Rates and Risk Factors for Nonadherence to the Medical Regimen After Adult Solid Organ Transplantation

Adult provider role in transition of care for young adult pediatric recipients of liver transplant: An expert position statement

Health care transition (HCT) is the process of changing from a pediatric to an adult model of care. Young adult pediatric recipients of liver transplant transferring from pediatric to adult health care services are highly vulnerable and subject to poor long-term outcomes. Barriers to successful transition are multifaceted. A comprehensive HCT program should be initiated early in pediatrics and continued throughout young adulthood, even after transfer of care has been completed. It is critical that pediatric and adult liver transplant providers establish a partnership to optimize care for these patients. Adult providers must recognize the importance of HCT and the need to continue the transition process following transfer. While this continued focus on HCT is essential, current literature has primarily offered guidance for pediatric providers. This position paper outlines a framework with a sample set of tools for the implementation of a standardized, multidisciplinary approach to HCT for adult transplant providers utilizing "The Six Core Elements of HCT." To implement more effective strategies and work to improve long-term outcomes for young adult patients undergoing liver transplant, HCT must be mandated as a routine part of posttransplant care. Increased advocacy efforts with the additional backing and support of governing organizations are required to help facilitate these practices.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A multimodal aftercare intervention improves the outcome after kidney transplantation - results of the KTx360° aftercare program using claims data

Background

The after-care treatment project KTx360° aimed to reduce graft failure and mortality after kidney transplantation (KTx).

Methods

The study was conducted in the study centers Hannover, Erlangen and Hannoversch Muenden from May 2017 to October 2020 under the trial registration ISRCTN29416382. The program provided a multimodal aftercare program including specialized case management, telemedicine support, psychological and exercise assessments, and interventions. For the analysis of graft failure, which was defined as death, re-transplantation or start of long-term dialysis, we used longitudinal claims data from participating statutory health insurances (SHI) which enabled us to compare participants with controls. To balance covariate distributions between these nonrandomized groups we used propensity score methodology, in particular the inverse probability of treatment weighting (IPTW) approach.

Findings

In total, 930 adult participants were recruited at three different transplant centres in Germany, of whom 320 were incident (enrolled within the first year after KTx) and 610 prevalent (enrolled >1 year after KTx) patients. Due to differences in the availability of the claims data, the claims data of 411 participants and 418 controls could be used for the analyses. In the prevalent group we detected a significantly lower risk for graft failure in the study participants compared to the matched controls (HR = 0.13, 95% CI = 0.04-0.39, p = 0.005, n = 389 observations), whereas this difference could not be detected in the incident group (HR = 0.92, 95% CI = 0.54-1.56, p = 0.837, n = 440 observations).

Interpretation

Our findings suggest that a multimodal and multidisciplinary aftercare intervention can significantly improve outcome after KTx, specifically in patients later after KTx. For evaluation of effects on these outcome parameters in patients enrolled within the first year after transplantation longer observation times are necessary.

Funding

The study was funded by the Global Innovation fund of the Joint Federal Committee of the Federal Republic of Germany, grant number 01NVF16009.

The Equitable Benefit Approach to guide the assessment of medical and psychosocial factors in liver transplant candidacy

Lack of available organs poses a significant challenge in meeting the needs of patients with life-threatening liver disease who could benefit from liver transplantation (LT). Psychosocial vulnerability markers have been linked to post-transplant outcomes, raising questions about their use in patient selection. However, their incorporation into selection criteria raises concerns about health equity and potential discrimination. As a result, there is a pressing need to refine fair allocation systems that consider both clinical and psychosocial factors to ensure equitable access and optimize post-transplant outcomes. The Equitable Benefit Approach (EBA) proposed in this paper by the multidisciplinary group of clinical experts in LT from the Italian Society for the Study of the Liver seeks to address these concerns. It presents four procedural principles, the two allocative principles usually applied in transplantation (urgency and utility) and introduces a new one, the principle of health equity. The EBA aims to prioritize patients with the highest transplant benefit while addressing health inequalities. It emphasizes evidence-based decision-making and standardized assessment tools to reliably evaluate psychosocial risk factors. Implementing the EBA involves a multi-step process, including stakeholder engagement, prospective studies to validate its efficacy, development of institutional policies and algorithms, and ongoing monitoring and revision. By following these steps, health care providers can ensure that LT allocation decisions are transparent and responsive to evolving clinical and social contexts. Ultimately, the EBA should offer a comprehensive framework for fair patient selection in LT, considering both biomedical and psychosocial aspects.

