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Huh KY, Lee H, Lee S, Yu K, Kim KH, Kim H. Exploration of smart adherence-monitoring methods in vitamin D-deficient patients: A pilot feasibility clinical study. Clin Transl Sci 2023; 16:1866-1875. [PMID: 37461832 PMCID: PMC10582656 DOI: 10.1111/cts.13594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/07/2023] [Accepted: 07/08/2023] [Indexed: 07/26/2023] Open
Abstract
Treatment adherence is an underestimated determinant of treatment success. Poor treatment adherence can also affect the efficacy of clinical trials. A combination of multiple adherence-monitoring methods is required to ensure robustness. We investigated whether multiple adherence-monitoring methods, including a novel smartwatch-based monitoring method, would yield reliable and concordant results. In this open, randomized, decentralized clinical trial, vitamin D-deficient individuals were randomized to an App - only group (an electronic medication diary) or an App + Watch group (i.e., App and smartwatch-based monitoring) groups after a week run-in period. The participants received vitamin D supplements (1000 IU) for 12 weeks (two consecutive periods of 6 weeks) with two pill counts (at the sixth week) and biweekly blood samplings for serum 25(OH) vitamin D concentration. Adherence was assessed and compared between the methods. Sixteen participants were enrolled, of which 13 completed the study. Serum 25(OH) vitamin D levels comparably increased in both groups until the first 7 weeks but trended higher in the App + Watch group in the second period. The number of doses recorded by the pill count and App did not differ significantly between the run-in and Period 1 (p = 0.5534) but became significantly discrepant in Period 2 (p = 0.0225). In contrast, the concordance for smartwatch-based monitoring was consistent in either period (p = 0.5898 and p = 0.5839, respectively). We explored multiple adherence-monitoring methods in this pilot feasibility clinical study. Smartwatch-based adherence monitoring may be an objective and sensitive method for measuring treatment adherence.
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Affiliation(s)
- Ki Young Huh
- Department of Clinical Pharmacology and TherapeuticsSeoul National University College of Medicine and HospitalSeoulKorea
| | | | - SeungHwan Lee
- Department of Clinical Pharmacology and TherapeuticsSeoul National University College of Medicine and HospitalSeoulKorea
| | - Kyung‐Sang Yu
- Department of Clinical Pharmacology and TherapeuticsSeoul National University College of Medicine and HospitalSeoulKorea
| | - Kyung Hwan Kim
- Department of Thoracic and Cardiovascular SurgerySeoul National University College of Medicine and HospitalSeoulKorea
| | - Heejin Kim
- Clinical Trials CenterSeoul National University HospitalSeoulKorea
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2
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Shemesh E, Duncan-Park S, Mazariegos G, Annunziato R, Anand R, Reyes-Mugica M, Mitchell J, Shneider BL. The improving Medication Adherence in Adolescents and young adults following Liver Transplantation (iMALT) multisite trial: Design and trial implementation considerations. Clin Trials 2023; 20:528-535. [PMID: 37269062 PMCID: PMC10524899 DOI: 10.1177/17407745231176834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND/AIMS Medication non-adherence is a leading cause of transplant rejection, organ loss, and death; yet no rigorous controlled study to date has shown compelling clinical benefits from an adherence-improving intervention. Non-adherent patients are less likely to participate in trials, and therefore, most studies enroll a majority of adherent patients who do not stand to benefit from the intervention, as they do not have the condition (non-adherence) under investigation. The improving Medication Adherence in adolescent Liver Transplant recipients trial specifically targets non-adherent patients to investigate whether a remote intervention to improve adherence results in reduced incidence of biopsy-confirmed rejection. METHODS Improving Medication Adherence in adolescent Liver Transplant is a randomized single-blind controlled multisite, multinational National Institutes of Health-funded trial involving 13 pediatric transplant centers in the United States and Canada. An innovative, objective adherence biomarker-the Medication Level Variability Index, which is the standard deviation of a series of medication blood levels for each patient, is used to identify non-adherent patients at risk for rejection. The index is computed using electronic health record information for all potentially eligible patients based on repeated reviews of the entire clinic's roster. Identified patients, after consent, are randomized to intervention versus control (treatment as usual) arms. The remote intervention is delivered for 2 years by trained interventionists who reside in various locations in the United States. The primary outcome is the incidence of biopsy-confirmed acute cellular rejection, as confirmed by a majority vote of three pathologists who are masked to the study allocation and clinical information. DISCUSSION Improving Medication Adherence in adolescent Liver Transplant includes several innovative design elements. The use of a validated, objective adherence index to survey a large cohort of transplant recipients allows the teams to avoid bias inherent in both convenience sampling and referral-based recruitment and enroll only patients whose computed index indicates substantially increased risk of rejection. The remote intervention paradigm helps to engage patients who are by definition hard to engage. The use of an objective, masked medical (rather than behavioral) outcome measure reduces the likelihood of biases related to clinical information and ensures broad acceptance by the field. Finally, monitoring for potential adverse events related to increased medication exposure due to the adherence intervention acknowledges that a successful intervention (increasing adherence) could have detrimental side effects via increased exposure to and potential toxicity of the medication. Such monitoring is almost never attempted in clinical trials evaluating adherence interventions.
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Affiliation(s)
- Eyal Shemesh
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Rachel Annunziato
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Fordham University, Bronx, NY, USA
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3
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Batsis I, Bucuvalas J, Eisenberg E, Lau J, Squires JE, Feng S, Perito ER. Immunosuppression after pediatric liver transplant: The parents' perspective. Clin Transplant 2023; 37:e14931. [PMID: 36774540 DOI: 10.1111/ctr.14931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 01/12/2023] [Accepted: 02/03/2023] [Indexed: 02/13/2023]
Abstract
BACKGROUND For children with liver transplants (LT), achieving an "ideal outcome" is a balancing act: too little immunosuppression begets graft injury; too much begets systemic complications. We aimed to delineate the parental perspective on this tightrope. METHODS Parents of children with LT completed an internet-based survey about their child's immunosuppression. RESULTS Children of respondents (n = 82) were a median 4 years from primary LT (range 0-22); 73% were on immunosuppression monotherapy. Parents' top concerns were related to immunosuppression complications; 46% were more concerned about immunosuppression complications than rejection; only 17% were more concerned about rejection than immunosuppression complications. Among parents of children on immunosuppression monotherapy, 29% still worried more about immunosuppression complications than rejection, 48% expressed equal concern for both. Time since LT (0-4 vs. >4 years) was not associated with concern level for rejection or immunosuppression complications. Caregivers were significantly more certain that their child's immunosuppression regimen was correct to prevent rejection than to mitigate complications (p < .005). CONCLUSION Caregivers of children with LTs reported higher levels of concern and uncertainty about immunosuppression complications than rejection risk. Understanding parent and patient perspectives on IS, and incorporating them into immunosuppression counseling and decision-making, is critical to achieving truly "ideal" long-term outcomes.
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Affiliation(s)
- Irini Batsis
- Department of Pediatrics, Icahn School of Medicine, Kravis Children's Hospital at Mount Sinai, New York, New York, USA
| | - John Bucuvalas
- Department of Pediatrics, Icahn School of Medicine, Kravis Children's Hospital at Mount Sinai, New York, New York, USA
| | | | - Jennifer Lau
- Patient and Family Engaged Partners, Society for Pediatric Liver Transplantation, Palo Alto, California, USA
| | - James E Squires
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sandy Feng
- Department of Pediatrics, San Francisco School of Medicine, University of California, San Francisco, California, USA
| | - Emily R Perito
- Department of Pediatrics, San Francisco School of Medicine, University of California, San Francisco, California, USA
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4
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Killian MO, Clifford S, Lustria MLA, Skivington GL, Gupta D. Directly observed therapy to promote medication adherence in adolescent heart transplant recipients. Pediatr Transplant 2022; 26:e14288. [PMID: 35436376 DOI: 10.1111/petr.14288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 03/28/2022] [Accepted: 04/01/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE HT recipients experience high levels of medication non-adherence during adolescence. This pilot study examined the acceptability and feasibility of an asynchronous DOT mHealth application among adolescent HT recipients. The app facilitates tracking of patients' dose-by-dose adherence and enables transplant team members to engage patients. The DOT application allows patients to self-record videos while taking their medication and submit for review. Transplant staff review the videos and communicate with patients to engage and encourage medication adherence. METHODS Ten adolescent HT recipients with poor adherence were enrolled into a single-group, 12-week pilot study examining the impact of DOT on adherence. Secondary outcomes included self-report measures from patients and parents concerning HRQOL and adherence barriers. Long-term health outcomes assessed included AR and hospitalization 6 months following DOT. FINDINGS Among 14 adolescent HT patients approached, 10 initiated the DOT intervention. Of these, 8 completed the 12-week intervention. Patients and caregivers reported high perceptions of acceptability and accessibility. Patients submitted 90.1% of possible videos demonstrating medication doses taken. MLVI values for the 10 patients initiating DOT decreased from 6 months prior to the intervention (2.86 ± 1.83) to 6 months following their involvement (2.08 ± 0.87) representing a 21.7% decrease in non-adherence, though not statistically significant given the small sample size. CONCLUSIONS Result of this pilot study provides promising insights regarding the feasibility, acceptability, and potential impact of DOT for adolescent HT recipients. Further randomized studies are required to confirm these observations.
