Low Adherence to Immunosuppressants Is Associated With Symptom Experience Among Kidney Transplant Recipients

Development of a Patient Reported Outcome Measure of Side Effects for Patients Taking Calcineurin Inhibitors: The FACIT-CNI-Ntx

RATIONALE & OBJECTIVE

Valid measures of side effects are important to inform clinical use of calcineurin inhibitors (CNIs). This study sought to develop and establish the content validity of a PRO measure to capture side effects among kidney transplant recipients taking CNIs.

STUDY DESIGN

Qualitative interviews for concept elicitation and cognitive debriefing.

SETTING & PARTICIPANTS

Participants enrolled in the qualitative study were adults who received a kidney transplant ≤5 years earlier and were currently taking a CNI for immunosuppression.

ANALYTICAL APPROACH

Concept elicitation interview data were analyzed by developing a codebook from a list of symptoms described by participants that they attributed to CNIs or their immunosuppression regimen and by applying the constant comparative approach separately by two coders. The most bothersome and important side effects reported by participants were used to select existing PRO items. Cognitive debriefing examined item comprehensibility, comprehensiveness, and relevance.

RESULTS

Among 24 participating patients, 12 underwent concept elicitation interviews. Most (n=10) participants reported neurological or cognitive CNI side effects and a majority of those (n=6) reported that neurological and cognitive side effects were the most bothersome adverse consequences of therapy. Based on these findings, 16 items were either selected from the Functional Assessment for Chronic Illness Therapy (FACIT) PRO item library or were newly written. These items were refined and reduced to 13 for cognitive debriefing that was completed by 18 participants. These items were organized into two scales: Tremors and Cognitive Side Effects.

LIMITATIONS

Though a diverse set of patients participated, they were not representative of all recipients of kidney transplants. The PRO's reliability, convergent and known-groups validity, and responsiveness to change were not evaluated. Symptoms could not be definitively attributed to CNIs.

CONCLUSIONS

A newly developed PRO measure, the Functional Assessment of Chronic Illness Therapy-Calcineurin Inhibitor-Neurotoxicity (FACIT-CNI-Ntx), captures important side effects among patients receiving CNIs.

A viewpoint describing the American Society of Transplantation rationale to conduct a comprehensive patient survey assessing unmet immunosuppressive therapy needs

This viewpoint aims to "set the stage" and provide the rationale for the proposed development of a large-scale, comprehensive survey assessing transplant patients' perceived unmet immunosuppressive therapy needs. Research in organ transplantation has historically focused on reducing the incidence and impact of rejection on allograft survival and minimizing or eliminating the need for chronic immunosuppressive therapies. There has been less emphasis and investment in therapies to improve patient-reported outcomes including health-related quality of life and side-effects. Patient-focused drug development (PFDD) is a new and important emphasis of the Food and Drug Administration (FDA) that provides a guiding philosophy for incorporating the patient experience into drug development and evaluation. The American Society of Transplantation (AST) Board of Directors commissioned this working group to prepare for the conduct of a comprehensive patient survey assessing unmet immunosuppressive therapy needs. This paper aims to describe the basis for why it is important to conduct this survey and briefly outline the plan for broad stakeholder engagement to ensure the information gained is diverse, inclusive, and relevant for advancing PFDD in organ transplant recipients.

Exploring Transplant Medication-Taking Behaviours in Older Adult Kidney Transplant Recipients: A Qualitative Study of Semi-Structured Interviews

Background

Today, older adult patients routinely undergo kidney transplantation. To support graft survival, patients must take immunosuppressant medicines for the rest of their lives. The post-transplant medication regimen is complex, and barriers to medication taking are likely confounded by both functional and intrinsic changes associated with advancing age. To develop diverse and innovative approaches to support best health outcomes in this vulnerable age group, it is imperative that the degree to which patients’ needs are currently being met, be identified.

Aim

The aim of this study was to examine medication-taking behaviours of kidney transplant recipients transplanted at 60 years of age or older.