A pharmacist-led intervention to improve kidney transplant recipient outcomes and identify patients at risk of highly variable trough tacrolimus levels: a cohort study

OBJECTIVES

Given the positive impact of appropriate medication management on graft outcome and therefore of patient survival and graft function, the pharmacist's role in the kidney transplantation team has evolved over recent decades. The primary objective of this study was to determine whether pharmacist-led intervention after kidney transplantation is associated with a lower graft rejection rate and intra-patient variation in tacrolimus trough concentrations (Cmin). The study's secondary objective was to develop a questionnaire to identify patients at risk for highly variable Cmin.

METHODS

We retrospectively analysed kidney transplant recipients at Rennes University Hospital (France) between January 2013 and December 2020. Patients who received pharmacist-led education (intervention group, n=139) were compared with patients who did not (control group, n=131), according to graft survival at 1 year post-transplant, coefficient of variation (%CV) for the tacrolimus Cmin, age, sex, length of hospital stay post-transplantation, body mass index, and Charlson Comorbidity Index. In the intervention group, a questionnaire assessing patient knowledge was introduced to compare scores with the %CV.

RESULTS

In the intervention group, 1 year post-transplant graft survival was higher (95.7% vs 88.5%, p=0.0289) and patients had fewer variabilities in Cmin. The %CV was correlated with questionnaire scores (r=-0.9758, p<0.0001).

CONCLUSIONS

Pharmacist-led interventions may have contributed to improved graft survival and patient management of immunosuppressants. Because %CV correlates with the patient questionnaire score, its introduction could be useful in identifying kidney transplant patients who would benefit most from a pharmacist-led patient education.

Electronic health record-enabled routine assessment of medication adherence after solid organ transplantation: the time is now

Medication nonadherence after solid organ transplantation is recognized as an important impediment to long-term graft survival. Yet, assessment of adherence is often not part of routine care. In this Personal Viewpoint, we call for the transplant community to consider implementing a systematic process to screen and assess medication adherence. We believe acceptable tools are available to support integrating adherence assessments into the electronic health record. Creating a standard assessment can be done efficiently and cost-effectively if we come together as a community. More importantly, such monitoring can improve outcomes and strengthen provider-patient relationships. We further discuss the practical challenges and potential rebuttals to our position.

Transplant recipient, care partner, and clinician perceptions of medication adherence monitoring technology: A mixed methods study

Medication nonadherence is a leading cause of graft loss. Adherence monitoring technologies-reminder texts, smart bottles, video-observed ingestion, and digestion-activated signaling pills-may support adherence. However, patient, care partner, and clinician perceptions of these tools are not well studied. We conducted qualitative individual semistructured interviews and focus groups among 97 participants at a single center: kidney and liver transplant recipients 2 weeks to 18 months posttransplant, their care partners, and transplant clinicians. We assessed adherence practices, reactions to monitoring technologies, and opportunities for care integration. One-size-fits-all approaches were deemed infeasible. Interviewees considered text messages the most acceptable approach; live video checks were the least acceptable and raised the most concerns for inconvenience and invasiveness. Digestion-activated signaling technology produced both excitement and apprehension. Patients and care partners generally aligned in perceptions of adherence monitoring integration into clinical care. Key themes were importance of routine, ease of use, leveraging technology for actionable medication changes, and aversion to surveillance. Transplant clinicians similarly considered text messages most acceptable and video checks least acceptable. Clinicians reported that early posttransplant use and real-time adherence tracking with patient feedback may facilitate successful implementation. The study provides initial insights that may inform future adherence technology implementation.

[Comprehensive care for kidney transplantation-optimization of interdisciplinary support before and after kidney transplantation]

Due to the divergence between the number of potential organ recipients and organ availability, transplant survival is of particular importance. In order to create the best possible conditions, it is not only important to address the risk factors for loss of organ functionality after transplantation, but also to focus on the time before transplantation. During this period, which lasts several years on average, the patient can create the conditions for risk reduction before and after transplantation with support. The optimization of physical health plays an important role here in order to maintain transplantability, on the one hand, and to counteract the general loss of physical performance due to dialysis, on the other. Therefore, the focus must be placed on "exercise" and "nutrition", which represent an increased risk of declining physical health in dialysis patients. After transplantation, the focus should again be on physical health. Through support, patients learn how to improve their cardiovascular risk profile and increase their physical performance. Psychosocial support is also important to combat psychological comorbidities and prevent risks such as nonadherence. In addition to improved physical and mental health, the focus here is also on the long-term survival of the patient and the transplant.

