Increasing adherence to immunosuppression: a clinical priority

Addressing Substance Use in the Adolescent Transplant Population

Adolescence is a unique period of physical and psychosocial changes as youth transition, over many years, to adulthood. The psychosocial changes that accompany adolescence include emotional separation from parents, greater influence of peer groups, an interest in self-identification and autonomy, and increased risk-taking behaviors. Substance use is a common form of risk-taking behavior in the adolescent developmental stage. Alcohol, nicotine, and cannabis are the most common types of substances used in the United States. In the adolescent transplant population, rates of substance use appear to be at, or slightly below, their peer counterparts. Substance use can lead to deleterious health outcomes for adolescent transplant patients as a result of impaired decision-making, reduction in medication and clinic visit compliance, increases in mental health disorders, and risk for developing dependence and a substance use disorder. Given the close relationship that many pediatric transplant providers have with their patients and families, transplant care teams are in an excellent position to help their patients by addressing adolescent substance use. This narrative review describes how providers can use proactive standardized approaches to identify and intervene with substance use behavior.

Improving adherence to immunosuppression after liver or kidney transplantation in individuals with impairments in personality functioning – A randomized controlled single center feasibility study

Introduction

Although adherence to immunosuppressive medication is the key factor for long-term graft survival today, 20–70% of transplant recipients are non-adherent to their immunosuppressive medication.

Objective

A prospective, randomized, controlled single-center feasibility study was designed to evaluate the impact of a step guided multicomponent interprofessional intervention program for patients after kidney or liver transplantation on adherence to their immunosuppressive medication in daily clinical practice.

Materials and methods

The intervention consisted of group therapy and daily training as well as individual sessions in a step guided approach. The primary endpoint of the study was adherence to immunosuppression as assessed with the “Basel Assessment of Adherence to Immunosuppressive Medications Scale” (BAASIS). The coefficient of variation (CV%) of Tacrolimus (TAC) through levels and the level of personality functioning was a secondary endpoint. We conducted six monthly follow-up visits.

Results

Forty-one age- and sex-matched patients [19 females, 58.5 (SD = 10.56) years old, 22 kidney- and 19 liver transplantation] were randomized to the intervention- (N = 21) or control-group (N = 20). No differences between intervention- and control groups were found in the primary endpoint adherence and CV% of TAC. However, in further exploratory analyses, we observed that individuals with higher impairments in personality functioning showed higher CV% of TAC in the controls. The intervention might compensate personality-related susceptibility to poor adherence as evident in CV% of TAC.

Discussion

The results of the feasibility study showed that this intervention program was highly accepted in the clinical setting. The Intervention group could compensate higher CV% of TAC after liver or kidney transplantation in individuals with lower levels of personality functioning and non-adherence.

Clinical trial registration

ClinicalTrials.gov, identifier NCT04207125.

Empowering patients to adhere to their treatment regimens: A multifaceted approach

It is well-recognized that adolescence and early adulthood are a high-risk period for non-adherence with treatment regimens in solid organ transplant recipients, leading to high rates of rejection and graft loss (Transplantation, 92, 2011, 1237; Pediatr Transplant, 9, 2005, 381; Transplantation, 77, 2004, 769). Preventing medication non-adherence is the holy grail of transplant adolescent care. If we can determine how best to support our patients in taking their daily medications as prescribed, we can improve long-term health, reduce need for re-transplantation, and reduce healthcare costs. In the last few years, several studies have provided us with additional insights into potentially effective interventions and have highlighted existing gaps in knowledge. This article reviews recent literature published over the last 5 years on the topic of adherence in transplant recipients, highlighting insights and opportunities to promote adherence at the individual patient level, family level, healthcare system level, and community level. Above all, the recent work that is highlighted suggests that adherence interventions for prevention and treatment must be multifaceted, individualized, and longitudinal to be effective.

Life Quality and Compliance After Transplant: The Case of Turkey

OBJECTIVE

Chronic renal failure is one of the most significant health problems in Turkey, as it is all over the world, and negatively affects quality of life. The aim of this study is to find factors affecting compliance levels and quality of life of patients undergoing kidney transplant.