Methods

This qualitative study used semi-structured patient interviews to explore how kidney transplant recipients currently manage their immunosuppressant regimen and how they cope after transplantation with the complex routine. Data were themed using the principles of Grounded Theory methodology; with interviews conducted until data saturation was reached.

Results

Quantitative information was collected from 14 participants who ranged in age from 66 to 77 years (at time of interview), and were prescribed a median of 13 (min: 10, max: 26) medicines. The main themes that emerged from the interview were variability in health literacy toward medicines, the importance of support networks, the need to adjust health expectations, factors that were motivators for self-care, different approaches to medication management, and different approaches to medication taking. Overall, it was found that patients prioritised medication taking above all else, and gratitude to their donor was a powerful motivator to adhere. However, strategies to support medication taking were sometimes ineffective when patients’ routine changed.

Conclusions

Future interventions should consider approaches to foster adaptable medication taking behaviours that stand up to changes in the day-to-day routine.

Medication taking is complicated in transplant recipients, due to the number of medicines that need to be taken and the complex nature of the treatment regimen. Challenges in older transplant recipients may be more pronounced and varied compared with younger adults. There are multiple factors that may impact medication taking in older adults and each requires consideration, including level of dependence, living arrangements, level of mobility and manual dexterity, vision and memory, and social situation. To better identify the gaps in support, patients’ current perspectives around medication taking and how they cope after transplantation must be explored. Therefore, this study aimed to identify how older adult transplant recipients currently manage their anti-rejection medicine regimen. Participants described several strategies around how they manage a complex medication regimen. These included cues such as an alarm and linking the time they should take their medication to already established habits such as eating meals. Most participants discussed at length their relationships, and it seems that these relationships are often crucial to post-transplant positivity. Additionally, extreme gratitude to the donor, relative improvement in their life quality (compared with the rapid deterioration in their health when on dialysis), and fear of consequences (particularly graft failure) were important facilitators of self-care and served as timely reminders to prioritise one’s own health. To foster more robust medication-taking habits, future education needs to be tailored to each individual patient and include details about how to link medication taking to already established routines (coined ‘habit stacking’).

The Effect of Immunosuppressant Therapy Adherence on the Comfort of Liver Transplant Recipients

Inadequate immunosuppressive therapy causes rejection, whereas an overdose may lead to infections or malignancy to affect a patient's life and comfort. This study used a descriptive correlational design to determine how compliance with immunosuppressive therapy affected the well-being of liver transplant patients. The study was conducted in the liver transplant unit of a university hospital with 103 patients who underwent liver transplant surgery. The target population included patients who received treatment in liver transplant clinics between July 2016 and August 2017. Mean age of the patients in the study was 44.66 ± 14.86 years and the time after transplant was 15.48 ± 16.90 months on the average. A significant difference was found between mean General Comfort Scale scores according to the variable of adherence status (t = 6.898, p < .05). Simple linear regression analysis showed a positive moderate, significant correlation between the adherence variable and mean General Comfort Scale scores (R = 0.543, p < .001). It was found that the patients who adhered to immunosuppressive therapy experienced higher levels of comfort. Therefore, arrangements to improve patient adherence to therapy, hence comfort, are recommended, as well as periodic evaluations of patient comfort levels.

Fatigue in Kidney Transplantation: A Systematic Review and Meta-Analysis

Fatigue is still present in up to 40–50% of kidney transplant recipients (KTR), the results of studies comparing the prevalence among patients on hemodialysis (HD) and KTR led to conflicting results. Fatigue correlates include inflammation, symptoms of depression, sleep disorders and obesity. Fatigue in KTR leads to significant functional impairment, it is common among KTR poorly adherent to immunosuppressive therapy and is associated with a serious deterioration of quality of life. The following databases were searched for relevant studies up to November 2020: Medline, PubMed, Web of Science and the Cochrane Library. Several studies have compared the prevalence and severity of fatigue between KTR and hemodialysis or healthy patients. They have shown that fatigue determines a significant functional deterioration with less chance of having a paid job and a significant change in quality of life. The aim of the review is to report methods to assess fatigue and its prevalence in KTR patients, compared to HD subjects and define the effects of fatigue on health status and daily life. There is no evidence of studies on the treatment of this symptom in KTR. Efforts to identify and treat fatigue should be a priority to improve the quality of life of KTR.

