Beliefs of Immunosuppressive Medication Among Chinese Renal Transplant Recipients, as Assessed in a Cross-Sectional Study With the Basel Assessment of Adherence to Immunosuppressive Medications Scale

Nonadherence to Immunosuppressant Therapy of Kidney Transplant Candidate Patients: External Validation of the KATITA-25 Scale

BACKGROUND

The self-administered Kidney AlloTransplant Immunosuppressive Therapy Adherence (KATITA-25) questionnaire is a multidimensional scale for use in the pretransplant setting that evaluates the predisposition to nonadherence of patients who are candidates to kidney transplant. The scale has shown adequate internal consistency and test-retest reliability. This study presents the results of an external validation study of the KATITA-25 scale.

METHODS

Patients >18 y old scheduled for kidney transplant were included in this multicenter study. The KATITA-25 scale was administered before surgery and then at 3-mo posttransplantation for evaluation of scale sensitivity to change. At this time, 2 validated medication adherence scales were applied for assessment of concurrent validity. For evaluation of predictive validity, nonadherence to immunosuppressive medication was assessed at 6 and 12 mo after transplantation by 3 independent methods: patient self-report of nonadherence using the Morisky-Green-Levine Medication Assessment Questionnaire scale, serum trough levels of immunosuppressants, and pharmacy refills.

RESULTS

Three twenty-two patients were available for evaluation of concurrent validity and 311 patients of predictive validity. After kidney transplant, the median KATITA-25 score decreased from 20 to 8 ( P  < 0.001), demonstrating scale sensitivity to change, and the KATITA-25 score showed correlation with the Basel Assessment of Adherence to Immunosuppressive Medication Scale score (Spearman's ρ 0.18, P  = 0.002) and the Cuestionario para la Evaluación de la Adhesión al Tratamiento Antiretroviral scores (ρ -0.17, P  = 0.002), confirming concurrent validity. The nonadherence rate was 57.6%. The scale predictive validity was demonstrated by the area under the receiver operating characteristics curve (0.68), sensitivity (59.8%), specificity (68.2%), and positive predictive value (71.8%).

CONCLUSIONS

This external validation study of KATITA-25 scale provided evidence of sensitivity to change, and structural, criterion, and predictive validity.

Development and validation of a LASSO-based prediction model for immunosuppressive medication nonadherence in kidney transplant recipients

INTRODUCTION

To establish a prediction model to predict immunosuppressive medication (IM) nonadherence in kidney transplant recipients (KTRs) based on a combined theory framework.

METHODS

This polycentric, cross-sectional study included 1191 KTRs from October 2020 to February 2021 in China, with 1011 KTRs enrolled in the derivation set and 180 in the external validation set. Variables selected based on the combined theory of planned behavior (TPB)/health belief model (HBM) theory were analyzed by the least absolute shrinkage and selection operator (LASSO). Internal 10 cross-validation was conducted to determine the optimal lambda value. The receiver operating characteristic (ROC) curve, specificity, and sensitivity were used to evaluate the prediction model, and further assessment was run by external validation.

RESULTS

IM nonadherence rate was 38.48% in the derivation set and 37.22% in the validation set. The LASSO model was developed with eight predictors for IM nonadherence: age, preoperative drinking history, education, marital status, perceived barriers, social support, perceived behavioral control, and perceived susceptibility. The model demonstrated acceptable discrimination with the area under the ROC curve of 0.797 (95% CI: 0.745-0.850) in the internal validation set and 0.757 (95% CI: 0.684-0.829) in the external validation set. The specificity and sensitivity in the internal validation and external validation set were 0.741, 0.748, 0.673, and 0.716, respectively.

CONCLUSIONS

The LASSO model was developed to guide identifying high-risk nonadherent patients and timely and effective interventions to improve their prognosis and survival.