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Affiliation(s)
- Michael O Killian
- College of Social Work, Florida State University, Tallahassee, Florida, USA.,College of Medicine, Florida State University, Tallahassee, Florida, USA
| | - Stephanie Clifford
- Congenital Heart Center, UF Health Shands Children's Hospital, University of Florida, Gainesville, Florida, USA.,College of Nursing, University of Florida, Gainesville, Florida, USA
| | - Mia Liza A Lustria
- College of Medicine, Florida State University, Tallahassee, Florida, USA.,School of Information, College of Communication and Information, Florida State University, Tallahassee, Florida, USA
| | - Gage L Skivington
- College of Social Work, Florida State University, Tallahassee, Florida, USA
| | - Dipankar Gupta
- Congenital Heart Center, UF Health Shands Children's Hospital, University of Florida, Gainesville, Florida, USA.,Department of Pediatrics, College of Medicine, University of Florida, Gainesville, Florida, USA
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González-Vílchez F, Crespo-Leiro MG, Delgado-Jiménez J, Pérez-Villa F, Segovia-Cubero J, Díaz-Molina B, Mirabet-Pérez S, Arizón del Prado JM, Blasco-Peiró T, Martínez-Sellés M, Almenar-Bonet L, Garrido-Bravo I, Rábago G, Vázquez de Prada JA. Impacto de la variabilidad intrapaciente en la concentración sanguínea de anticalcineurínicos en los resultados del trasplante cardiaco. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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6
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González-Vílchez F, Crespo-Leiro MG, Delgado-Jiménez J, Pérez-Villa F, Segovia-Cubero J, Díaz-Molina B, Mirabet-Pérez S, Arizón Del Prado JM, Blasco-Peiró T, Martínez-Sellés M, Almenar-Bonet L, Garrido-Bravo I, Rábago G, Vázquez de Prada JA. Impact of intrapatient blood level variability of calcineurin inhibitors on heart transplant outcomes. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2022; 75:129-140. [PMID: 33744197 DOI: 10.1016/j.rec.2021.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/08/2021] [Indexed: 06/12/2023]
Abstract
INTRODUCTION AND OBJECTIVES Intrapatient blood level variability (IPV) of calcineurin inhibitors has been associated with poor outcomes in solid-organ transplant, but data for heart transplant are scarce. Our purpose was to ascertain the clinical impact of IPV in a multi-institutional cohort of heart transplant recipients. METHODS We retrospectively studied patients aged ≥18 years, with a first heart transplant performed between 2000 and 2014 and surviving≥ 1 year. IPV was assessed by the coefficient of variation of trough levels from posttransplant months 4 to 12. A composite of rejection or mortality/graft loss or rejection and all-cause mortality/graft loss between years 1 to 5 posttransplant were analyzed by Cox regression analysis. RESULTS The study group consisted of 1581 recipients (median age, 56 years; women, 21%). Cyclosporine immediate-release tacrolimus and prolonged-release tacrolimus were used in 790, 527 and 264 patients, respectively. On multivariable analysis, coefficient of variation> 27.8% showed a nonsignificant trend to association with 5-year rejection-free survival (HR, 1.298; 95%CI, 0.993-1.695; P=.056) and with 5-year mortality (HR, 1.387; 95%CI, 0.979-1.963; P=.065). Association with rejection became significant on analysis of only those patients without rejection episodes during the first year posttransplant (HR, 1.609; 95%CI, 1.129-2.295; P=.011). The tacrolimus-based formulation had less IPV than cyclosporine and better results with less influence of IPV. CONCLUSIONS IPV of calcineurin inhibitors is only marginally associated with mid-term outcomes after heart transplant, particularly with the tacrolimus-based immunosuppression, although it could play a role in the most stable recipients.
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Affiliation(s)
| | - María G Crespo-Leiro
- Servicio de Cardiología, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - Juan Delgado-Jiménez
- Servicio Cardiología y Fundación Investigación Hospital Universitario 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Félix Pérez-Villa
- Servicio de Cardiología, Hospital Clínic Universitari, Barcelona, Spain
| | - Javier Segovia-Cubero
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain
| | - Beatriz Díaz-Molina
- Servicio de Cardiología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Sonia Mirabet-Pérez
- Servei de Cardiologia, Hospital Universitari Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Teresa Blasco-Peiró
- Servicio de Cardiología, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Manuel Martínez-Sellés
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Gregorio Marañón, Madrid, Spain; Facultad de Medicina, Universidad Europea, Madrid, Spain; Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Luis Almenar-Bonet
- Servicio de Cardiología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Iris Garrido-Bravo
- Servicio de Cardiología, Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - Gregorio Rábago
- Servicio de Cirugía Cardiaca, Clínica Universitaria de Navarra, Pamplona, Spain
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Gandolfini I, Palmisano A, Fiaccadori E, Cravedi P, Maggiore U. Detecting, preventing, and treating non-adherence to immunosuppression after kidney transplantation. Clin Kidney J 2022; 15:1253-1274. [PMID: 35756738 PMCID: PMC9217626 DOI: 10.1093/ckj/sfac017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Indexed: 11/12/2022] Open
Abstract
Medication non-adherence (MNA) is a major issue in kidney transplantation and it is associated with increased risk of rejection, allograft loss, patients’ death and higher healthcare costs. Despite its crucial importance, it is still unclear what are the best strategies to diagnose, prevent and treat MNA. MNA can be intentional (deliberate refusal to take the medication as prescribed) or unintentional (non-deliberate missing the prescribed medication). Its diagnosis may rely on direct methods, aiming at measuring drug ingestions, or indirect methods that analyse the habits of patients to adhere to correct drug dose (taking adherence) and interval (time adherence). Identifying individual risk factors for MNA may provide the basis for a personalized approach to the treatment of MNA. Randomized control trials performed so far have tested a combination of strategies, such as enhancing medication adherence through the commitment of healthcare personnel involved in drug distribution, the use of electronic reminders, therapy simplification or various multidisciplinary approaches to maximize the correction of individual risk factors. Although most of these approaches reduced MNA in the short-term, the long-term effects on MNA and, more importantly, on clinical outcomes remain unclear. In this review, we provide a critical appraisal of traditional and newer methods for detecting, preventing and treating non-adherence to immunosuppression after kidney transplantation from the perspective of the practising physician.
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Affiliation(s)
- Ilaria Gandolfini
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Nephrology Unit, University Hospital of Parma, Parma, Italy
| | | | - Enrico Fiaccadori
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Nephrology Unit, University Hospital of Parma, Parma, Italy
| | - Paolo Cravedi
- Department of Medicine, Division of Nephrology and Translational Transplant Research Center, Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Umberto Maggiore
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Nephrology Unit, University Hospital of Parma, Parma, Italy
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Nigam N, Addepalli S, Kumar S. Antidiabetic effect and preference of fenugreek with dietary modifications in patients with prediabetes: An interventional parallel randomized study. JOURNAL OF DIABETOLOGY 2022. [DOI: 10.4103/jod.jod_40_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Bülbüloğlu S, Demir B. The effect of perceived social support on psychological resilience in liver transplant patients receiving immunosuppression therapy. Transpl Immunol 2021; 69:101475. [PMID: 34600070 DOI: 10.1016/j.trim.2021.101475] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 09/24/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVE This study was conducted to investigate the effect of social support on psychological resilience in liver transplant patients receiving immunosuppression therapy. METHOD This study was carried out as a descriptive and cross-sectional study with the participation of 290 liver transplant patients hospitalized in the liver transplant center of a research and application hospital. Personal Information Form, Multidimensional Scale of Perceived Social Support (MSPSS) and Brief Resilience Scale (BRS) were used in data collection. The data analysis was performed with IBM Statistical Package for the Social Sciences Statistics 25. RESULTS According to the data obtained, it was determined that 30.4% of the patients were 58 years old and over, 81% of them were male and 92.8% of them were married. It was found that all of the patients used antimetabolites and corticosteroids, and 82.8% of them used calcineurin inhibitors. It was determined that 32.8% of the patients experienced infection, neuropsychiatric problems and nephrotoxicity at the same time. The psychological resilience of the patients was found to be moderate, and their perceived social support was found to be low. CONCLUSION It is not always possible for liver transplant patients to deal with their situation effectively. The psychological resilience and social support levels of patients who have undergone liver transplantation should be noticed, and social, economic and psychological support should be provided.