Association Between Regulatory Emotional Self-Efficacy and Immunosuppressive Medication Adherence in Renal Transplant Recipients:Does Medication Belief Act as a Mediator?

Background: Few studies have investigated the association between regulatory emotional self-efficacy (RESE) and immunosuppressive medication adherence or the mechanisms underlying this relationship. Considering that previous evidence of immunosuppressive medication adherence depended on the level of immunosuppressive medication beliefs, a model of multiple mediation was tested in which immunosuppressive medication beliefs acted as mediators of the relationship between RESE and immunosuppressive medication adherence. Methods: A retrospective cross-sectional study was performed in 293 renal transplant patients during outpatient follow-ups from November 2019 to February 2020 in China. All participants completed a general demographic questionnaire, the Chinese version of the RESE, the Beliefs about Medication Questionnaire, and the Basel Assessment of Adherence with Immunosuppressive Medication Scale (BAASIS). Spearson correlation analysis was carried out to identify the correlation between RESE and immunosuppressive medication adherence. Binary logistic regression analysis was performed to confirm factors associated with immunosuppressive medication adherence in renal transplant recipients. Mediating effect analysis was used to explore the internal interaction between RESE and immunosuppressive medication adherence. Results: A total of 293 renal transplant patients were recruited, including 111 women and 182 men with a mean age of 42.5 years (SD = 10.0). A total of 23.21% of patients exhibited immunosuppressive medication none-adherence behavior, and 12.97% reported altering the prescribed amount of immunosuppressive medication without physician permission, which was most popular behavior among patients. The mean RESE score was 45.78 ± 6.12; the positive (POS) score was the highest, and the anger-irritation (ANG) score was the lowest. The correlation analysis results showed that RESE (r = -0.642, p < 0.01) and immunosuppressive medication beliefs (r = -0.534, p < 0.01) were significantly associated with immunosuppressive medication adherence. Binary logistic regression analysis indicated that marital status, fertility status, rejection, immunosuppressive medication beliefs, and RESE were found to be independent predictors of immunosuppressive medication adherence [R 2 = 0.803, p < 0.05]. The results of the mediating effect analysis showed that immunosuppressive medication necessity had a partial mediating effect, RESE directly and indirectly affected immunosuppressive medication adherence via immunosuppressive medication necessity, and immunosuppressive medication concerns were not a mediator between RESE and immunosuppressive medication adherence. Conclusion: The levels of immunosuppressive medication adherence in renal transplant patients need to be improved in China. Marital status, fertility status, rejection, immunosuppressive medication beliefs, and RESE were major factors affecting immunosuppressive medication adherence. RESE could affect immunosuppressive medication adherence indirectly through immunosuppressive medication necessity.

Adherence of Renal Transplant Recipients to Once-daily, Prolonged-Release and Twice-daily, Immediate-release Tacrolimus-based Regimens in a Real-life Setting in Sweden

BACKGROUND

In this study we investigated medication adherence of kidney transplant patients (KTPs) to an immediate-release tacrolimus (IR-T) regimen and, after conversion, to a prolonged-release tacrolimus (PR-T) regimen in routine clinical practice.

METHODS

This was a noninterventional, observational, multicenter Swedish study. We included adult KTPs with stable graft function, remaining on IR-T or converting from IR-T to PR-T. Data were collected at baseline, and months 3, 6, and 12 postbaseline. The primary endpoint was adherence using the Basel Assessment of Adherence to Immunosuppressive Medication Scale (BAASIS). Secondary assessments included tacrolimus dose and trough levels, clinical laboratory parameters (eg, estimated glomerular filtration rate), and adverse drug reactions (ADRs).