Locus of control, self-efficacy perception and treatment adherence in kidney transplant patients

OBJECTIVE

Among the factors forming the health behavior are the concept of locus of control and the perception of health self-efficacy. Studies investigating self-efficacy beliefs and the impact of health locus of control on immunosuppressive drugs are not adequate in number. Therefore the study sought to determine locus of control, self-efficacy perception and treatment adherence in kidney transplant patients.

METHODS

The sample of the study comprised 276 kidney transplant patients who applied to a university hospital. We collected the data using the Personal Information Form, the Multidimensional Health Locus of Control Scale, the Health Self-efficacy Perception Scale and the Compliance to Immunosuppressive Treatment Scale.

RESULTS

The study found the patients' mean Multidimensional Health Locus of Control scale external locus of control score to be 21.51 ± 3.74, mean Internal locus of control score to be 21.36 ± 3.92 and mean chance/fate score to be 15.48 ± 5.43. This result in the study demonstrates that kidney transplant individuals tend to believe in external forces in the disease management. The study determined the mean Health Self-efficacy Perception scale score of the kidney transplant patients to be 25.34 ± 3.89 and the patients had moderate level of self-efficacy perception. The study found that the patients' mean Compliance to Immunosuppressive Treatment Scale score was 11.26 ± 0.96 and their immunosuppressive treatment adherence was high but not adequate. The study found a significant negative weak correlation between the Health Self-efficacy Perception scale and the Multidimensional Health Locus of Control scale chance/fate subscale (p < 0.01). The study found no significant correlation between the Health Self-efficacy Perception scale and the Compliance to Immunosuppressive Treatment Scale (p > 0.05).

CONCLUSION

In order to increase drug adherence, we recommend that patients be supported to reinforce their self-efficacy perception. It is necessary to develop internal locus of control in kidney transplant patients in terms of treatment adherence and positive health behaviors.

Graft Failure Due to Nonadherence among 150 Prospectively-Followed Kidney Transplant Recipients at 18 Years Post-transplant: Our Results and Review of the Literature

Background: We previously reported that graft failure due to nonadherence (GFNA) was a major cause of graft loss in kidney transplantation. Here, among 150 prospectively-followed kidney transplant recipients at 18 years post-transplant, we provide: updated (longer-term) estimates of cause-specific graft loss probabilities, risk factors for developing GFNA, and detailed characterizations of patients’ overt nonadherent (NA) behavior, including timing, extent, and clinical consequences. Methods: Determination of the patient becoming NA in taking his/her immunosuppressive medications, and the underlying cause of graft loss, were determined prospectively by the attending physicians. For never-functioning-graft, GFNA, GF due to causes other than NA (Other GF), and death with a functioning graft (DWFG), cumulative incidence functions were used to estimate the cumulative probabilities of cause-specific graft loss. Cox stepwise regression was used to determine significant multivariable predictors for the hazard rate of developing GFNA. Results: GFNA was a major cause of graft loss (22/150 patients), particularly among African-American and Hispanic recipients <50 years of age-at-transplant (20/56 experienced GFNA), with estimated percentages of such patients ever developing GFNA ranging between 36.9 and 41.5%. These patients were also at a higher risk of developing Other GF. For the remaining patients (2/94 experienced GFNA), estimated percentages of ever-developing GFNA were much lower (range: 0.0−6.7%). The major cause of graft loss among recipients ≥50 years of age was DWFG; GFNA rarely occurred among older recipients. In 21/22 GFNA patients, NA behavior lasted continuously from the time of developing NA until GFNA. In total, 28/150 patients became NA, and 67.9% (19/28) occurred beyond 36 months post-transplant. A total of 25 of 28 NA patients (89.3%) developed biopsy-proven acute rejection and/or chronic rejection that was directly attributed to the NA behavior. Lastly, 25/28 admitted to NA behavior, with financial and psychological components documented in 71.4% (20/28) and 96.4% (27/28) of NA cases, respectively. Conclusions: These results highlight the importance of performing serial monitoring of patients for overt NA behavior throughout their post-transplant follow-up. Financial and psychological components to NA behavior need to be simultaneously addressed with the goal of achieving complete avoidance/elimination of NA behavior among higher risk patients.

