normally administered twice a day. The aim of this prospective, single-center, exploratory study was to compare the efficacy and safety of a once a day (OD) everolimus regimen versus the standard twice a day regimen (BID) for immunosuppressive therapy in renal transplantation.

METHODS

Forty de novo renal transplant recipients prospectively assigned to OD (n = 21) or BID (n = 19) were followed for 6 months. In the OD group, everolimus was given orally once a day to target a trough blood level of 2-6 ng/mL. In the BID, group everolimus was given twice a day to target a trough blood level of 3-12 ng/mL. All patients also received induction treatment with basiliximab and low-dose calcineurin inhibitors.

RESULTS

At 6 months follow-up, patient and graft survivals were 100%; renal function and acute rejection rates were similar between the 2 regimens. Patients in the OD group showed significantly lower cholesterol and triglyceride levels compared with those in the BID group, namely, total cholesterol level, OD 212 +/- 54 versus BID 249 +/- 59 mg/dL (P < .05), and serum triglycerides, OD 162 +/- 72 versus BID 245 +/- 133 mg/dL (P < .02).

DISCUSSION

This study showed that OD administration of everolimus provided excellent patient and graft survivals and good renal function without an increased incidence of acute rejection episodes. The lipid profile was significantly better among patients receiving everolimus OD. These findings suggested that everolimus can be safely administered once a day.

Electronically measured adherence to immunosuppressive medications and kidney function after deceased donor kidney transplantation

BACKGROUND

Non-adherence with immunosuppressive medications can result in allograft rejection and eventually allograft loss.

METHODS

In a racially diverse population, we utilized microelectronic cap monitors to determine the association of adherence with a single immunosuppressive medication and kidney allograft outcomes post-transplantation. This prospective cohort study enrolled 243 patients from eight transplant centers to provide adherence and kidney allograft outcomes data. To determine the association of adherence with change in estimated glomerular filtration rate (eGFR), we fit mixed effects models with the outcome being change in eGFR over time. We also fit Cox proportional hazards models to determine the association of adherence with time to persistent 25% and 50% decline in eGFR.

RESULTS

The distribution of adherence post-transplant was as follows: 164 (68%), 49 (20%), and 30 (12%) had >85-100%, 50-85%, and <50% adherence, respectively. Seventy-nine (33%) and 36 (15%) of the subjects experienced a persistent 25% decline in eGFR or allograft loss and 50% decline in eGFR or allograft loss during follow-up. Adherence was not associated with acute rejection or 25% decline or 50% decline in eGFR. In the adjusted and unadjusted model, adherence and black race were not associated with change in eGFR over time.

CONCLUSIONS

Non-adherence with a single immunosuppressive medication was not associated with kidney allograft outcomes.

Attitudes towards medication non-adherence in elderly kidney transplant patients: a Q methodology study

BACKGROUND

Non-adherence to the post-transplant regime is a common problem in kidney transplant patients and may lead to rejection or even graft failure. This study investigated attitudes towards the post-transplant regime of immunosuppressive medication among the ever growing population of elderly kidney recipients.

METHODS

Q methodology was used to explore attitude profiles. Participants (> 65 years) were asked to rank-order opinion statements on issues associated with (non-)adherence. The rankings were subject to by-person factor analysis, and the resulting factors were interpreted and described as attitudes.

RESULTS

Twenty-six elderly renal transplant recipients participated in the study. All passed the Mini-Mental State Examination. Two attitude profiles were found: (i) satisfied and easy-going (attitude A), and (ii) reserved and concerned (attitude B). Elderly patients with attitude A want to enjoy the new life following their kidney transplant, are not very concerned about having to recommence dialysis, now and then even forget their regime, and do not really worry about it. Elderly patients with attitude B feel more insecure about their kidney transplant, are fairly concerned over issues like rejection or going back on dialysis, and try to adapt their way of life to the regime. One-third of these elderly patients forget their medication at least once a month, but there was no difference between attitude groups.