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Affiliation(s)
- Semra Bülbüloğlu
- Division of Surgical Nursing, Nursing Department, Erbaa Health Sciences Faculty, Gaziosmanpasa University, Erbaa, Tokat, Turkey.
| | - Bilsev Demir
- Division of Surgical Nursing, Nursing Department, Health Sciences Faculty, Turgut Özal University, Malatya, Turkey
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10
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Larpparisuth N, Pongnatcha T, Panprom P, Promraj R, Premasathian N, Vongwiwatana A. High Intrapatient Variability in Tacrolimus Exposure Calculated Over a Long Period Is Associated With De Novo Donor-Specific Antibody Development and/or Late Rejection in Thai Kidney Transplant Patients Receiving Concomitant CYP3A4/5 Inhibitors. Ther Drug Monit 2021; 43:624-629. [PMID: 33278239 DOI: 10.1097/ftd.0000000000000850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 08/16/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND High intrapatient variability in tacrolimus trough levels (Tac IPV) is associated with poor allograft outcomes. Tac IPV was previously calculated using trough levels 6-12 months after kidney transplantation (KT). Data on the accuracy of Tac IPV calculation over a longer period, the association between high Tac IPV and donor-specific antibody (DSA) development after KT in Asian patients, and the role of IPV in patients receiving concomitant cytochrome P450 (CYP)3A4/5 inhibitors (CYPinh) are limited. METHODS A retrospective review of patients who underwent KT at our center in 2005-2015, and who received Tac with mycophenolate during the first 2 years after KT was performed. IPV was calculated using Tac levels adjusted by dosage. DSA was monitored annually after KT using a Luminex microbead assay. RESULTS In total, 236 patients were enrolled. CYPinh were prescribed to 189 patients (80.1%): 145 (61.4%), 31 (13.1%), and 13 (5.5%) received diltiazem, fluconazole, and ketoconazole, respectively. Mean IPV calculated from adjusted Tac levels for 6-12 months (IPV6-12) and 6-24 months (IPV6-24) after KT were 20.64% ± 11.68% and 23.53% ± 10.39%, respectively. Twenty-six patients (11%) showed late rejection and/or DSA occurrence, and had significantly higher IPV6-24 (29.42% ± 13.78%) than others (22.77% ± 9.64%; P = 0.02). There was no difference in IPV6-12 (24.31% ± 14.98% versus 20.17% ± 10.90%; P = 0.18). IPV6-12 and IPV6-24 were comparable in patients who did and did not receive CYPinh. When using mean IPV6-24 as a cutoff, patients with higher IPV6-24 had a higher probability of developing DSA and/or late rejection (P = 0.048). CONCLUSIONS Tac IPV6-24 was higher and more significantly associated with DSA development and/or late rejection than Tac IPV6-12, independent of Tac trough level. This is the first study to demonstrate the impact of high IPV on DSA development in Asian patients, and that Tac IPV is comparable between patients with and without CYPinh.
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Affiliation(s)
- Nuttasith Larpparisuth
- Division of Nephrology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University
| | - Tanapon Pongnatcha
- Division of Nephrology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University
| | - Pera Panprom
- Department of Nursing Siriraj Hospital, Faculty of Medicine Siriraj Hospital, Mahidol University; and
| | - Ratchawat Promraj
- Ambulatory Pharmaceutical Care Unit, Pharmacy Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nalinee Premasathian
- Division of Nephrology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University
| | - Attapong Vongwiwatana
- Division of Nephrology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University
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Life experiences of adult heart transplant recipients: a new life, challenges, and coping. Qual Life Res 2021; 30:1619-1627. [PMID: 33523403 DOI: 10.1007/s11136-021-02763-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE The process during and after heart transplantation is quite complicated, and studies addressing patient experiences are needed. Heart transplantation particularly affects the recipients' activities of daily living and exposes them to various complications. The aim of this study is to explore the experiences of heart transplant recipients during and after heart transplantation. METHODS This qualitative, phenomenological research was conducted with 11 heart transplant recipients in the university hospital, which is one of the 14 heart transplantation centers in Turkey. The data were collected through in-depth semi-structured interviews in a private room that ensured both the comfort of the participants and the necessary conditions for safe data collection. The interviews were recorded using an audio recorder, transcribed, and then analyzed using inductive content analysis. Data collection was terminated after the 11th interview when the data reached the saturation point. RESULTS The study data were categorized into the following three main themes and subthemes: (1) a new life with a new heart; an opportunity arising at an unexpected time, heart donation, and transplantation as a value, (2) challenges; management of medication therapy and side effects, emotion management, maintaining social relations, and social stigma, and (3) coping; faith in God and praying, responsibility of living with a blessing (donated heart), health professional support, family support, and peer counseling. In line with these themes, expressions of value given to new life and gratitude to heart transplantation were important. The availability and diversity of support sources came to the fore in coping. Social stigma expressions of especially male patients were remarkable in challenges. CONCLUSION At the end of the study, the experiences of heart transplant recipients were obtained regarding a new life with a new heart, challenges, and coping. The study results provide an insight into the challenges that the heart transplant recipients face and their coping strategies, guiding the healthcare professionals. The challenges and relevant coping strategies of heart transplant recipients may be integrated into clinical practice and may help plan patient's care. The results may also be used to design and implement an intervention program to improve care for these patients.
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Mazariegos GV, Shneider BL, Shemesh E, Schady D, Melin-Aldana H, Cho SJ, Anand R, Erinjeri J, Annunziato R, Reyes-Mugica M. Approaches to Research Determination of Late Acute Cellular Rejection in Pediatric Liver Transplant Recipients. Liver Transpl 2021; 27:106-115. [PMID: 32978871 PMCID: PMC7785571 DOI: 10.1002/lt.25903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 07/10/2020] [Accepted: 08/19/2020] [Indexed: 01/13/2023]
Abstract
A central pathology or site reading of biopsy slides is used in liver transplant clinical trials to determine rejection. We evaluated interrater reliability of readings of "rejection or not" using digitized slides from the Medication Adherence in Children who had a Liver Transplant (MALT) study. Four masked experienced pathologists read the digitized slides and then reread them after a study-specific histologic endpoint development program. Agreement was expressed throughout as a Kappa or Fleiss Kappa statistic (ҡ). A ҡ > 0.6 was predefined as desirable. Readings were correlated with immunosuppressant adherence (the Medication Level Variability Index, [MLVI]), and maximal liver enzyme levels during the study period. Interrater agreement between site and central review in MALT, and between 4 pathologists later on, was low (ҡ = 0.44, Fleiss ҡ = 0.41, respectively). Following the endpoint development program, agreement improved and became acceptable (ҡ = 0.71). The final reading was better-aligned with maximal gamma-glutamyl transferase levels and MLVI as compared with the original central reading. We found substantial disagreement between experienced pathologists reading the same slides. A unique study-specific procedure improved interrater reliability to the point it was acceptable. Such a procedure may be indicated to increase reliability of histopathologic determinations in future research, and perhaps also clinically.
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Affiliation(s)
- George V. Mazariegos
- Hillman Center for Pediatric Transplantation, Thomas E. Starzl Transplantation Institute, UPMC Children's Hospital of Pittsburgh, PA
| | | | - Eyal Shemesh
- Icahn School of Medicine at Mount Sinai and the Department of Pediatrics, Mount Sinai Health System, New York, NY
| | - Deborah Schady
- Department of Pathology, Baylor College of Medicine, Houston, TX
| | - Hector Melin-Aldana
- Department of Pathology and Laboratory Medicine, Northwestern University Feinberg School of Medicine and Ann and Robert H. Lurie Children’s Hospital, Chicago, IL
| | - Soo-Jin Cho
- Department of Pathology, UCSF, San Francisco, CA
| | | | | | - Rachel Annunziato
- Icahn School of Medicine at Mount Sinai and the Department of Pediatrics, Mount Sinai Health System, New York, NY
| | - Miguel Reyes-Mugica
- Hillman Center for Pediatric Transplantation Department of Pathology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
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Becker JH, Shemesh E, Shenoy A, Posillico A, Knight CS, Kim SK, Florman SS, Schiano T, Annunziato RA. The Utility of a Pre-Transplant Psychosocial Evaluation in Predicting Post-Liver Transplant Outcomes. Prog Transplant 2020; 31:4-12. [PMID: 33272096 DOI: 10.1177/1526924820978605] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND There is insufficient evidence about the ability of pretransplant psychosocial evaluations to predict posttransplant outcomes. While standardized assessments were developed to increase predictive validity, it is unclear whether the risk scores they yield predict outcomes. We investigated if the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT), a scaling approach to those assessments, would have been a superior predictor than the standard psychosocial evaluation. METHODS In this retrospective study, medical records of 182 adult liver transplant recipients who were at least 1 year posttransplant and prescribed tacrolimus for immunosuppression were analyzed. Regression analyses predicted outcomes of interest, including immunosuppressant nonadherence and biopsy-proven rejection, obtained 1-year posttransplant to time of data collection. Nonadherence was determined using the medication level variability index (MLVI). RESULTS Approximately 49% of patients had MLVI > 2.5, suggestive of nonadherence, and 15% experienced rejection. SIPAT total score did not predict adherence either using the continuous (P = .70), or dichotimized score, above or below > 2.5 (P = .14), or rejection (P = 0.87). Using a SIPAT threshold (total score > 69) did not predict adherence (p = .16) nor was a superior predictor of the continuous adherence score (P = .45), MLVI > 2.5 (P = .42), or rejection (P = 0.49), than the standard evaluation. CONCLUSION Our findings suggest that the SIPAT is unable to predict 2 of the most important outcomes in this population, immunosuppressant adherence and rejection. Research efforts should attempt to evaluate the best manner to use psychosocial evaluations.