RESULTS

Overall, 233 KTPs were analyzed (PR-T, n = 175; IR-T, n = 58). Mean change in PR-T dose from baseline (4.8 mg/d) to month 12 was -0.2 mg/d, and for IR-T (4.2 mg/d) was -0.4 mg/d; tacrolimus trough levels remained similar. Overall adherence was similar between baseline and month 12 in both groups (PR-T: 54.4% vs 57.0%, respectively; IR-T: 65.5% vs 69.4%); timing adherence followed a similar pattern. The probability of taking adherence improved between baseline and month 12 (odds ratio, 1.97; P = .0092) in the PR-T group only. Mean BAASIS visual analog scale score at baseline was 94.3 ± 11.1% (PR-T) and 95.3 ± 7.6% (IR-T), and >95% at subsequent visits. Laboratory parameters remained stable. Eight (4.6%) patients receiving PR-T (none receiving IR-T) had ADRs considered probably/possibly treatment-related.

CONCLUSION

Disparity existed between high, patient-perceived and low, actual adherence. Overall adherence to the immunosuppressive regimen (measured by BAASIS) did not improve significantly over 12 months in stable KTPs converting to PR-T or remaining on IR-T; renal function remained stable.

Validation and Adaptation of the "Modified Transplant Symptom Occurrence and Symptom Distress Scale" for Kidney Transplant Recipients

The aim was to adapt and validate the Modified Transplant Symptom Occurrence and Symptom Distress Scale (MTSOSD-59R) for kidney transplant recipients undergoing immunosuppressive therapy in Korea. The MTSOSD-59R has been used with solid organ transplant recipients globally to assess the adverse effects of immunosuppressive medication. A descriptive cross-sectional design was used. MTSOSD-59R was first translated, and pilot tested. Next, content validity was established with nine organ transplant experts. Then, from October 2017 to October 2018, the Korean MTOSOSD-59R was administered to a convenience sample of 122 kidney transplant recipients recruited from a single center. Ridit analysis was used to measure symptom occurrence and distress. The known-group approach was used to test the construct validity using Mann-Whitney U tests for between-group comparisons. The content validity index for MTSOSD-59R was 0.98, and known-group validity was confirmed. The split-half Spearman-Brown corrected reliability coefficient was 0.902 for symptom occurrence and 0.893 for symptom distress. The four most frequent and distressing symptoms were fatigue, lack of energy, thinning hair, and erectile dysfunction (male). Results suggest this Korean MTSOSD-59R adaptation has adequate language, construct validity, and reliability to gather meaningful information from kidney transplant recipients in Korea.

Symptom experience as a predictor of cardiac rehabilitation education programme attendance after percutaneous coronary intervention: A prospective questionnaire survey

BACKGROUND

Despite evidence that participation in cardiac rehabilitation programmes after percutaneous coronary intervention is associated with better clinical outcomes, many patients with coronary artery disease do not participate in such programmes. A traditional educational approach is recommended to provide patients with information regarding the benefits of cardiac rehabilitation in relation to their underlying coronary artery disease and modification of risk factors.

AIMS

The purpose of this study was to examine the role of patient factors (symptom experience and health belief) on cardiac rehabilitation education programme attendance among Korean patients subjected to percutaneous coronary intervention.

METHODS

A prospective survey was conducted enrolling 173 patients who underwent percutaneous coronary intervention. Information on symptom experience, health belief (perceived susceptibility/severity/benefits/ barriers) and sociodemographic and clinical characteristics was collected at baseline (after percutaneous coronary intervention). Three to four weeks later, information on disease-related knowledge and health behaviour was compared between cardiac rehabilitation education programme attendees and non-attendees.

RESULTS

Eighty of 173 (46.2%) patients surveyed attended the cardiac rehabilitation education programme. Symptom experience before percutaneous coronary intervention was the most significant predictor of programme attendance (odds ratio=3.46; 95% confidence interval 1.45-8.27), followed by higher perceived socioeconomic status (odds ratio=2.90; 95% confidence interval 1.28-6.58), perceived susceptibility (odds ratio=1.22, 95% confidence interval 1.08-1.39), perceived benefits (odds ratio=1.09; 95% confidence interval 1.02-1.17) and perceived severity (odds ratio=1.04; 95% confidence interval 1.00-1.08). Better disease-related knowledge and health behaviour were significantly associated with cardiac rehabilitation education programme attendance.