Study of therapeutic patient education practices in French renal transplantation centres

OBJECTIVES

Therapeutic patient education (TPE) plays a critical role in the management of kidney transplant recipients. However, discrepancies exist in the guidance provided regarding the usage of immunosuppressants across different kidney transplant centres in France.

METHODS

To assess the current landscape of TPE practices in this patient population, an online questionnaire consisting of 51 questions was distributed to 32 French renal transplantation centres.

RESULTS

The participation rate in our survey was 96.9%, (31 of the 32 centres contacted). The respondents had diverse professions: they were nurses (15/31), physicians (9/31) and pharmacists (7/31). Virtually all institutions have implemented TPE initiatives, with an implementation rate of 93.5% (29/31). The topic of anti-rejection medication was consistently addressed, with only one centre not providing support at the conclusion of these sessions. However, the content of the sessions varied significantly from one centre to another, particularly regarding the proper management of anti-rejection medications. Only 19.4% (6/31) of the centres provided the correct recommendation regarding fasting when taking tacrolimus. Dietary guidance was a topic covered in 89.7% (26/29) of the centres, but significant divergences were also observed. TPE teams primarily consisted of nurses, with pharmacists present in only 51.6% (16/31) of the centres. We also observed limited involvement of patient partners, with just 9.7% (3/31) of the centres including them in their programme.

CONCLUSION

These findings highlight considerable variability in the approach towards TPE among kidney transplant centres. Addressing counselling variability and increasing pharmacist and patient partner involvement is an essential step to improving the quality and effectiveness of TPE. By establishing a standardised and comprehensive approach to patient education, healthcare providers can ensure that kidney transplant recipients receive information that will ultimately help them improve their health and well-being.

Cannabis use is associated with reduced access to kidney transplantation and an increased risk of acute rejection post-transplant

BACKGROUND

The association between cannabis use and access to waitlisting, transplantation, and post-transplant outcomes remains uncertain.

METHODS

Patients referred for kidney transplant (KT) to the University Health Network from January 1, 2003, to June 30, 2020, and followed until December 31, 2020, were included. Predictors of reported cannabis use were examined using a logistic regression model. The association between cannabis use and time to clearance for KT, undergoing KT, and post-transplant outcomes was evaluated using Cox proportional hazards models.

RESULTS

Among 3734 patients, the prevalence of reported cannabis use was 11.8%. Cannabis use was associated with a lower likelihood of KT clearance (adjusted hazard ratio [aHR] .82 [95% confidence interval (CI): .72, .94]). Once cleared for KT, cannabis use did not predict the subsequent receipt of KT (aHR .92, [95% CI: .79, 1.08]). Among 2091 KT recipients, cannabis use was associated with a higher likelihood of biopsy-proven acute rejection (aHR 1.55, [95% CI: 1.06, 2.27]). The relative hazard of death-censored graft failure was similarly elevated (aHR 1.60 [95% CI: .95, 2.72]). Cannabis use did not predict total graft failure (aHR 1.33 [95% CI: .90, 1.96]), death with graft function (aHR 1.06 [95% CI: .59, 1.89]), or hospital readmission in the first-year post-transplant (aHR 1.26 [95% CI: .95, 1.68]).

CONCLUSIONS

Cannabis users have less access to transplantation and an increased risk of acute rejection, possibly leading to more graft loss. Further studies are warranted to understand possible mechanisms for the increased risk of allograft immune injury among cannabis users.

The combinatorial effect of age and biological sex on alloimmunity and transplantation outcome

Both age and biological sex affect transplantation outcomes. We have recently shown in a large volume clinical analysis utilizing the SRTR data that graft survival is inferior in young female kidney transplant recipients. In this multi-factorial analysis, older female recipients presented with a trend towards improved transplant outcomes compared to both young female recipients and male recipients of any age. Those data supported by reports of those of others suggest that sex and age impact alloimmune responses both, individually and synergistically. Biological sex and hormone levels change throughout a lifetime with recognized effects on longevity in addition to an impact on the development and course of several disease preconditions. Detailed mechanisms of those sex and age-specific aspects have thus far been studied outside of transplantation. Effects on alloimmunity are largely unknown. Moreover, the combinatorial impact that both, biological sex and age have on transplant outcomes is not understood. Here, we summarize available data that analyze how age in combination with biological sex may shape alloimmune responses and affect transplant outcomes.