CONCLUSIONS

Attitudes about the post-transplant regime differ among elderly patients, implying different needs for assistance, monitoring and risk of non-adherence to the regime. The proportion of elderly patients who forget their medication is considerable, but may be much higher among those with mild and severe cognitive limitations.

The psychometric properties and practicability of self-report instruments to identify medication nonadherence in adult transplant patients: a systematic review

INTRODUCTION

Nonadherence to immunosuppressive therapy is recognized as a key prognostic indicator for poor posttransplantation long-term outcomes. Several methods aiming to measure medication nonadherence have been suggested in the literature. Although combining measurement methods is regarded as the gold standard for measuring nonadherence, self-report is generally considered a central component of adherence assessment. However, no systematic review currently exists to determine which instrument(s) are most appropriate for use in transplant populations.

METHODOLOGY

The transplant360 Task Force first performed a survey of the self-report adherence instruments currently used in European centers. Next, a systematic literature review of self-report instruments assessing medication adherence in chronically ill patients was conducted. Self-report instruments were evaluated to assess those which were: (a) short and easy to score; (b) assessed both the taking and timing of medication intake; and (c) had established reliability and validity.

RESULTS

Fourteen instruments were identified from our survey of European centers, of which the Basel Assessment of Adherence Scale for Immunosuppressives met the aforementioned criteria. The systematic review found 20 self-report instruments, of which only two qualified for use in transplantation, that is, the Brief Antiretroviral Adherence Index and the Medication Adherence Self-Report Inventory.

DISCUSSION

The three selected self-report scales may assist transplant professionals in detecting nonadherence. However, these scales were only validated in patients with HIV. Although HIV shares similar characteristics with transplantation, including the importance of taking and timing of medication, further validation in transplant populations is required.

Adherence to the immunosuppressive regimen in pediatric kidney transplant recipients: a systematic review

As most prior reviews on NA focus on adult transplant patients, there is a need for a comprehensive overview on adherence to the immunosuppressive regimen in pediatric kidney transplant patients. This systematic review searched for English-language papers (1990-2008) addressing the prevalence of NA to the immunosuppressive regimen, its consequences, determinants, and interventions in pediatric kidney transplant patients (< age 21 yr). We found 36 papers, showing a prevalence of NA (weighted mean) of 31.8% with adolescents being more at risk compared to younger patients. About 44% of all graft losses and 23% of late acute rejection episodes are associated with NA. Most studies investigated socio-economic, condition-related or treatment-related determinants. Only one educational intervention has been tested but yielded inconclusive results. NA to the immunosuppressive regimen is prevalent with serious clinical consequences in pediatric kidney transplant patients, but the economic consequences have not yet been explored. More studies on determinants of NA are needed. The literature currently lacks fully powered RCTs testing adherence-enhancing interventions. The results of this systematic review identify the gaps in the present evidence-based information regarding NA and can be used as a tool to pursue future adherence research in pediatric populations.

A new electronic monitoring device to measure medication adherence: usability of the Helping Hand™

The aim of this study was to test the user performance, satisfaction and acceptability of the Helping Hand™ (B&O Medicom) electronic medication adherence monitor. Using a mixed-method design, we studied 11 kidney transplant patients and 10 healthy volunteers during three weeks. Although testing showed positive usability aspects, several areas requiring technical improvement were identified: the most important obstacles to usability and acceptability were the weak sound signal, problems loading the medication, and the fact that only one medication could be used at a time.

Gastrointestinal Symptoms in Kidney Transplant Recipients: What about Silent Sufferers?

Context

Transplantation improves health-related quality of life in patients with end-stage renal disease. However, primarily because of adverse effects of medication, among other gastrointestinal symptoms, health-related quality of life is not completely restored to normal. Although many patients have various gastrointestinal symptoms only a small proportion may be reported spontaneously.

Objective

To evaluate the prevalence of gastrointestinal symptoms in kidney transplant recipients, also the difference between spontaneously reported symptoms and symptoms elicited by specific questioning was assessed. The burden of these symptoms in daily life also was analyzed.