CONCLUSION

This study provides evidence that educational programmes to help improve patients' perceptions of their disease susceptibility and severity, especially health behaviour benefits in patients without symptom experience before percutaneous coronary intervention, are necessary.

A Canadian Survey on Adverse Symptoms Experienced by Solid Organ Transplant Recipients

INTRODUCTION

Adverse symptoms experienced by solid organ transplant recipients remain largely unexplored despite their purported frequency.

OBJECTIVE

To characterize patient perspectives on adverse symptoms, identifying the most problematic symptoms and the perceived cause and treatability, and to evaluate their impact on quality of life (QoL) and medication adherence.

METHODS

An electronic survey was distributed to members of the Canadian Transplant Association, to characterize perceptions on symptom experience (Modified Transplant Symptom Occurrence and Distress Scale), and QoL (Short Form-12), medication adherence (Basel Assessment of Adherence to Immunosuppressive Medications Scale), demographics, and clinical situation.

RESULTS

The questionnaire was distributed to 249 solid organ transplant recipients and achieved a 51% response rate (N = 127). Respondents reported a mean of 25 (standard deviation 10) adverse symptoms each. In women, the most prevalent and distressing symptoms were tiredness, lack of energy, sleep difficulties, difficulty concentrating or memory problems, diarrhea, joint pain, and depression. In men, they were tiredness, flatulence, lack of energy, sleep difficulties, and erectile problems. With the exception of flatulence, these symptoms were more often perceived to be caused by medical conditions rather than by immunosuppressants or other medications. Quality of life was similar to the general public, with mean physical and mental component scores of 47.4 (9.9) and 52.1 (8.2), respectively (relative to a US average of 50 [10]). However, QoL scores inversely correlated to the number of symptoms reported and were higher in patients who perceived all symptoms to be treatable.

CONCLUSION

Adverse symptoms may impact patient well-being. Perceived cause and treatability should be further explored.

Trajectories of health-related quality of life among renal transplant patients associated with graft failure and symptom distress: Analysis of the BENEFIT and BENEFIT-EXT trials

Understanding the correlation between transplant symptoms, health-related quality of life (HRQoL), and graft outcomes is needed to support patient-focused drug development and posttransplant management. A post-hoc analysis of patient-reported outcomes from the Phase III belatacept trials was conducted in order to investigate the interrelationship between trajectories of HRQoL, symptom experience, and allograft outcomes. HRQoL and symptom experience were evaluated using Short-Form 36 Survey (SF-36) and Modified Transplant Symptom Occurrence and Distress Scale (MTSOSD-59R), respectively. HRQoL was captured in 831 eligible renal transplant patients at baseline, 12, 24, and 36 months posttransplant. Following transplantation, patients reported improvements in all SF-36 subscales compared to baseline. Latent class analysis revealed four trajectories in perceived general health, which were associated with graft failure after adjustment. Compared to patients with good perceived health, patients with fair and poor perceived health had 4.7 (95% confidence interval [CI] 1.5-14.8, P < .01) and 19.8 (95% CI 5.9-66.0, P < .01) times the risk of graft failure, respectively. Using multinomial logistic regression, different sets of symptoms were associated with perceived general health at baseline and 12 months posttransplant. The study supports monitoring HRQoL and symptom experience to capture each patient's health perspective, improve drug development, and optimize posttransplant management.

Evaluating symptom burden in kidney transplant recipients: validation of the revised Edmonton Symptom Assessment System for kidney transplant recipients - a single-center, cross-sectional study