Development and Internal Validation of a Questionnaire Assessing Predisposition to Nonadherence to Immunosuppressive Medication in Kidney Pretransplant Patients

BACKGROUND

After kidney transplant, nonadherence to immunosuppressive therapy is the main cause of impaired kidney function and graft loss. The objective of this study was the development and internal validation of a clinical questionnaire for assessing the predisposition to adherence to immunosuppressive therapy in kidney pretransplant patients.

METHODS

Multicenter prospective study conducted in 7 kidney hemodialysis and 6 kidney transplant centers of 3 Brazilian state capitals. Kidney transplant candidate patients of both sexes and >18-y-old were included. Retransplanted patients were excluded. A 72-item pilot version of the questionnaire, created through literature review complemented with a focus group of 8 kidney pretransplant patients, was administered to 541 kidney transplant candidate patients. Factor analysis with varimax rotation was used for questionnaire development. Internal validity evaluation used Cronbach's alpha and test-retest reliability. Construct validity was assessed by differentiation by known groups.

RESULTS

The final questionnaire, named Kidney AlloTransplant Immunosuppressive Therapy Adherence (KATITA) Questionnaire, consisting of 25 items in 3 dimensions, presented good internal consistency reliability (Cronbach's alpha 0.81). The 3 dimensions and respective Cronbach's alpha were "Carelessness" (14 items, 0.81), "Skepticism" (6 items, 0.57), and "Concern" (5 items, 0.62). The interdimension correlation matrix showed low correlation coefficients (<0.35). Test-retest reliability, evaluated with 154 patients, showed an intraclass correlation coefficient of 0.62 (moderate agreement). The scale showed construct validity.

CONCLUSIONS

The KATITA-25 questionnaire is the first psychometric instrument for evaluation of predisposition to nonadherence to immunosuppressive medication in candidate patients for kidney transplant in the pretransplant setting.

Implementing a self-reported immunosuppression adherence questionnaire to screen for non-adherence in routine care of kidney transplant recipients

INTRODUCTION

Self-reported measures of immunosuppression adherence have been largely examined in research settings.

METHODS

In this single center study of 610 kidney transplant recipients, we examined if a voluntary, non-anonymous self-report measure could identify non-adherence in a routine clinic setting and how patients perceived such a measure. Non-adherence was measured using the Basel Assessment of Adherence to Immunosuppressive Medications Scale (BAASIS) and patient perception was elicited using a customized questionnaire.

RESULTS

Non-responders to the survey (15%) were younger, more likely to be black, and less likely to have had a pre-emptive transplant. Among complete responders (n = 485), 38% reported non-adherence with non-adherent patients being younger (54 y vs. 60 y; p = .01), less likely to have been on dialysis pre-transplant (59% vs. 68%; p = .04), further out from transplant (37 vs. 22 months; p < .001) and had more rejections in the preceding year (8% vs. 3%; p = .02). Self-reported non-adherence was associated with higher calcineurin inhibitor intra-patient variability (27.4% vs. 24.5%; p = .02), but not with donor-specific antibody detection (27.8% vs. 21.2%, p = .15). Of patients providing feedback (n = 500), the majority of patients felt comfortable reporting adherence (92%), that the survey was relevant to their visit (71%), and that the survey did not interfere with their clinic visit (88%).

CONCLUSION

In summary, a self-reported questionnaire during clinic visits identified immunosuppression non-adherence in a significant proportion of patients and was well received by patients. Integrating self-report measures into routine post-transplant care may enable early identification of non-adherence.

Alcohol consumption, alcohol use disorder and organ transplantation

In the present experience we have evaluated the link alcohol consumption/alcohol use disorder (AUD) and organ transplantation (OT) in order to provide adequate suggestions. The data used for the preparation of these recommendations are based on a detailed analysis of the scientific literature published before August 31, 2022 (Web of Science, Scopus, Google Scholar). Furthermore, in the process of developing this work, we consulted the guidelines/position papers of the scientific societies. With regard to the liver transplantation, there are position papers/guidelines that clearly define indications and contraindications for including the AUD patient in the transplant list. One of the major difficulties in this area is psychosocial assessment which can be influenced by stigma. To solve this problem, it is necessary to use objective tools. However, this assessment should be carried out after providing the patient and family adequate tools to be able to create or recreate reliable socio-family support. This behavior should also be used in the case of other OTs. For the latter, however, adequate guidelines must be created which at the moment do not exist or if there are, as in the case of heart transplantation, they are not sufficient. Even in the absence of obvious alcohol addiction, it is recommended to use alcohol use disorder identification test and to include the addiction specialist in the multidisciplinary transplant team. Besides, providing family members with the tools necessary to better support the patient is essential. They are patients with alcohol use disorder/ possible presence of psychopathological manifestations and alcohol-related pathology (cirrhosis, cardiomyopathy, liver-kidney disfunction, etc.). A cardiovascular and oncologic surveillance post-OT is recommended. For the selection of patients to be included in the list for non-LT (heart, lung, kidney, multivisceral, etc.) it is mandatory to include the diagnosis and treatment of AUDs in the guidelines. What has already been indicated for LT may be useful. Timing of alcoholic abstention in relation to clinical severity, optimal psychosocial activity, anticraving therapy in relation to the type of underlying disease and clinical severity. Close collaboration between scientific societies is required to better manage AUD patients who need OT.