Prediction Model of Immunosuppressive Medication Non-adherence for Renal Transplant Patients Based on Machine Learning Technology

Objectives

Predicting adherence to immunosuppressive medication (IM) is important to improve and design future prospective, personalized interventions in Chinese renal transplant patients (RTPs).

Methods

A retrospective, multicenter, cross-sectional study was performed in 1,191 RTPs from October 2020 to February 2021 in China. The BAASIS was used as the standard to determine the adherence of the patients. Variables of the combined theory, including the general data, the HBM, the TPB, the BMQ, the PSSS and the GSES, were used to build the models. The machine learning (ML) models included LR, RF, MLP, SVM, and XG Boost. The SHAP method was used to evaluate the contribution of predictors to predicting the risk of IM non-adherence in RTPs.

Results

The IM non-adherence rate in the derivation cohort was 38.5%. Ten predictors were screened to build the model based on the database. The SVM model performed better among the five models, with sensitivity of 0.59, specificity of 0.73, and average AUC of 0.75. The SHAP analysis showed that age, marital status, HBM-perceived barriers, use pill box after transplantation, and PSSS-family support were the most important predictors in the prediction model. All of the models had good performance validated by external data.

Conclusions

The IM non-adherence rate of RTPs was high, and it is important to improve IM adherence. The model developed by ML technology could identify high-risk patients and provide a basis for the development of relevant improvement measures.

Follow-Up Factors Contribute to Immunosuppressant Adherence in Kidney Transplant Recipients

PURPOSE

Follow-up and immunosuppressive medication (ISM) adherence are both important for kidney transplant recipients postoperatively and whether follow-up factors affect the ISM adherence remains unclear. The aim of this study was to examine the relationship between follow-up factors and ISM adherence, and the factors associated with ISM adherence.

PATIENTS AND METHODS

An internet-based cross-sectional survey was conducted in a single kidney transplant center in China. The participants completed the internet-based questionnaire and the Basel Assessment of Adherence to Immunosuppressive Medication Scale (BAASIS©) from January 12 to January 26, 2021.

RESULTS

Finally, 288 (66.7%) participants responded to this survey. The percentage of full adherence to immunosuppressant was 51.7% (149/288), with 33.3% of the participants reporting a problem in timing dimension. We found that follow-up with a fixed doctor was significantly positive to good adherence (OR=2.124, 95% CI=1.111-4.062, P=0.023) after analyzing the survey data. Time since kidney transplantation and number of non-immunosuppressants were both associated with immunosuppressant adherence. No significant difference was found regarding the effect of the follow-up adherence on ISM adherence.

CONCLUSION

Our study demonstrated an insufficient prevalence of adherence to immunosuppressant in Chinese renal transplant recipients and revealed that follow-up with a fixed doctor may be a way to improve the patients' ISM adherence. This anonymous internet-based survey provides valuable insight into the actual adherence rate, factors associated with non-adherence, and situations that may improve medication-taking.

Immunosuppressive Medication Adherence in Kidney Transplant Recipients During the COVID-19 Pandemic: A Cross-Sectional Study in Hong Kong

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has put an enormous burden on health care systems worldwide. Limited access to medical care and fear of increased infective risks due to the use of immunosuppressive medication (IM) have increased concerns about IM adherence in kidney transplant recipients (KTRs). The aim of this study was to determine the various dimensions of IM nonadherence in KTRs during the COVID-19 pandemic.

METHODS

This was a single-center, cross-sectional study using a convenient sampling approach. KTRs with follow-up in Queen Elizabeth Hospital, Hong Kong between May 1, 2020 and September 30, 2020, were invited to complete a self-reported questionnaire on IM adherence. The sociodemographic factors associated with IM adherence were extracted from medical records.