We assessed the validity of the Edmonton Symptom Assessment System (ESAS-r) in kidney transplant recipients (KTR). A cross-sectional sample of 252 KTR was recruited. Individual ESAS-r symptom scores and symptom domain scores were evaluated. Internal consistency, convergent validity, and construct validity were assessed with Cronbach's α, Spearman's rank correlations, and a priori-defined risk group comparisons. Mean (SD) age was 51 (16), 58% were male, and 58% Caucasian. ESAS-r Physical, Emotional, and Global Symptom Scores demonstrated good internal consistency (α > 0.8 for all). ESAS-r Physical and Global Symptom Scores strongly correlated with PHQ-9 scores (0.72, 95% CI: 0.64-0.78 and 0.74, 95% CI: 0.67-0.80). For a priori-defined risk groups, individual ESAS-r symptom score differed between groups with lower versus higher eGFR [pain: 1 (0-3) vs. 0 (0-2), delta = 0.18; tiredness: 3 (1-5) vs. 1.5 (0-4), delta = 0.21] and lower versus higher hemoglobin [tiredness: 3 (1-6) vs. 2 (0-4), delta = 0.27]. ESAS-r Global and Physical Symptom Scores differed between groups with lower versus higher hemoglobin [13 (6-29) vs. 6.5 (0-18.5), delta = 0.3, and 9 (2-19) vs. 4 (0-13), delta = 0.24] and lower versus higher eGFR [11 (4-20) vs. 6.5 (2-13), delta = 0.21, and 7 (2-16) vs. 3 (0-9), delta = 0.26]. These data support reliability and construct validity of ESAS-r in KTR. Future studies should explore its clinical utility for symptom assessment among KTR.

Exploration of symptom experience in kidney transplant recipients based on symptoms experience model

PURPOSE

Kidney transplant recipients suffer from a variety of symptoms, and symptom management is crucial in improving their quality of life (QOL). Accordingly, this study aims to identify the symptoms experienced by kidney transplant recipients and examine the relationship amongst antecedents, symptom experience and QOL of recipients in China.

METHODS

A total of 300 kidney transplant recipients were investigated in one of the most first-rate hospitals in China by asking them to fill out a self-designed general questionnaire, the Symptom Experience Scale, the Sense of Coherence Scale (Chinese version), the Revised Life Orientation Test (Chinese version) and the 36-item Short Form Health Survey (Chinese version).

RESULTS

Kidney transplant recipients experienced multiple symptoms that were frequent, severe and bothersome. The final model showed significant consistency with the data. In the QOL model, post-transplant time, complications, immunosuppressive agents and sense of coherence explained 30.7% of the variance of symptom experience. Moreover, habitual residence, economic burden, post-transplant time, kidney function, optimism and symptom experience accounted for 70.6% of the variance on QOL.

CONCLUSIONS

We can explain the relationship between antecedents, symptom experience and QOL amongst Chinese kidney transplant recipients by using Symptoms Experience Model. Clinicians and caregivers can manage the recipient's symptoms during follow-up from psychological, physical and medication management perspectives. Improving sense of coherence, maintaining optimism and managing symptoms are essential for enhancing QOL.

Factors Associated With Adherence To Immunosuppressive Therapy And Barriers In Asian Kidney Transplant Recipients

Background

Medication non-adherence is the major risk factor for rejection episodes. The aim of this study was to determine the risk factors associated with adherence to immunosuppressive regimen and its barriers among kidney transplant (KT) recipients.

Methods

A cross-sectional study was performed in two outpatient post-transplant clinics in Mashhad, northeast of Iran. All patients who attended the clinics from August to October 2017 were included. Patients’s knowledge, adherence to immunosuppressive regimen, and quality of life were measured using the Kidney Transplant Understanding Tool, Basel Assessment of Adherence to Immunosuppressive Medications Scale (BAASIS), and SF-12V2 questionnaire, respectively. The barriers in adhering immunosuppressive regimen were investigated by Immunosuppressive Therapy Barriers Scale. Logistic regression was used to screen the significant risk factors of medication non-adherence.

Results

In this study, 244 KT recipients were included with a mean age of 39.6±12.5 years. Based on the BAASIS score, 111 (45.5%) patients were adherent to immunosuppressive regimen. Female patients were more likely to be adherent (OR=0.48, p<0.01). The patients with higher level of quality of life were more likely to follow immunosuppressive medications (OR=1.078, p<0.05). The main barriers were as follows: concurrent use of many immunosuppressants, lack of knowledge about the usefulness of immunosuppressive medications, confusion in medication taking, and difficulty in remembering medication taking.