Design

A single-center, sequential, mixed method study to assess the difference between spontaneous patient reports of gastrointestinal symptoms and active screening by a questionnaire in kidney transplant patients.

Patients

In February 2008, patients received a questionnaire on gastrointestinal symptoms; notes in medical records were consulted for patients scoring less than 100. In June 2008, those patients received a second, extended questionnaire aimed to assess the burden of gastrointestinal symptoms in daily life.

Results

Ninety-two of 513 patients eventually proved to have gastrointestinal symptoms. Completed questionnaires were compared with notes in the patients' files of the past year. A total of 51 of these 92 patients appeared to have not mentioned their gastrointestinal symptoms during the outpatient clinic visits. Of these 51 patients, 37 reported a significant impact of gastrointestinal symptoms on daily life.

Conclusions

The silent sufferer exists. Specific questioning helps to improve communication concerning bothersome gastrointestinal symptoms. To assess the burden of these symptoms, a validated questionnaire should be developed.

Health-related quality of life, treatment adherence, symptom experience and depression in adolescent renal transplant patients

Few studies comprehensively assessed psychological and behavioral functioning in adolescent kidney transplant patients. The purpose of this cross-sectional study was to evaluate depression, QOL, treatment adherence and presence of side effects from the perspective of the patient and his parents, and to compare scores with norm data. All patients (age 10-18 yr) and their parents completed the following instruments: KIDSCREEN-27 (QOL), a treatment adherence interview, the MTSOSD-59R (side effects) and the Beck Depression Inventory (depression). Twenty-three of 26 patients and 22 parents agreed to participate (70% male; median age 15 yr). Adolescents rated their QOL as satisfactory, but parents reported significant problems on several QOL dimensions. Depressive symptoms occurred in 17.4%, and 75% were non-adherent with their immunosuppressive drugs (confirmed by their parents) and show other problematic health behavior, including smoking, illicit drug use, dietary non-adherence, and suboptimal exercise levels. The most frequently occurring side effects were increased appetite, fatigue and headache; the most distressing ones were hair loss or thinning of hair, warts on hands or feet, and sores in the mouth or on the lips. Our results underscore the need for regular screening and adequate treatment of the above-mentioned aspects.

Mycophenolate mofetil dose reduction in renal transplant recipients: a 5-year follow-up study

OBJECTIVE

Mycophenolate mofetil (MMF), an immunosuppressant that is widely used in renal transplantation, is associated with several dose-dependent hematologic and gastrointestinal side effects that may require dose reduction or even discontinuation. The aim of this study was to compare renal allograft function and acute rejection episodes among kidney allograft recipients who were on 2 regimens of MMF for at least 5 years.

MATERIALS AND METHODS

This prospective cohort of 55 kidney allograft recipients was followed for deterioration of allograft function, evidence of acute rejection, and allograft survival. Twenty-two patients (40%) underwent MMF dose reduction to 1.35 to 0.23 g/d due to perceived side effects or economic reasons (group 1). The mean time for this change was 4.2 +/- 2.1 months after kidney transplantation. The remaining patients (group 2, n = 33) were continued on MMF (2 g/d). All patients were followed for at least 5 years after transplantation. Renal function tests (blood urea and serum creatinine) were measured monthly for 2 years and then every 2 months. Statistical analysis was performed using SPSS 11.0 (Student t test). P <or= .05 was considered significant.

RESULTS

The 2 groups were comparable regarding age, gender, and immunosuppressive medications. The renal function tests were comparable at the end of the study. Mean blood urea values were 44.8 +/- 5.8 and 46.8 +/- 6.8 mg/dL in groups 1 and 2 (P > .05); mean serum creatinine values were 1.32 +/- 0.14 and 1.38 +/- 0.21 mg/dL, respectively (P > .05). There were 2 graft losses and 1 patient loss in group 2. There were also 2 graft losses among group 1 patients.

CONCLUSION

Our study showed that MMF dose reduction was not associated with an increased risk of acute renal allograft rejection or impaired allograft function at 5 years.