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Affiliation(s)
- Jacqueline H Becker
- Department of Medicine, 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Pediatrics, 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eyal Shemesh
- Department of Pediatrics, 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Akhil Shenoy
- Center for Liver Disease and Transplantation, 21611Columbia University Medical Center, New York, NY, USA
| | - Ailie Posillico
- Department of Psychology, 5923Fordham University, Bronx, NY, USA
| | | | - Se-Kang Kim
- Department of Psychology, 5923Fordham University, Bronx, NY, USA
| | - Sander S Florman
- 52100Recanati/Miller Transplantation Institute/Division of Liver Disease, Mount Sinai Medical Center, New York, NY, USA
| | - Thomas Schiano
- 52100Recanati/Miller Transplantation Institute/Division of Liver Disease, Mount Sinai Medical Center, New York, NY, USA
| | - Rachel A Annunziato
- Department of Pediatrics, 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA.,52100Recanati/Miller Transplantation Institute/Division of Liver Disease, Mount Sinai Medical Center, New York, NY, USA
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14
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Jones LS, Serper M. Medication non-adherence among liver transplant recipients. CURRENT HEPATOLOGY REPORTS 2020; 19:327-336. [PMID: 33816051 PMCID: PMC8011544 DOI: 10.1007/s11901-020-00545-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/07/2020] [Indexed: 01/30/2023]
Abstract
PURPOSE OF REVIEW We provide an overview of the recent evidence on the prevalence, risk factors, and consequences of medication non-adherence (NA) in liver transplant (LT) recipients. RECENT FINDINGS NA in LT is associated with socio-demographic and medication-related factors, low social support, and poor health literacy. Patient-reported adherence is one of the most common methods to measure NA using validated assessments; immunosuppression (IS) drug levels and electronic monitoring may also be used. Simplification of IS regimens such as the conversion from twice daily to once daily has been shown to be safe, effective, and improves adherence. Relatively few studies have prospectively investigated NA predictors or interventions to reduce NA in LT. SUMMARY Medication non-adherence is a multi-faceted issue that is common among LT recipients and associated with adverse outcomes. NA in LT recipients warrants further study as only a few interventions have been published focused on reducing NA in LT.
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Affiliation(s)
- Lauren S. Jones
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine
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15
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Beliefs about immunosuppressant medication and correlates in a German kidney transplant population. J Psychosom Res 2020; 132:109989. [PMID: 32151820 DOI: 10.1016/j.jpsychores.2020.109989] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 02/29/2020] [Accepted: 02/29/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVE A common reason for organ rejection after transplantation is the lack of adherence regarding immunosuppressive medication (ISM). A variety of different aspects can promote non-adherent behavior, including the relationship between perceived benefits and concerns regarding ISM ("necessity-concerns-framework"). Little is known about the variables associated with this framework. METHODS As part of this cross-sectional study, 570 patients after kidney transplantation who participated in a structured multimodal follow-up program (KTx360°) were examined in two transplant centers in Lower Saxony. We used the Beliefs about Medicines Questionnaire (BMQ) to evaluate the patients' believes and concerns regarding their ISM. RESULTS The mean age of the participants was 51.9 (SD 14.17) years, 58.4% were men, and 25.8% had ≥12 years of school attendance. The mean time since transplantation was 65.9 months. In patients undergoing kidney transplantation, the perceived benefit of ISM mostly exceeded the concerns. We found an association between lower perceived benefits and greater concerns and lower adherence. Also, a higher perceived necessity was significantly associated with higher age and lower levels of depression and anxiety. Greater concerns were significantly associated with more symptoms of depression and anxiety, lower perceived social support, and lower kidney functioning (eGFR). CONCLUSION Even though patients after kidney transplantation usually acknowledge the importance of their ISM, they still have considerable concerns that are associated with less adherence and various psychosocial risk factors. Further longitudinal studies are needed to assess the extent to which beliefs about medication are variable and can be individually addressed to improve adherence.
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16
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Kerr SM, Jorgensen NW, Hong BJ, Friedland-Little JM, Albers EL, Newland DM, Law YM, Kemna MS. Assessment of rejection risk following subtherapeutic calcineurin inhibitor levels after pediatric heart transplantation. Pediatr Transplant 2020; 24:e13616. [PMID: 31820529 DOI: 10.1111/petr.13616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 09/24/2019] [Accepted: 10/22/2019] [Indexed: 11/29/2022]
Abstract
CNIs are the mainstay of immunosuppressive therapy after pediatric HTx. While regular laboratory surveillance is performed to ensure blood levels are within targeted range, the risk of acute rejection associated with subtherapeutic CNI levels has never been quantified. This is a retrospective single-center review of 8413 CNI trough levels in 138 pediatric HTx recipients who survived >1 year after HTx. Subtherapeutic CNI levels were defined as <50% of the lower limit of target range. The risk of acute, late (>12 months post-transplant) rejection following recipients' subtherapeutic CNI levels was assessed using time-varying multivariable Cox proportional hazards analysis. We found that 79 of 138 recipients (57%) had at least one subtherapeutic CNI level on routine surveillance laboratories during a mean follow-up of 5.5 ± 3.6 years. Following an episode of subtherapeutic levels, 17 recipients (22%) had biopsy-proven rejection within the next 3 months; the majority (9/17) within the first 2 weeks. After presenting with subtherapeutic CNI levels, recipients incurred a 6.1 times increased risk of acute rejection in the following 3 months (HR = 6.11 [2.41, 15.51], P = <.001). Age at HTx, HLA sensitization, or positive crossmatch were not associated with acute late rejection, but rejection in the first post-transplant year was (HR 2.61 [1.27, 5.35], P = .009). Thus, maintaining therapeutic CNI levels is the most important factor in preventing acute rejection in recipients who are >12 months after pediatric HTx. Recipients who present with subtherapeutic CNI levels on surveillance monitoring are 6.1 times more likely to develop rejection in the following 3 months.
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Affiliation(s)
- Sarah M Kerr
- School of Medicine, University of Washington, Seattle, Washington
| | - Neal W Jorgensen
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Borah J Hong
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Joshua M Friedland-Little
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Erin L Albers
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - David M Newland
- Pharmacy, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Yuk M Law
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Mariska S Kemna
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
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17
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Triplett KN, El-Behadli AF, Masood SS, Sullivan S, Desai DM. Digital medicine program with pediatric solid organ transplant patients: Perceived benefits and challenges. Pediatr Transplant 2019; 23:e13555. [PMID: 31328842 DOI: 10.1111/petr.13555] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 05/06/2019] [Accepted: 06/18/2019] [Indexed: 11/28/2022]
Abstract
Given the complexity of the pediatric post-transplant medication regimen and known medication adherence difficulties within the solid organ transplant population, interventions to improve adherence continue to be explored and fine-tuned. Advances in technology have led to the development of new programs aimed at improving medication adherence and the overall care of transplant patients. This manuscript describes implementation of a DMP where transplant patients' medications were co-encapsulated with ingestible sensors, and adherence was monitored via a patient mobile application and a provider portal. The benefits and challenges of the DMP as reported by patients, caregivers, and medical providers are explored in this manuscript. Participant feedback regarding best practices highlighted these benefits: ease of use/intuitive technology, sense of improved communication with medical team, increased knowledge and motivation around treatment regimen, and positive self-reports of medication adherence. Challenges included reluctance to participate (n = 43, 54.43% of patients approached declined participation) and patch wearability difficulties reported by participants (n = 20; 68.97%). Other notable challenges included the following: limited drug profile compatibility with the DMP technology and concerns about privacy and electronic data sharing for patients who chose not to participate. DMP implementation highlighted how technological advances offer novel methods to assess adherence, enhance medical decision-making, and can potentially improve clinical outcomes. Although numerous benefits of the program were recognized by participants, challenges were identified and the DMP technology and medication panel continues to be refined; further investigation of such programs continues to be warranted.
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Affiliation(s)
- Kelli N Triplett
- Solid Organ Transplant Department, Children's Health - Children's Medical Center, Dallas, Texas.,University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ana F El-Behadli
- Solid Organ Transplant Department, Children's Health - Children's Medical Center, Dallas, Texas.,University of Texas Southwestern Medical Center, Dallas, Texas
| | - Saba S Masood
- Solid Organ Transplant Department, Children's Health - Children's Medical Center, Dallas, Texas.,University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sarah Sullivan
- Solid Organ Transplant Department, Children's Health - Children's Medical Center, Dallas, Texas
| | - Dev M Desai
- Solid Organ Transplant Department, Children's Health - Children's Medical Center, Dallas, Texas.,University of Texas Southwestern Medical Center, Dallas, Texas
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18
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Cajanding R. Immunosuppression following organ transplantation. Part 2: complications and their management. ACTA ACUST UNITED AC 2019; 27:1059-1065. [PMID: 30281349 DOI: 10.12968/bjon.2018.27.18.1059] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Advances in the care of patients who have had a solid organ transplant has led to a growing population of post-transplant patients, who are also living for longer. As a result of their longer life expectancy, transplant recipients often face a multitude of challenges, including optimising their immunosuppressive regimens and managing potential complications. Life-threatening infections, malignancies, and organ-specific toxicities are the complications post-transplant patients commonly encounter and these complications are often associated with increased morbidity and mortality, adverse graft functioning and survival, profound impairment in the patient's quality of life, and significant healthcare burden. This article, the second of two parts, gives an overview of the issues involved in the care of patients who are receiving immunosuppressants. The common complications encountered by post-transplant patients are discussed and their assessment, management, prevention and treatment explored.