Conclusion

More than half of the KT recipients were non-adherence to immunosuppressive regimen. These findings highlight the need for designing interventions in order to reduce or eliminate these barriers and consequently increase medication adherence among KT recipients.

Life and expectations post-kidney transplant: a qualitative analysis of patient responses

BACKGROUND

The effect of a kidney transplant on a recipient extends beyond the restoration of kidney function. However, there is limited qualitative analysis of recipient perspectives on life following transplantation, particularly in the United States. To understand the full patient experience, it is necessary to understand recipient views on life adjustments after kidney transplantation, medical management, and quality of life. This could lead to improvements in recipient care and sense of well-being.

METHODS

We conducted a paper-based survey from March 23 to October 1, 2015 of 476 kidney transplant recipients at the University of Michigan Health System in Ann Arbor, Michigan. We analyzed their open-ended responses using qualitative research methods. This is a companion analysis to a previous quantitative report on the closed-ended responses to that survey.

RESULTS

Common themes relating to changes following transplantation included: improvements in quality of life, a return to normalcy, better health and more energy. Concerns included: duration of graft survival, fears about one day returning to dialysis or needing to undergo another kidney transplant, comorbidities, future quality of life, and the cost and quality of their healthcare. Many recipients were grateful for their transplant, but some were anxious about the burdens transplantation placed on their loved ones.

CONCLUSIONS

While most recipients reported meaningful improvements in health and lifestyle after kidney transplantation, a minority of participants experienced declines in energy or health status. Worries about how long the transplant will function, future health, and cost and quality of healthcare are prevalent. Future research could study the effects of providing additional information, programs, and interventions following transplantation that target these concerns. This may better prepare and support kidney recipients and lead to improvements in the patient experience.

Comparison of patient and provider goals, expectations, and experiences following kidney transplantation

OBJECTIVE

This study examined whether kidney transplant recipients' post-transplant goals and expectations align with those as perceived by their healthcare providers.

METHODS

Post-transplant goals and expectations across four domains were assessed via a descriptive survey of healthcare providers (N=72) and kidney transplant recipients (N=476) at the University of Michigan from March 23 - October 1, 2015. Demographic and transplant-related data were collected via a retrospective review of medical records, and survey responses were compared using Chi-square tests, Wilcoxon two-sample tests, and logistic regression.

RESULTS

Patients expressed higher quality of life (mean Neuro-QOL T-score 60.2 vs. 52.7), were less likely to report that they were currently experiencing complications (11% vs. 24%), and anticipated their transplants to last longer (median 25 vs. 15 years) and to live longer (median 80 vs. 71 years) than providers expected for their typical patient. However, provider perceptions of patients' future ability to feel well, perform daily activities and work were significantly higher than those expressed by patients (all p<0.05).

CONCLUSION

Kidney transplant patient and provider expectations differ in significant ways.

PRACTICE IMPLICATIONS

Identified areas of discordance may provide opportunities for patients and providers to better evaluate treatment option tradeoffs in post-transplant clinical interactions.

Posttransplant Medical Adherence: What Have We Learned and Can We Do Better?

Purpose of review

Non-adherence to the medical regimen after kidney transplantation can contribute to poor clinical outcomes, and strategies to maximize adherence are sought by care providers and patients alike. We assessed recent evidence on prevalence, risk factors, and clinical outcomes associated with non-adherence to the medical regimen after kidney transplantation. We summarized recent clinical trials testing interventions to improve adherence and generated recommendations for future research and clinical practice.

Recent findings

A large evidence base documents rates of non-adherence to each of the multiple components of the regimen, including medication-taking, lifestyle activities, clinical care requirements, and substance use restrictions. Some risk factors for non-adherence are well known but the full range of risk factors remains unclear. Non-adherence to immunosuppressants and to other components of the regimen increases morbidity and mortality risks. Recent interventions, including education and counseling; electronic health strategies; and medication dose modifications, show promise for reducing immunosuppressant non-adherence. However, most of these interventions would be difficult to deploy in everyday clinical practice. Systematic dissemination of efficacious interventions into clinical practice has not been undertaken.