MATERIALS AND METHODS

The population of the study consisted of 244 patients who underwent kidney transplant. Although the study aimed to cover the entire target population in the sampling selection, it was conducted among 206 patients. The data were collected by face-to-face interview.

RESULTS

Of the patients, 92.7% were between 46 and 59 years of age, 54.4% had a living donor transplant, 54.9% had adverse effects, and 2.9% had rejection due to incompatibility. There was a significant relationship between compliance and quality of life; increasing frequency of adverse effects would decrease in direct proportion to compliance, which would, therefore, increase quality of life. All the subscale scores of the 36-Item Short Form Health Survey were found to have an average of 60 and above. The mean of the compliance scale was 48.33 (SD, 3.21), and, with the maximum score at 55, the mean of the group was high. In our country, patients view transplant as a final and definite treatment method. This might be related to fact that the longer the time after transplant, the lower the level of compliance.

Medication adherence in pediatric renal transplant patients: The role of family functioning and parent health locus of control

Children and adolescents with renal disease experience daily social, emotional, and medical challenges. Renal transplantation can help to improve quality of life but requires a lifelong regimen of immunosuppressant medication to maintain health. Adherence to a daily complex regimen can be difficult, particularly for adolescents who are beginning to develop autonomy from caregivers and are faced with a unique set of socio-emotional challenges. This study examines two factors that have shown to influence adherence in other pediatric populations, namely family functioning and parent health locus of control, from mothers' perspectives, in predicting medication non-adherence for adolescents (ages 12-19 years) 1 year post-transplant. Non-adherence was defined as the percentage of missed doses and late doses of the weekly immunosuppressant doses prescribed. Regression results demonstrated that mothers' perceptions of poorer overall family functioning predicted missed medication doses (ΔR²  = 0.383, F(7, 21) = 2.570, P = 0.044) with significant contributions in the domains of problem-solving (β = -0.795, t(21) = -2.927, P = 0.008) and affective involvement (β = 0.872, t(21) = 3.370, P = 0.003). Moreover, mothers who perceived that their adolescent had control over his/her health also predicted more missed medication doses (ΔR²  = 0.133, F(1, 27) = 5.155, P = 0.031). Important implications for these findings include implementation of family-based interventions that promote developmentally appropriate skills for adolescents and cultivate emotional involvement within the family.

Factors relevant to medication non-adherence in kidney transplant: a systematic review

Background Medication non-adherence is a major issue after transplant that can lead to misdiagnosis, rejection, poor health affecting quality of life, graft loss or death. Several estimations of adherence and related factors have previously been described but conclusions leave doubt as to the most accurate assessment method. Aim of the review To identify the factors most relevant to medication non-adherence in kidney transplant in current clinical practice. Method This systematic review is registered in the PROSPERO data base and follows the Prisma checklist. Articles in English in three databases from January 2009 to December 2014 were analysed. A synthesis was made to target adherence assessment methods, their prevalence and significance. Results Thirty-seven studies were analysed rates of non-adherence fluctuating from 1.6 to 96%. Assessment methods varied from one study to another, although self-reports were mainly used. It appears that youth (≤50 years old), male, low social support, unemployment, low education, ≥3 months post graft, living donor, ≥6 comorbidities, ≥5 drugs/d, ≥2 intakes/d, negative beliefs, negative behavior, depression and anxiety were the factors significantly related to non-adherence. Conclusion As there are no established guidelines, consideration should be given to more than one approach to identify medication non-adherence although self-reports should remain the cornerstone of adherence assessment.

Health-related quality of life after kidney transplantation: who benefits the most?

The influence of dialysis modalities on HRQoL before and after kidney transplantation (KT) and the role of adherence to medication on HRQoL have not been fully studied. Sixty four dialysis patients who answered the 15D HRQoL survey during dialysis were surveyed again after KT. Adherence and employment were also investigated. The mean 15D score was highest among home hemodialysis patients (HHD) and lowest among in-center hemodialysis patients (icHD). After KT, the mean 15D score improved significantly in 78.6% of peritoneal dialysis patients (PD), 47.6% of HHD, and 53.8% of icHD. Then, mean 15D score remained unchanged in 28.6% of HHD and in 23.1% of icHD patients. A deterioration in the 15D score occurred in 14.3% of PD, 23.1% of icHD, and 23.8% of HHD patients, and this was influenced by the number of pills (P = 0.04). Adherence to medication was the lowest in PD, timing being the most challenging task showing a connection to higher creatinine concentration (never forgot 1.41 mg/dl vs. forgot 2.08 mg/dl P = 0.05). Employed patients had a higher mean 15D score. The icHD and PD patients benefited the most from KT and HHD the least. Low pill burden and employment were linked to a better HRQoL.