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Affiliation(s)
- Ruff Cajanding
- Staff Nurse, Liver Intensive Therapy Unit, Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London
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19
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Gokoel SRM, Gombert-Handoko KB, Zwart TC, van der Boog PJM, Moes DJAR, de Fijter JW. Medication non-adherence after kidney transplantation: A critical appraisal and systematic review. Transplant Rev (Orlando) 2019; 34:100511. [PMID: 31627978 DOI: 10.1016/j.trre.2019.100511] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 08/27/2019] [Accepted: 08/28/2019] [Indexed: 10/26/2022]
Abstract
Medication non-adherence is one of the most important causes for shortened graft survival subsequently leading to a reduction in kidney graft survival results. Our aim was to provide an overview of its prevalence, risk factors, diagnostic methods and interventions to improve adherence in kidney transplant recipients. Therefore, we systematically searched the databases PubMed, COCHRANE Library, Web of Science and EMBASE for studies addressing "medication adherence", "compliance", "adherence", "kidney transplantation" and "life style factors". We identified 96 studies that satisfied our inclusion criteria. A problematic lack of a uniformly accepted definition for non-adherence was found, consequently leading to a wide range in non-adherence prevalence (36-55%). Using one uniformly accepted non-adherence definition should therefore be encouraged. A wide range in diagnostic methods makes it difficult to accurately detect non-adherence. Heterogeneous results of intervention studies make it difficult to select the best adherence enhancing method, challenging the battle against medication non-adherence. Literature suggests a combination of personalized interventions, based on patient-specific non-adherent behavior, to be most successful in improvement of adherence. High quality diagnostic methods and multidisciplinary, personalized interventions with focus on relevant clinical outcome are essential in overcoming medication non-adherence in kidney transplant recipients.
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Affiliation(s)
- Sumit R M Gokoel
- Division of Nephrology, Department of Medicine, Leiden University Medical Center, Leiden, the Netherlands.
| | - Kim B Gombert-Handoko
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Tom C Zwart
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Paul J M van der Boog
- Division of Nephrology, Department of Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Dirk Jan A R Moes
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Johan W de Fijter
- Division of Nephrology, Department of Medicine, Leiden University Medical Center, Leiden, the Netherlands
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20
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Gender Differences in Medication Adherence Among Adolescent and Young Adult Kidney Transplant Recipients. Transplantation 2019; 103:798-806. [PMID: 29994983 DOI: 10.1097/tp.0000000000002359] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Among kidney transplant recipients, gender differences in medication adherence may contribute to higher graft failure risks observed in girls and young women compared with boys and young men. Our aim was to determine whether adherence differs by gender, and whether gender differences vary by age in adolescent and young adult kidney transplant recipients. METHODS We examined data from the 3-month run-in period (no intervention) of the randomized Teen Adherence in Kidney transplant Effectiveness of Intervention trial. Adherence was monitored using electronic pillboxes in 136 patients (11-24 y) followed in 8 transplant centers in Canada and the United States. We used ordinal logistic regression with generalized estimating equations to estimate the association between gender and each of daily taking (proportion of prescribed doses taken) and timing (proportion of prescribed doses taken on time) adherence, considering effect modification by age (11-16 y vs 17-24 y). RESULTS No difference in taking adherence was observed by gender among participants aged 11 to 16 years (odds ratio [OR], 0.92; 95% confidence interval [CI], 0.55-1.54), whereas among participants aged 17 to 24 years, women had significantly greater odds of higher taking adherence scores (OR, 3.03; 95% CI, 1.20-7.66) than men. Results were similar for timing adherence, with no difference among participants aged 11 to 16 years (OR, 1.03; 95% CI, 0.65-1.63) but a greater odds of higher timing adherence scores in women than in men among participants aged 17 to 24 years (OR, 3.26; 95% CI, 1.43-7.45). There were no differences in adherence assessed by self-report or SD of tacrolimus trough levels. CONCLUSIONS Gender differences in adherence vary by age. Whereas younger adolescents show no adherence differences by gender, young women show much better adherence than young men.
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21
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Abstract
Introduction Patients with hypothyroidism are managed with life-long levothyroxine (LT4) therapy. However, as with other chronic illnesses, drug adherence (DA) is a prominent issue in these patients. The aim of this study is to identify the extent of DA to LT4 in hypothyroidism patients and study the clinical factors contributing to DA in these patients. Methods This cross-sectional study assessed patient adherence to LT4 therapy by Modified Morisky Adherence Scale (MMAS). Factors predicting the pattern of medication adherence were also assessed in all patients. Data were entered and analyzed using SPSS v. 22.0. Results On MMAS, 79 (27.3%) participants indicated low adherence, 117 (40.48%) indicated medium adherence, and 93 (32.2%) participants indicated high adherence. Regular endocrinologist visits and knowledge about medication were highest in high adherent patients (p < 0.05). Need for assistance in taking medication, avoidance of medication with symptomatic relief and busy work schedule was highest in low adherent patients (p < 0.05). Conclusion Patients with hypothyroidism showed moderate adherence to their treatment.
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Affiliation(s)
- Rohan Kumar
- Medical Education and Simulation, Jinnah Sindh Medical University, Karachi, PAK
| | - Faizan Shaukat
- Internal Medicine, Jinnah Postgraduate Medical Center, Karachi, PAK
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22
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Menditto E, Costa E, Midão L, Bosnic-Anticevich S, Novellino E, Bialek S, Briedis V, Mair A, Rajabian-Soderlund R, Arnavielhe S, Bedbrook A, Czarlewski W, Annesi-Maesano I, Anto JM, Devillier P, De Vries G, Keil T, Sheikh A, Orlando V, Larenas-Linnemann D, Cecchi L, De Feo G, Illario M, Stellato C, Fonseca J, Malva J, Morais-Almeida M, Pereira AM, Todo-Bom AM, Kvedariene V, Valiulis A, Bergmann KC, Klimek L, Mösges R, Pfaar O, Zuberbier T, Cardona V, Mullol J, Papadopoulos NG, Prokopakis EP, Bewick M, Ryan D, Roller-Wirnsberger RE, Tomazic PV, Cruz AA, Kuna P, Samolinski B, Fokkens WJ, Reitsma S, Bosse I, Fontaine JF, Laune D, Haahtela T, Toppila-Salmi S, Bachert C, Hellings PW, Melén E, Wickman M, Bindslev-Jensen C, Eller E, O'Hehir RE, Cingi C, Gemicioğlu B, Kalayci O, Ivancevich JC, Bousquet J. Adherence to treatment in allergic rhinitis using mobile technology. The MASK Study. Clin Exp Allergy 2019; 49:442-460. [PMID: 30597673 DOI: 10.1111/cea.13333] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 11/06/2018] [Accepted: 11/07/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Mobile technology may help to better understand the adherence to treatment. MASK-rhinitis (Mobile Airways Sentinel NetworK for allergic rhinitis) is a patient-centred ICT system. A mobile phone app (the Allergy Diary) central to MASK is available in 22 countries. OBJECTIVES To assess the adherence to treatment in allergic rhinitis patients using the Allergy Diary App. METHODS An observational cross-sectional study was carried out on all users who filled in the Allergy Diary from 1 January 2016 to 1 August 2017. Secondary adherence was assessed by using the modified Medication Possession Ratio (MPR) and the Proportion of days covered (PDC) approach. RESULTS A total of 12 143 users were registered. A total of 6 949 users reported at least one VAS data recording. Among them, 1 887 users reported ≥7 VAS data. About 1 195 subjects were included in the analysis of adherence. One hundred and thirty-six (11.28%) users were adherent (MPR ≥70% and PDC ≤1.25), 51 (4.23%) were partly adherent (MPR ≥70% and PDC = 1.50) and 176 (14.60%) were switchers. On the other hand, 832 (69.05%) users were non-adherent to medications (MPR <70%). Of those, the largest group was non-adherent to medications and the time interval was increased in 442 (36.68%) users. CONCLUSION AND CLINICAL RELEVANCE Adherence to treatment is low. The relative efficacy of continuous vs on-demand treatment for allergic rhinitis symptoms is still a matter of debate. This study shows an approach for measuring retrospective adherence based on a mobile app. This also represents a novel approach for analysing medication-taking behaviour in a real-world setting.