RESULTS

Overall, 210 patients completed the questionnaires. The overall IM nonadherence rate was 35.2% in the 4 weeks before survey completion. None of the patients stopped taking IMs without instructions from their health care providers. The most common pattern of IM nonadherence was timing adherence (n = 63; 30.1%), followed by dose-skipping item. Among the different sociodemographic factors studied, only marital status was an independent risk factor of IM nonadherence (odds ratio, 1.97; 95% confidence interval, 1.04-3.72; P = .03).

CONCLUSIONS

The impact of COVID-19 on IM adherence in KTRs was not significant. All the patients continued their IM despite of the pandemic. Good family support can have a positive influence on treatment adherence in KTRs during the COVID-19 pandemic.

Identification of Immunosuppressive Medication Nonadherence Factors Through a Combined Theory Model in Renal Transplant Recipients: 6-12

Background: Immunosuppressive medication (IM) nonadherence is associated with poor transplant outcomes. Therefore, it is of great importance to identify predictive factors with IM nonadherence. We aimed to improve the predicted capacity of the theory of planned behavior (TPB) by adding health belief model's (HBM) variables in renal transplant patients (RTPs). Methods: This cross-sectional study distributed questionnaires to patients who had undergone renal transplant and follow-up regularly in the transplant center of Third Xiangya Hospital in China. The self-developed questionnaire collected data in three aspects: general data questionnaire, TPB, HBM-specific questionnaire, and Basel Assessment of Adherence to Immunosuppressive Medications scale. Results: A total of 1,357 of 1,480 patients completed the survey, with a participation rate of 91.69% and IM nonadherence rate of 33.53%. The marital status, household income, preoperative drinking history, the time after transplantation, and religion showed independent predictive factors with IM nonadherence (p < 0.05). Strikingly, adding HBM variables to the TPB theory model significantly increased its prediction ability to IM nonadherence (52%). Also, HBM manifested the highest coefficient of effect (-0.620). Particularly, perceived barriers and perceived seriousness, the variables of the HBM model, played a vital influence on medication nonadherence (-0.284 and 0.256). Conclusion: Our study here reveals the first investigation of the combined effects of the TPB and HBM model on IM nonadherence in Chinese RTPs, which could significantly improve the predictive ability of any single model. Meanwhile, future interventions should be conducted to both increase perceived seriousness and reduce perceived barriers for taking IM, which will effectively decrease IM nonadherence rates and improve transplant outcomes.

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.

From Nonadherence to Adherence

Medication nonadherence (MNA) after solid organ transplantation is highly prevalent and associated with (late) (sub)clinical acute rejection, graft dysfunction and graft loss, development of donor-specific anti-HLA antibodies, and antibody-mediated rejection. MNA is predominantly unintentional and originates from barriers to adherence that are often multifactorial and complex. Tools to establish an early diagnosis of MNA include incorporation of MNA as a vital sign in daily clinical practice, self-reporting using validated questionnaires, calculating intrapatient variability in drug exposure and applying electronic monitoring, and recent audio and video technologies such as in home telemonitoring. MNA is a modifiable risk factor after organ transplantation, and treatment is most effective if a multimodal approach is used. Management of MNA comprises education (cognitive) and counseling (behavioral) that require the involvement of a trained multidisciplinary team [ideally physician, nurse (specialist), social worker, transplant coordinator, psychologist, clinical pharmacist], electronic reminder and support systems (eg, Medication Event Monitoring System, smartphone), and different types of novel mobile health applications as well as simplification of the medication dosing regimen. Future studies that evaluate novel therapeutic approaches for MNA should assure the use of reliable MNA measures, focus on multimodal individualized therapy for enriched nonadherent target populations (eg, adolescents), and incorporate clinically relevant endpoints. Costs, time, and personnel investments should be taken into account when assessing scalability and cost-effectiveness of novel therapeutic strategies. This review provides suggestions how different types of transplant centers can set up a dedicated MNA program according to available resources to define and achieve realistic clinical goals in managing MNA.