Summary

Rates and risk factors for non-adherence to the medical regimen have been examined and there is evidence that non-adherence may be ameliorated by a range of interventions. Although gaps in the evidence base remain, it would be timely to devote greater efforts to dissemination of findings. Thus, efforts are needed to assist transplant programs in using existing evidence to better identify patients who are non-adherent and to design and implement strategies to reduce or prevent non-adherence.

Symptom Experience, Self-Care Adherence, and Quality of Life Among Heart Transplant Recipients in South Korea

Among heart transplant recipients, the perceived quality of life (QOL) is a key indicator of successful transplantation. QOL is affected by posttransplant treatments, including immunosuppressive therapy or self-care. However, few studies have evaluated QOL after heart transplantation in South Korea. This study aimed to investigate posttransplant symptoms associated with immunosuppressant, self-care adherence, and QOL in 105 heart transplant recipients in South Korea. Educational status (β = −1.05, p = .013), symptoms (β = −3.98, p = .004), and diet (β = 0.38, p < .001) were found to affect subjects’ overall QOL. In addition to these factors, caregivers and the duration of heart disease (years) were found to be influencing factors, depending on the individual QOL subdimension. These findings highlight the importance of controlling symptoms and managing medications as well as of self-care (particularly dietary compliance). Educational programs targeting beneficial changes in lifestyle, including diet, are needed.

Non-adherence to immunosuppressants following renal transplantation: a protocol for a systematic review

INTRODUCTION

Adherence to immunosuppressant medication is essential for renal transplant recipients. This review aims to summarise what is known about non-adherence, with a view to providing comprehensive evidence to inform strategies aimed at advancing adherent behaviour.

METHODS AND ANALYSIS

A systematic review of quantitative studies that report adherence to immunosuppressants in adult (over 18 years) renal transplant recipients. The review will follow the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines; study quality will be assessed using the Downs and Black checklist. Systematic searches will be completed across relevant databases. Two reviewers will independently extract data using a predefined data extraction form. We will summarise the operationalisation of adherence across studies and use narrative synthesis to identify factors associated with non-adherence. A meta-analysis will be conducted if there is sufficient homogeneity, and available data, across studies to estimate the prevalence of non-adherence in renal transplant recipients. Heterogeneity will be assessed using the I² test. Survival analysis will be conducted to estimate hazard ratios to explore the impact of non-adherence on graft survival, graft failure and patient survival.

ETHICS AND DISSEMINATION

Findings will be published in a peer-reviewed journal and disseminated at conferences for professionals and researchers. Review outcomes will help support clinical practice by highlighting the extent of non-adherence among adults, and in doing so, signpost the need for suitable intervention.

TRIAL REGISTRATION NUMBER

PROSPERO registration number (CRD42016038751).

Clinical Evaluation of Modified Release and Immediate Release Tacrolimus Formulations

The science of drug delivery has evolved considerably and has led to the development of multiple sustained release formulations. Each of these formulations can present particular challenges in terms of clinical evaluation and necessitate careful study to identify their optimal use in practice. Tacrolimus is an immunosuppressive agent that is widely used in organ transplant recipients. However, it is poorly soluble, has an unpredictable pharmacokinetic profile subject to important genetic polymorphisms and drug-drug interactions, and has a narrow therapeutic index. For these reasons, it represents an agent that could benefit from modified release formulations to overcome these limitations. The objective of this review is to discuss the clinical evaluation of immediate and modified release tacrolimus formulations in renal transplant recipients. Clinical trials from early development of immediate release tacrolimus to formulation-specific post-marketing trials of modified release tacrolimus formulations are reviewed with an emphasis on key elements relating to trial design end endpoint assessment. Particular elements that can be addressed with formulation alterations, such as pharmacokinetics, pharmacogenomics, and toxicity and corresponding clinical evaluations are discussed. In addition, current knowledge gaps in the clinical evaluation of immediate and modified release tacrolimus formulations are discussed to highlight potential avenues for the future development of different tacrolimus formulations with outcomes relevant to the regulators, the transplant community, and to transplant recipients. This review shows that new formulations may alter tacrolimus bioavailability, alleviate certain adverse events while potentially enhancing patient convenience.