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Affiliation(s)
- Enrica Menditto
- CIRFF, Center of Pharmacoeconomics, University of Naples Federico II, Naples, Italy
| | - Elisio Costa
- UCIBIO, REQUIMTE, Faculty of Pharmacy, and Competence Center on Active and Healthy Ageing of University of Porto (Porto4Ageing), University of Porto, Porto, Portugal
| | - Luis Midão
- UCIBIO, REQUIMTE, Faculty of Pharmacy, and Competence Center on Active and Healthy Ageing of University of Porto (Porto4Ageing), University of Porto, Porto, Portugal
| | - Sinthia Bosnic-Anticevich
- Woolcock Institute of Medical Research, University of Sydney Woolcock Emphysema Centre and Sydney Local Health District, Glebe, New South Wales, Australia
| | | | - Slawomir Bialek
- Department of Biochemistry and Clinical Chemistry, Faculty of Pharmacy with the Division of Laboratory Medicine, Warsaw Medical University, Warsaw, Poland
| | | | - Alpana Mair
- DG for Health and Social Care, Scottish Government, Edinburgh, UK
| | | | | | - Anna Bedbrook
- MACVIA-France, Fondation partenariale FMC VIA-LR, Montpellier, France
| | | | - Isabella Annesi-Maesano
- Epidemiology of Allergic and Respiratory Diseases, Department Institute Pierre Louis of Epidemiology and Public Health, INSERM and Sorbonne Université, Medical School Saint Antoine, Paris, France
| | - Josep M Anto
- ISGlobAL, Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain.,IMIM (Hospital del Mar Research Institute), Barcelona, Spain.,CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain.,Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Philippe Devillier
- Laboratoire de Pharmacologie Respiratoire UPRES EA220, Hôpital Foch, Suresnes, France.,Université Versailles Saint-Quentin, Université Paris Saclay, Paris Saclay, France
| | | | - Thomas Keil
- Institute of Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Institute for Clinical Epidemiology and Biometry, University of Wuerzburg, Wuerzburg, Germany
| | - Aziz Sheikh
- The Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
| | - Valentina Orlando
- CIRFF, Center of Pharmacoeconomics, University of Naples Federico II, Naples, Italy
| | - Désirée Larenas-Linnemann
- Center of Excellence in Asthma and Allergy, Médica Sur Clinical Foundation and Hospital, México City, Mexico
| | - Lorenzo Cecchi
- SOS Allergology and Clinical Immunology, USL Toscana Centro, Prato, Italy
| | - Giulia De Feo
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Salerno, Italy
| | - M Illario
- Division for Health Innovation, Campania Region and Federico II University Hospital Naples (R&D and DISMET), Naples, Italy
| | - Cristiana Stellato
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Salerno, Italy
| | - Joao Fonseca
- CINTESIS, Center for Research in Health Technologies and Information Systems, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.,MEDIDA, Lda, Porto, Portugal
| | - Joao Malva
- Faculty of Medicine, Coimbra Institute for Clinical and Biomedical Research (iCBR), University of Coimbra, Coimbra, Portugal.,Ageing@Coimbra EIP-AHA Reference Site, Coimbra, Portugal
| | | | - Ana Maria Pereira
- Allergy Unit, CUF-Porto Hospital and Institute, Porto, Portugal.,Center for Research in Health Technologies and Information Systems CINTESIS, Universidade do Porto, Porto, Portugal
| | - Ana Maria Todo-Bom
- Imunoalergologia, Centro Hospitalar Universitário de Coimbra and Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | | | - Arunas Valiulis
- Department of Public Health, Clinic of Children's Diseases, and Institute of Health Sciences, Vilnius University Institute of Clinical Medicine, Vilnius, Lithuania.,European Academy of Paediatrics (EAP/UEMS-SP), Brussels, Belgium
| | - Karl Christian Bergmann
- Charité - Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,Department of Dermatology and Allergy, Comprehensive Allergy Center, Berlin Institute of Health, Berlin, Germany
| | | | - Ralph Mösges
- Medical Faculty, Institute of Medical Statistics, and Computational Biology, University of Cologne, Cologne, Germany.,CRI-Clinical Research International-Ltd, Hamburg, Germany
| | - Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery, Section of Rhinology and Allergy, University Hospital Marburg, Phillipps-Universität Marburg, Germany
| | - Torsten Zuberbier
- Charité - Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,Department of Dermatology and Allergy, Comprehensive Allergy Center, Berlin Institute of Health, Berlin, Germany
| | - Vicky Cardona
- Allergy Section, Department of Internal Medicine, Hospital Vall d'Hebron, & ARADyAL Spanish Research Network, Barcelona, Spain
| | - Joaquim Mullol
- Rhinology Unit & Smell Clinic, ENT Department, Hospital Clínic, Barcelona, Spain.,Clinical & Experimental Respiratory Immunoallergy, IDIBAPS, CIBERES, University of Barcelona, Barcelona, Spain
| | - Nikos G Papadopoulos
- Division of Infection, Immunity& Respiratory Medicine, Royal Manchester Children's Hospital, University of Manchester, Manchester, UK.,Allergy Department, 2nd Pediatric Clinic, Athens General Children's Hospital "P&A Kyriakou", University of Athens, Athens, Greece
| | - Emmanuel P Prokopakis
- Department of Otorhinolaryngology, University of Crete School of Medicine, Heraklion, Greece
| | | | - Dermot Ryan
- Allergy and Respiratory Research Group, The University of Edinburgh, Edinburgh, UK
| | | | | | - Alvaro A Cruz
- ProAR - Nucleo de Excelencia em Asma, Federal University of Bahia, Salvador, Brazil.,WHO GARD Planning Group, Salvador, Brazil
| | - Piotr Kuna
- Division of Internal Medicine, Asthma and Allergy, Barlicki University Hospital, Medical University of Lodz, Lodz, Poland
| | - Boleslaw Samolinski
- Department of Prevention of Envinronmental Hazards and Allergology, Medical University of Warsaw, Warsaw, Poland
| | - Wytske J Fokkens
- Department of Otorhinolaryngology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Sietze Reitsma
- Department of Otorhinolaryngology, Academic Medical Centre, Amsterdam, The Netherlands
| | | | | | | | - Tari Haahtela
- Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Sanna Toppila-Salmi
- Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Claus Bachert
- Upper Airways Research Laboratory, ENT Department, Ghent University Hospital, Ghent, Belgium
| | - Peter W Hellings
- Department of Otorhinolaryngology, Univ Hospitals Leuven, Leuven, Belgium.,Academic Medical Center, Univ of Amsterdam, Amsterdam, The Netherlands.,Euforea, Brussels, Belgium
| | - Erik Melén
- Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden.,Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Wickman
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
| | - Carsten Bindslev-Jensen
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense Research Center for Anaphylaxis (ORCA), Odense, Denmark
| | - Esben Eller
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense Research Center for Anaphylaxis (ORCA), Odense, Denmark
| | - Robyn E O'Hehir
- Department of Allergy, Immunology and Respiratory Medicine, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Immunology, Monash University, Melbourne, Victoria, Australia
| | - Cemal Cingi
- ENT Department, Medical Faculty, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Bilun Gemicioğlu
- Department of Pulmonary Diseases, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Omer Kalayci
- Pediatric Allergy and Asthma Unit, Hacettepe University School of Medicine, Ankara, Turkey
| | | | - Jean Bousquet
- MACVIA-France, Fondation partenariale FMC VIA-LR, Montpellier, France.,Euforea, Brussels, Belgium.,INSERM U 1168, VIMA: Ageing and Chronic Diseases Epidemiological and Public Health Approaches, Villejuif, France.,Université Versailles St-Quentin-en-Yvelines, UMR-S 1168, Montigny le Bretonneux, France
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23
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Klewitz F, Nöhre M, Bauer-Hohmann M, Tegtbur U, Schiffer L, Pape L, Schiffer M, de Zwaan M. Information Needs of Patients About Immunosuppressive Medication in a German Kidney Transplant Sample: Prevalence and Correlates. Front Psychiatry 2019; 10:444. [PMID: 31316406 PMCID: PMC6609567 DOI: 10.3389/fpsyt.2019.00444] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 06/04/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Worldwide clinical guidelines for the care of kidney transplant (KT) recipients recognize the importance of health care providers imparting appropriate immunosuppressive medication (ISM) information for the facilitation of safe medication self-management. The extent of medication information made available is, however, not necessarily what patients require to know about their prescribed medicines. A useful indicator for determining the quality of prescription practice is to what degree the provided information meets the personal needs of patients. No previous studies have focused on the ISM information needs of KT patients. This study aims to investigate how satisfied KT patients are with the provided ISM information and to examine the association between satisfaction levels and socio-demographic, psychosocial, and transplant-related variables. Materials and Methods: KT patients (n = 440) were asked to complete a series of self-report questionnaires to evaluate the variables adherence, ISM experience, perceived social support, symptoms of anxiety, and depression, and transplant-related information (e.g., donation type). ISM information needs were assessed with the Satisfaction with Information about Medicines Scale (SIMS-D). Results: On average, 35.9% of the answers to the SIMS-D items indicated dissatisfaction with the received information; dissatisfaction was more prevalent for the SIMS-D subscale "potential problems" (46.1%) than the SIMS-D subscale "action and usage" (26.7%). On an individual item level, the dissatisfaction with information concerning ISM side effects on drowsiness (57.1%) and sex life (56.3%) was most notable. Higher satisfaction with ISM information was correlated with higher age, better adherence, higher perceived social support, and lower anxiety levels. Multiple linear regression analyses revealed that adherence, perceived social support, and age were independently associated with ISM information satisfaction. No associations were found with sex, educational level, partnership status, symptoms of depression, experience of side effects, and transplant-related variables. Discussion: The data indicate that a substantial proportion of KT patients have unmet ISM information needs, especially with regard to potential problems of ISM. Dissatisfaction with ISM information is a potential amendable risk factor for KT patients engaging in non-adherent behavior, thus justifying further research in this area. ISM information should be tailored to meet the individual needs of KT patients in order to promote optimal medication self-management and adherence behavior.