Recent developments in kidney transplantation in children

PURPOSE OF REVIEW

Renal transplantation in childhood is a well established procedure with excellent short-term outcomes. However, waiting times for transplantation are still relatively long if living donation cannot be performed, and long-term outcomes after transplantation have not significantly improved during the last decade.

RECENT FINDINGS

This review describes alternative modalities to improve donation rates such as en bloc kidney transplantation from young donors, ABO-incompatible transplantation and kidney paired donation. This review also deals with long-term post-transplant morbidities, such as follows: first, medication side-effects (metabolic syndrome, cardiovascular disease) and with the benefits of steroid and calcineurin inhibitor drug minimization; second, the deleterious impact of viral infections and their management and third, chronic antibody-mediated rejection, its therapeutic and prevention possibilities.

SUMMARY

Donor shortage and long-term morbidities, after transplantation, are still relevant issues in paediatric renal transplantation medicine. Significant research and efforts have been made to advance the field and create novel approaches for improvement of transplantation rates and post-transplant graft or patient survival. These modalities are to be established in the routine setting.

Educational intervention for liver transplantation candidates

OBJECTIVE

The objective in this study was to analyze candidates' knowledge on the liver transplantation process before and after putting in practice an educational intervention.

METHOD

A quasi-experimental, one-group pretest-posttest research design was adopted. The final sample included 15 subjects. Research data were collected between January and March 2010 in three phases, which were: pretest, implementation of the educational intervention (two meetings) and posttest.

RESULTS

The results evidenced significant cognitive gains after the intervention, with improvements in the participants' performance .

CONCLUSIONS

The research presents evidence that putting in practice a patient education strategy can enhance candidates' knowledge on the liver transplantation process and consequently contribute to a successful treatment.

Adherence with drug therapy in pregnancy

Available information suggests that nonadherence with medication is a common problem in pregnant women. Not taking prescribed drugs may have potentially negative consequences as patients may not achieve their therapeutic goal. In addition to the many factors that may influence medication-taking behaviour in the general population, unique challenges are encountered in pregnant women as both maternal health and fetal well-being must be considered. On the one hand, pregnant women may be motivated to keep their underlying disease under control, while, on the other hand, fear and anxiety regarding the potential harmful effects of their medication on their unborn child may result in poor adherence with needed medication. Providing evidence-based information, ideally preconceptually, regarding the effects of their medication during pregnancy may be important in avoiding misperceptions that lead to nonadherence.

Medical adherence in pediatric organ transplantation: what are the next steps?

PURPOSE OF REVIEW

Adherence within pediatric transplantation has gained importance as the complexities of long-term medical management of these patients are identified and knowledge regarding the negative consequences of nonadherence accumulates. We review recent findings to highlight gaps in the literature and make suggestions for future directions.

RECENT FINDINGS

Most research has focused on medication nonadherence, and a recent meta-analysis indicates that nonadherence is more prevalent in adolescent transplant recipients than in younger children. Nonadherence to other areas of the regimen (e.g. clinic attendance) may be even more common than medication nonadherence. However, work to date is based primarily on kidney and liver pediatric transplant patients, with a paucity of research on heart, lung and intestinal recipients. Risk factors for nonadherence after pediatric transplantation include poor family and child functioning. Intervention research remains rare. Challenges include the need for clearer definitions of what constitutes clinically significant nonadherence, longitudinal and prospective assessment of a wider range of potential risk factors, and the development and evaluation of interventions to treat or prevent nonadherence.

SUMMARY

Adherence research in pediatric transplantation is in its infancy. Significant opportunities exist to advance the field and create standards for effective identification, measurement, and treatment of nonadherence.