How accurate are electronic monitoring devices? A laboratory study testing two devices to measure medication adherence

In a prospective descriptive laboratory study, 25 Helping Hand(™) (HH) (10 without and 15 with reminder system) and 50 Medication Event Monitoring Systems (MEMS) (25 with 18-month and 25 with 2-year battery life) were manipulated twice daily following a predefined protocol during 3 consecutive weeks. Accuracy was determined using the fixed manipulation scheme as the reference. Perfect functioning (i.e., total absence of missing registrations and/or overregistrations) was observed in 70% of the HH without, 87% of the HH with reminder, 20% MEMS with 18 months, and 100% with 2-year battery life respectively.

Prevalence and determinants of physical activity and fluid intake in kidney transplant recipients

BACKGROUND AND SIGNIFICANCE

Self-care for kidney transplantation is recommended to maintain kidney function. Little is known about levels of self-care practices and demographic, psychosocial, and health-related correlates.

AIM

To investigate patients' self-reported exercise and fluid intake, demographic and psychosocial factors associated with these self-care practices, and health-related quality of life.

METHODS

Eighty-eight of 158 kidney recipients from two academic medical centers completed a semi-structured interview and surveys 2 months post-transplant.

RESULTS

Most patients were sedentary (76%) with a quarter exercising either regularly (11%) or not at current recommendations (13%). One-third (35%) reported drinking the recommended 3 L of fluid daily. Multivariate analyses indicated that private insurance, high self-efficacy, and better physical functioning were significantly associated with engaging in physical activity (p < 0.05); while male gender, private insurance, high self-efficacy, and not attributing oneself responsible for transplant success were significant predictors of adherence to fluid intake (p < 0.05). Despite the significance of these predictors, models for physical activity and fluid intake explained 10-15% of the overall variance in these behaviors. Multivariate analyses indicated that younger age, high value of exercise, and higher social functioning significantly (p < 0.05) predicted high self-efficacy for physical activity, while being married significantly (p < 0.05) predicted high self-efficacy for fluid intake.

CONCLUSION

Identifying patients at risk of inadequate self-care practice is essential for educating patients about the importance of self-care.

Transplant outcomes and economic costs associated with patient noncompliance to immunosuppression

We describe factors associated with immunosuppression compliance after kidney transplantation and examine relationships between compliance with allograft outcomes and costs. Medicare claims for immunosuppression in 15 525 renal transplant recipients with at least 1 year of graft function were used to calculate compliance as medication possession ratio. Compliance was categorized by quartiles as poor, fair, good and excellent. We modeled adjusted associations of clinical factors with the likelihood of persistent compliance by multiple logistic regressions (aOR), and estimated associations of compliance with subsequent graft and patient survival with Cox proportional hazards (aHR). Adolescent recipients aged 19-24 years were more likely to be persistently noncompliant compared to patients aged 24-44 years (aOR 1.49 [1.06-2.10]). Poor (aHR 1.80 [1.52-2.13]) and fair (aHR 1.63[1.37-1.93]) compliant recipients were associated with increased risks of allograft loss compared to the excellent compliant recipients. Persistent low compliance was associated with a $12 840 increase in individual 3-year medical costs. Immunosuppression medication possession ratios indicative of less than the highest quartile of compliance predicted increased risk of graft loss and elevated costs. These findings suggest that interventions to improve medication compliance among kidney transplant recipients should emphasize the benefits of maximal compliance, rather than discourage low compliance.