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Affiliation(s)
- Felix Klewitz
- Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School, Hannover, Germany.,Project Kidney Transplantation 360° (NTX 360°), Hannover Medical School, Hannover, Germany
| | - Mariel Nöhre
- Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School, Hannover, Germany.,Project Kidney Transplantation 360° (NTX 360°), Hannover Medical School, Hannover, Germany
| | - Maximilian Bauer-Hohmann
- Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School, Hannover, Germany.,Project Kidney Transplantation 360° (NTX 360°), Hannover Medical School, Hannover, Germany
| | - Uwe Tegtbur
- Project Kidney Transplantation 360° (NTX 360°), Hannover Medical School, Hannover, Germany.,Department of Sports Medicine, Hannover Medical School, Hannover, Germany
| | - Lena Schiffer
- Project Kidney Transplantation 360° (NTX 360°), Hannover Medical School, Hannover, Germany.,Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Lars Pape
- Project Kidney Transplantation 360° (NTX 360°), Hannover Medical School, Hannover, Germany.,Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Mario Schiffer
- Project Kidney Transplantation 360° (NTX 360°), Hannover Medical School, Hannover, Germany.,Department of Nephrology and Hypertension, University Hospital Erlangen, Erlangen, Germany
| | - Martina de Zwaan
- Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School, Hannover, Germany.,Project Kidney Transplantation 360° (NTX 360°), Hannover Medical School, Hannover, Germany
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24
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Shneider C, Dunphy C, Shemesh E, Annunziato RA. Assessment and Treatment of Nonadherence in Transplant Recipients. Gastroenterol Clin North Am 2018; 47:939-948. [PMID: 30337042 DOI: 10.1016/j.gtc.2018.07.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Stable intake of an immunosuppressant medication regimen is essential for posttransplant survival in the vast majority of cases. And yet, many patients are nonadherent (do not take their medications as prescribed), and suffer consequences ranging from rejection to morbidity and mortality. We review the evidence related to monitoring of adherence to medications, and intervention strategies. Our aim is to provide a baseline from which readers may approach behavioral aspects of posttransplant care. This review may also help readers in designing clinical programs for routine monitoring of adherence, and inform the choice of intervention when adherence falls below a certain threshold.
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Affiliation(s)
- Caitlin Shneider
- Center for Translational Science, Children's National Medical Center, 111 Michigan Avenue Northwest, 5th Floor Main, Suite 5500, Office 5533, Washington, DC 20010, USA
| | - Claire Dunphy
- Clinical Psychology, Department of Psychology, Fordham University, 441 East Fordham Road, Dealy Hall, Bronx, NY 10458, USA
| | - Eyal Shemesh
- Division of Behavioral and Developmental Health, The Department of Pediatrics, Kravis Children's Hospital, Icahn School of Medicine at Mount Sinai, Box 1198, 1 Gustave L Levy Place, New York, NY 10029, USA.
| | - Rachel A Annunziato
- Psychology, Fordham College at Rose Hill, Fordham University, 441 East Fordham Road, Dealy Hall, Bronx, NY 10458, USA
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25
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Sayegh CS, Szmuszkovicz JR, Menteer J, Sherer S, Thomas D, Lestz R, Belzer M. Cell phone support to improve medication adherence among solid organ transplant recipients. Pediatr Transplant 2018; 22:e13235. [PMID: 29920879 DOI: 10.1111/petr.13235] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/06/2018] [Indexed: 11/30/2022]
Abstract
For many adolescent and young adult solid organ transplant recipients, medication non-adherence is a mortal issue. This study investigated the feasibility, acceptability, and potential efficacy of a 12-week cell phone support intervention to improve immunosuppressant medication adherence. A small sample (N = 8) of non-adherent adolescent and young adult transplant recipients, aged 15-20.5 years, was enrolled. Cell phone support consisted of short calls each weekday including medication reminders, discussion of needs, problem-solving support, and promotion of clinic and community resources. Changes in adherence were measured by self-report and laboratory values, and intervention acceptability, adherence barriers, social support, depression, and substance use were assessed by self-report. Pre-post effect sizes showed medium-to-large improvements in adherence, lasting through a 12-week follow-up assessment. There were also small-to-medium changes in adherence barriers, social support, and depression. However, acceptability and feasibility were limited, due to a low rate of enrollment by eligible male participants. Cell phone support interventions may promote medication adherence among adolescents and young adults. Cell phone support warrants further investigation, including a randomized controlled trial to evaluate efficacy.
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Affiliation(s)
| | - Jacqueline R Szmuszkovicz
- Children's Hospital Los Angeles, Los Angeles, CA, USA
- University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Jondavid Menteer
- Children's Hospital Los Angeles, Los Angeles, CA, USA
- University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Sara Sherer
- Children's Hospital Los Angeles, Los Angeles, CA, USA
- University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Daniel Thomas
- Children's Hospital Los Angeles, Los Angeles, CA, USA
- University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Rachel Lestz
- Children's Hospital Los Angeles, Los Angeles, CA, USA
- University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Marvin Belzer
- Children's Hospital Los Angeles, Los Angeles, CA, USA
- University of Southern California Keck School of Medicine, Los Angeles, CA, USA
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26
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Steinberg EA, Moss M, Buchanan CL, Goebel J. Adherence in pediatric kidney transplant recipients: solutions for the system. Pediatr Nephrol 2018; 33:361-372. [PMID: 28349215 DOI: 10.1007/s00467-017-3637-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 02/24/2017] [Accepted: 02/27/2017] [Indexed: 12/13/2022]
Abstract
Non-adherence remains a significant problem among pediatric (and adult) renal transplant recipients. Non-adherence among solid organ transplant recipients results in US$15-100 million annual costs. Estimates of non-adherence range from 30 to 70% among pediatric patients. Research demonstrates that a 10% decrement in adherence is associated with 8% higher hazard of graft failure and mortality. Focus has begun to shift from patient factors that impact adherence to the contributing healthcare and systems factors. The purpose of this review is to describe problems within the systems implicated in non-adherence and potential solutions that may be related to positive adherence outcomes. Systems issues include insurance and legal regulations, provider and care team barriers to optimal care, and difficulties with transitioning to adult care. Potential solutions include recognition of how systems can work together to improve patient outcomes through improvements in insurance programs, a multi-disciplinary care team approach, evidence-based medical management, pharmacy-based applications and interventions to simplify medication regimens, improved transition protocols, and telehealth/technology-based multi-component interventions. However, there remains a significant lack of reliability in the application of these potential solutions to systems issues that impact patient adherence. Future efforts should accordingly focus on these efforts, likely by leveraging quality improvement and related principles, and on the investigation of the efficacy of these interventions to improve adherence and graft outcomes.
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Affiliation(s)
- Elizabeth A Steinberg
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Mary Moss
- Department of Pharmacy, Children's Hospital Colorado, Aurora, CO, USA
| | - Cindy L Buchanan
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, USA.,Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jens Goebel
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
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27
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Shemesh E, Mitchell J, Neighbors K, Feist S, Hawkins A, Brown A, Yin W, Anand R, Stuber ML, Annunziato RA. Recruiting a representative sample in adherence research-The MALT multisite prospective cohort study experience. Pediatr Transplant 2017; 21:10.1111/petr.13067. [PMID: 28984072 PMCID: PMC5698095 DOI: 10.1111/petr.13067] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/07/2017] [Indexed: 01/26/2023]
Abstract
Medication adherence is an important determinant of transplant outcomes. Attempts to investigate adherence are frequently undermined by selection bias: It is very hard to recruit and retain non-adherent patients in research efforts. This manuscript presents recruitment strategies and results from the MALT (Medication Adherence in children who had a Liver Transplant) multisite prospective cohort study. MALT sites recruited 400 pediatric liver transplant patients who agreed to be followed for 2 years. The primary purpose was to determine whether a marker of adherence, the Medication Level Variability Index (MLVI), predicts rejection outcomes. The present manuscript describes methods used in MALT to ensure that a representative sample was recruited, and presents detailed recruitment results. MALT sites were able to recruit a nationally representative sample, as determined by a comparison between the MALT cohort and a national sample of transplant recipients. Strategies that helped ensure that the sample was representative included monitoring of the outcome measure in comparison with a national sample, drastically limiting patient burden, and specific recruitment methods. We discuss the importance of a representative sample in adherence research and recommend that future efforts to study adherence pay special attention to sample characteristics.
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Affiliation(s)
- Eyal Shemesh
- Icahn School of Medicine at Mount Sinai, New York, NY USA
| | | | - Katie Neighbors
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Susan Feist
- Mattel Children’s Hospital at UCLA, Los Angeles, CA, USA
| | - Andre Hawkins
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Amanda Brown
- Hillman Center for Pediatric Transplantation, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | | | | | | | - Rachel A Annunziato
- Icahn School of Medicine at Mount Sinai, New York, NY USA,Fordham University, Department of Psychology, New York, NY USA
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28
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Shemesh E, Bucuvalas JC, Anand R, Mazariegos GV, Alonso EM, Venick RS, Reyes-Mugica M, Annunziato RA, Shneider BL. The Medication Level Variability Index (MLVI) Predicts Poor Liver Transplant Outcomes: A Prospective Multi-Site Study. Am J Transplant 2017; 17:2668-2678. [PMID: 28321975 PMCID: PMC5607074 DOI: 10.1111/ajt.14276] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 03/03/2017] [Accepted: 03/11/2017] [Indexed: 01/25/2023]
Abstract
Nonadherence to immunosuppressant medications is a leading cause of poor long-term outcomes in transplant recipients. The Medication Level Variability Index (MLVI) provides a vehicle for transplant outcome risk-stratification through continuous assessment of adherence. The MALT (Medication Adherence in children who had a Liver Transplant) prospective multi-site study evaluated whether MLVI predicts late acute rejection (LAR). Four hundred pediatric (1-17-year-old) liver transplant recipients were enrolled and followed for 2 years. The a-priori hypothesis was that a higher MLVI predicts LAR. Predefined secondary analyses evaluated other outcomes such as liver enzyme levels, and sensitivity analyses compared adolescents to pre-adolescents. In the primary analysis sample of 379 participants, a higher prerejection MLVI predicted LAR (mean prerejection MLVI with LAR: 2.4 [3.6 standard deviation] versus without LAR, 1.6 [1.1]; p = 0.026). Fifty-three percent of the adolescents with MLVI>2 in year 1 had LAR by the end of year 2, as compared with 6% of those with year 1 MLVI≤2. A higher MLVI was significantly associated with all secondary outcomes. MLVI, a marker of medication adherence that uses clinically derived information, predicts LAR in pediatric liver transplant recipients.
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Affiliation(s)
- Eyal Shemesh
- Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - John C Bucuvalas
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | | | | | | | | | | | - Rachel A Annunziato
- Icahn School of Medicine at Mount Sinai, New York, NY USA,Fordham University, Department of Psychology, New York, NY USA
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29
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Acute antibody-mediated rejection in kidney transplant recipients. Transplant Rev (Orlando) 2017; 31:47-54. [DOI: 10.1016/j.trre.2016.10.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 10/05/2016] [Indexed: 01/10/2023]
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30
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Shuker N, Shuker L, van Rosmalen J, Roodnat JI, Borra LCP, Weimar W, Hesselink DA, van Gelder T. A high intrapatient variability in tacrolimus exposure is associated with poor long-term outcome of kidney transplantation. Transpl Int 2016; 29:1158-1167. [PMID: 27188932 DOI: 10.1111/tri.12798] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 01/15/2016] [Accepted: 05/13/2016] [Indexed: 12/30/2022]
Abstract
Tacrolimus is a critical dose drug with a considerable intrapatient variability (IPV) in its pharmacokinetics. We investigated whether a high IPV in tacrolimus exposure is associated with adverse long-term renal transplantation outcomes. Tacrolimus IPV was calculated from predose concentrations measured between 6 and 12 months post-transplantation of 808 renal transplant recipients (RTRs) transplanted between 2000 and 2010. One hundred and eighty-eight (23.3%) patients reached the composite end point consisting of graft loss, late biopsy-proven rejection, transplant glomerulopathy, or doubling of serum creatinine concentration between month 12 and the last follow-up. The cumulative incidence of the composite end point was significantly higher in patients with high IPV than in patients with low IPV (hazard ratio: 1.41, 95% CI: 1.06-1.89; P = 0.019). After the adjustment for several factors, the higher incidence of the composite end point for RTRs with a high IPV remained statistically significant (hazard ratio: 1.42, 95% CI: 1.06-1.90; P = 0.019). Younger recipient age at transplantation, previous transplantation, worse graft function (at month 6 post-transplantation), and low mean tacrolimus concentration at 1 year post-transplantation were additional predictors for worse long-term transplant outcome. A high tacrolimus IPV is an independent risk factor for adverse kidney transplant outcomes that can be used as an easy monitoring tool to help identify high-risk RTRs.
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Affiliation(s)
- Nauras Shuker
- Department of Internal Medicine, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands. .,Department of Hospital Pharmacy, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands.
| | - Lamis Shuker
- Department of Internal Medicine, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Joke I Roodnat
- Department of Internal Medicine, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Lennaert C P Borra
- Department of Hospital Pharmacy, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Willem Weimar
- Department of Internal Medicine, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Dennis A Hesselink
- Department of Internal Medicine, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Teun van Gelder
- Department of Internal Medicine, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands.,Department of Hospital Pharmacy, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
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31
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Toward appropriate criteria in medication adherence assessment in older persons: Position Paper. Aging Clin Exp Res 2016; 28:371-81. [PMID: 26630945 DOI: 10.1007/s40520-015-0435-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 07/30/2015] [Indexed: 10/23/2022]
Abstract
Nonadherence to medication regimens is a worldwide challenge; adherence rates range from 38 to 57 % in older populations with an average rate of less than 45 % and nonadherence contributes to adverse drug events, increased emergency visits and hospitalisations. Accurate measurement of medication adherence is important in terms of both research and clinical practice. However, the identification of an objective approach to measure nonadherence is still an ongoing challenge. The aim of this Position Paper is to describe the advantages and disadvantages of the known medication adherence tools (self-report, pill count, medication event monitoring system (MEMS) and electronic monitoring devices, therapeutic drug monitoring, pharmacy records based on pharmacy refill and pharmacy claims databases) to provide the appropriate criteria to assess medication adherence in older persons. To the best of our knowledge, no gold standard has been identified in adherence measurement and no single method is sufficiently reliable and accurate. A combination of methods appears to be the most suitable. Secondly, adherence assessment should always consider tools enabling polypharmacy adherence assessment. Moreover, it is increasingly evident that adherence, as a process, has to be assessed over time and not just at one evaluation time point (drug discontinuation). When cognitive deficits or functional impairments may impair reliability of adherence assessment, a comprehensive geriatric assessment should be performed and the caregiver involved. Finally, studies considering the possible implementation in clinical practice of adherence assessment tools validated in research are needed.
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32
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Affiliation(s)
- Eyal Shemesh
- Department of Pediatrics and Kravis Children's Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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33
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Babalonis S, Hampson AJ, Lofwall MR, Nuzzo PA, Walsh SL. Quinine as a potential tracer for medication adherence: A pharmacokinetic and pharmacodynamic assessment of quinine alone and in combination with oxycodone in humans. J Clin Pharmacol 2015; 55:1332-43. [PMID: 26032168 DOI: 10.1002/jcph.557] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 05/21/2015] [Indexed: 11/12/2022]
Abstract
Effective strategies to monitor pharmacotherapy adherence are necessary, and sensitive biological markers are lacking. This study examined a subtherapeutic dose of quinine as a potential adherence tracer. Primary aims included examination of the plasma and urinary pharmacokinetic profile of once-daily quinine; secondary aims assessed pharmacokinetic/pharmacodynamic interactions with oxycodone (a CYP3A and CYP2D substrate). Healthy, nondependent opioid users (n = 9) were enrolled in this within-subject, double-blind, placebo-controlled inpatient study. Participants received the following oral doses: day 1, oxycodone (30 mg); days 2-4, quinine (80 mg); day 5, quinine and oxycodone (2 hours postquinine). Blood and 24-hour urine samples were collected throughout the study, and pharmacodynamic outcomes were assessed during experimental sessions (days 1, 4, 5). Quinine displayed a plasma Tmax ∼2 hours and t1/2 ∼10 hours. Oxycodone and noroxycodone parameters (Tmax , Cmax , t1/2 ) were similar with or without quinine present, although drug exposure (AUC) was slightly greater when combined with quinine. No pharmacodynamic interactions were detected, and doses were safely tolerated. During washout, quinine urinary concentrations steadily declined (elimination t1/2 ∼16 hours), with a 94% decrease observed 72 hours postdose. Overall, low-dose quinine appears to be a good candidate for a medication additive to monitor adherence for detection of missed medication.
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Affiliation(s)
- Shanna Babalonis
- University of Kentucky College of Medicine, Department of Behavioral Science, Lexington, KY, USA.,University of Kentucky, Center on Drug and Alcohol Research, Lexington, KY, USA
| | - Aidan J Hampson
- National Institute on Drug Abuse, Division of Pharmacotherapies and Medical Consequences, Rockville, MD, USA
| | - Michelle R Lofwall
- University of Kentucky College of Medicine, Department of Behavioral Science, Lexington, KY, USA.,University of Kentucky, Center on Drug and Alcohol Research, Lexington, KY, USA.,University of Kentucky College of Medicine, Department of Psychiatry, Lexington, KY, USA
| | - Paul A Nuzzo
- University of Kentucky, Center on Drug and Alcohol Research, Lexington, KY, USA
| | - Sharon L Walsh
- University of Kentucky College of Medicine, Department of Behavioral Science, Lexington, KY, USA.,University of Kentucky, Center on Drug and Alcohol Research, Lexington, KY, USA.,University of Kentucky College of Medicine, Department of Psychiatry, Lexington, KY, USA.,University of Kentucky College of Pharmacy, Department of Pharmaceutical Sciences, Lexington, KY, USA.,University of Kentucky College of Medicine, Department of Pharmacology, Lexington, KY, USA
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34
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Lieber SR, Shemesh E. Longitudinal stability of medication adherence: Trying to decipher an important construct. Pediatr Transplant 2015; 19:348-50. [PMID: 25940374 PMCID: PMC4429598 DOI: 10.1111/petr.12484] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Sarah R Lieber
- Division of Internal Medicine, Icahn School of Medicine at Mount
Sinai, New York, NY USA,Mount Sinai Medical Center, New York, NY, USA
| | - Eyal Shemesh
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai,
New York, NY, USA,Kravis Children’s Hospital, Mount Sinai Medical Center, New
York, NY, USA
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35
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Maggiore U. Measuring alloreactivity and drug adherence: making the best of what we have. Transplant Rev (Orlando) 2015; 29:43-4. [PMID: 25736694 DOI: 10.1016/j.trre.2015.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 02/17/2015] [Indexed: 11/18/2022]
Affiliation(s)
- Umberto Maggiore
- Department of Nephrology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy.
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