Longitudinal analysis of physical activity, fluid intake, and graft function among kidney transplant recipients

Self-care is recommended to kidney transplant recipients as a vital component to maintain long-term graft function. However, little is known about the effects of physical activity, fluid intake, and smoking history on graft function. This longitudinal study examined the relationship between self-care practices on graft function among 88 new kidney transplant recipients in Chicago, IL and Albany, NY between 2005 and 2008. Participants were interviewed, completed surveys, and medical charts were abstracted. Physical activity, fluid intake, and smoking history at baseline were compared with changes in estimated glomerular filtration rate (eGFR) (every 6 months up to 1 year) using bivariate and multivariate regression analysis, while controlling for sociodemographic and clinical transplant variables. Multivariate analyses revealed that greater physical activity was significantly (P < 0.05) associated with improvement in GFR at 6 months; while greater physical activity, absence of smoking history, and nonwhite ethnicity were significant (P < 0.05) predictors of improvement in GFR at 12 months. These results suggest that increasing physical activity levels in kidney recipients may be an effective behavioral measure to help ensure graft functioning. Our findings suggest the need for a randomized controlled trial of exercise, fluid intake, and smoking history on GFR beyond 12 months.

Medication adherence in successful kidney transplant recipients

OBJECTIVE

To explore the medication-taking behavior of successful kidney transplant recipients and determine what behaviors were common among this group.

METHODS

Open-ended interviews were conducted by telephone with 19 individuals who had successfully maintained a transplanted kidney for 25 years or more. Data were coded by using a grounded theory approach to explore patterns of phenomena, common descriptions, and relationships.

RESULTS

Four themes emerged as participants described the behaviors they developed to adhere successfully to the immunosuppressive medication required for maintaining their transplanted kidneys. The themes were reminder methods, obtaining medications, maintaining routines, and problem-solving strategies. Kidney transplant recipients identified the importance of developing and maintaining medication-taking skills and routines on medication adherence. Problem-solving abilities were also valuable during times of disruption of normal routines.

CONCLUSIONS

Interventions focusing on medication-taking skills, habit formation, and resources for problem solving may improve immunosuppressive medication adherence and clinical outcomes in kidney transplant recipients.

Interventions to improve medication-adherence after transplantation: a systematic review

Reports of interventions to improve adherence to medical regimens in solid organ transplant recipients are scarce. A systematic review identified 12 intervention studies. These studies focused on renal, heart, and liver transplant recipients. Five reports used randomized controlled trial (RCT) designs. Sample sizes varied between 18 and 110 subjects. The interventions are difficult to evaluate and categorize because of brief descriptions of intervention details. Of the 12 studies identified in this review, only five studies found a statistically significant improvement in at least one medication-adherence outcome with the intervention. In general, most included a combination of patient-focused cognitive/educational, counseling/behavioral, and psychologic/affective dimensions. Eight studies intervened at the healthcare provider, healthcare setting or healthcare system level, but showed a limited improvement in adherence. No single intervention proved to be superior at increasing medication-adherence in organ transplantation, but a combination of interventions in a team approach for the chronic disease management of organ transplant patients may be effective in a long-term perspective. In conclusion, finding the most effective combination of interventions to enhance adherence is vital. Utilizing an RCT design and adhering to the CONSORT guidelines can lead to higher quality studies and possibly more effective intervention studies to enhance medication-adherence.

Medication-taking among adult renal transplant recipients: barriers and strategies

Medication adherence is essential for the survival of kidney grafts, however, the complexity of the medication-taking regimen makes adherence difficult. Little is known about barriers to medication-taking and strategies to foster medication-taking. This cross-sectional study involved semi-structured interviews with 82 kidney transplant recipients approximately 2 months post-transplant on medication-related adherence, barriers to medication-taking, and strategies to foster medication-taking. Although self-reported adherence was high (88%), qualitative analysis revealed that half of the patients (49%) reported experiencing at least one barrier to medication-taking. The most common barriers were: not remembering to refill prescriptions (13%), changes to medication prescriptions or dosages (13%), being busy (10%), forgetting to bring medicines with them (10%), and being away from home (10%). The most common strategies to foster medication-taking were: maintaining a schedule of medication-taking (60%), organizing pills using pillboxes, baggies, cups (42%), bringing medicines with them (34%), organizing pills according to routine times (32%), and relying on other people to remind them (26%). Understanding the range of barriers to adherence and strategies kidney recipients devised to promote medication-taking may help transplant clinicians to better educate transplant recipients about appropriate medication-taking, mitigate the risk of medication nonadherence-related rejection, and may help inform patient-centered interventions to improve medication adherence.

Nonadherence consensus conference summary report

This report is a summary of a 'Consensus Conference' on nonadherence (NA) to immunosuppressants. Its aims were: (1) to discuss the state-of-the-art on the definition, prevalence and measurement of NA, its risk factors and impact on clinical and economical outcomes and interventions and (2) to provide recommendations for future studies. A two-day meeting was held in Florida in January 2008, inviting 66 medical and allied health adherence transplant and nontransplant experts. A scientific committee prepared the meeting. Consensus was reached using plenary and interactive presentations and discussions in small break-out groups. Plenary presenters prepared a summary beforehand. Break-out group leaders initiated discussion between the group members prior to the meeting using conference calls and e-mail and provided a summary afterward. Conclusions were that NA: (a) is more prevalent than we assume; (b) is hard to measure accurately; (c) tends to confer worse outcomes; (d) happens for a number of reasons, and system-related factors including the patient's culture, the healthcare provider and the setting and (e) it is not currently known how to improve adherence. This consensus report provided some roadmaps for future studies on this complicated, multifaceted problem.

Impact of gastrointestinal-related side effects on mycophenolate mofetil dosing and potential therapeutic strategies

In renal transplant patients receiving mycophenolate mofetil (MMF), maintaining an adequate dosing regimen has been shown to maximize short- and long-term outcomes. Gastrointestinal (GI) adverse events associated with MMF are frequent, and lead to MMF dose reduction or withdrawal in 40-50% of cases. Among MMF-treated patients experiencing GI complications, one analysis has reported MMF discontinuation to be associated with almost a threefold increase in risk of graft loss, while a dose reduction > or = 50% carried over a twofold increase in risk. If GI symptoms improve and the pre-reduction MMF dose is resumed the increased risk of graft loss may be reversed, but continuing intolerance can make this difficult to achieve. Investigation of contributing factors is important and may alleviate symptoms. Conversion to enteric-coated mycophenolate sodium (EC-MPS) may be an effective option. Two open-label studies using patient-reported outcomes data have shown a significant and clinically relevant benefit in GI-related symptom burden after conversion from MMF to EC-MPS. In conclusion, monitoring of GI complications is essential following renal transplantation, and maintaining adequate mycophenolic acid exposure should be a priority when considering treatment options.

Diagnostic accuracy of measurement methods to assess non-adherence to immunosuppressive drugs in kidney transplant recipients

Valid assessment of immunosuppressive therapy non-adherence (NAH) is vital: NAH is associated with negative transplantation outcomes. We studied the diagnostic accuracy of assay, patient self-reports and clinicians' collateral reports and composite adherence scores using electronic monitoring (EM) as a reference standard. This cross-sectional study included a convenience sample of 249 adult kidney transplant recipients (Ktx) (female: 43.4%; mean age 53.6 [SD: 12.7], median 7 years [IQR: 9 years] post-Ktx). NAH was assessed using EM over 3 months (i.e. reference standard), assays of cyclosporine, tacrolimus, mycophenolat-mofetil, patients' self-reports and clinicians' collateral reports. The constructed composite adherence score included assay, self-reports and collateral reports. NAH's prevalence across the measurement methods was EM: 17.3%; assay: 33% (cyclosporine: 25.8%; tacrolimus: 35.1%; mycophenolat-mofetil: 40.2%); self-report: 12.4%; collateral reports: 24.9% and composite adherence score: 38.9%, respectively. The composite adherence score and collateral reports showed the highest and lowest sensitivities to NAH (72.1% and 15.8%, respectively). Specificity was highest for collateral reports of at least three clinicians (93.1%). Likelihood ratio of a positive test was 2.74 for composite adherence score. No measures showed high sensitivity alongside high specificity. Combining measures increased diagnostic accuracy, indicating the relevance of combined measures for clinical and research purposes.