A Descriptive, Correlational Study of Perceptions of Adult Kidney Transplant Recipients and Those Waiting for a Kidney Transplant About Managing Their Medications During a Pandemic

Introduction: Little is known about COVID-19 impact on patient medication management. Research Question: The aim was to describe medication management, healthcare team interactions, and adherence during the COVID-19 pandemic in kidney transplant patients and those on the kidney transplant wait list. Design: Using a descriptive, correlational design 340 adults from a midwestern US transplant program were recruited. The Managing Medications in the Midst of a Pandemic Survey measured healthcare team encounters and medication management. The Basel assessment of adherence to medications scale measured medication adherence. Results: The response rate was 35% (119/340). During the pandemic, 88% had practiced/were currently practicing socially distancing, 85% had worn/were currently wearing a face mask in public, 18% had been/were currently diagnosed with COVID-19 and 82% received the vaccine. Medication management: 76% planned and organized their own medications. Healthcare team interactions: 89% met in the office, 20% via phone, 12% telehealth, and 13% delayed seeing a healthcare provider because of COVID-19 concerns. Pharmacy interactions: 11% changed their method of obtaining medications from pharmacy due to social distancing. Medication adherence implementation was problematic with 19% missing a dose; results from the binary logistic regression suggested that those with higher levels of education were more likely to report missing a dose. Conclusions: Patients acted to prevent COVID-19 but some still contracted the virus. The pandemic changed healthcare team medication management interactions. Adherence implementation problems were nearly 20%. Findings are relevant to the transplant healthcare team to understand the impact of a pandemic on patient/team interactions and medication adherence.

Measurement of the Immunosuppressant Possession Ratio by Transplant Clinical Pharmacists Captures a Non-Adherence Associated With Antibody-Mediated Rejection

Our objective was to calculate an immunosuppressant possession ratio (IPR) to diagnose non-adherence at the time of antibody-mediated rejection (ABMR). IPR was defined as the ratio of number of pills collected at the pharmacy to the number of pills prescribed over a defined period. In a first cohort of 91 kidney transplant recipients (KTRs), those with an IPR < 90% had more frequently a tacrolimus through level coefficient of variation >30% than patients with an IPR = 100% (66.7% vs. 29.4%, p = 0.05). In a case-control study, 26 KTRs with ABMR had lower 6 months IPRs than 26 controls (76% vs. 99%, p < 0.001). In KTRs with ABMR, non-adherence was more often diagnosed by a 6 months IPR < 90% than by clinical suspicion (73.1% vs 30.8%, p = 0.02). In the multivariable analysis, only de novo DSA and 6 months IPR < 90% were independently associated with ABMR, whereas clinical suspicion was not (odds ratio, 4.73; 95% CI, 1.17-21.88; p = 0.03; and odds ratio, 6.34; 95% CI, 1.73-25.59; p = 0.007, respectively). In summary, IPR < 90% is a quantifiable tool to measure immunosuppressant non-adherence. It is better associated with ABMR than clinical suspicion of non-adherence.

Optimizing medication adherence with home-monitoring - A feasibility study using capillary microsampling and mHealth in solid organ-transplanted adolescents

BACKGROUND

Reliable methods to detect and reduce medication nonadherence in solid organ-transplanted (SOT) adolescents are warranted. We aimed to evaluate the feasibility of combining a medication-manager application (TusenTac®-app) with home-sampling of tacrolimus (Tac) in young SOT recipients.

METHODS

Kidney and combined SOT recipients between 14 and 25 years were included. During an 8-week intervention period, the participants were instructed to use the transplant-specific, age-adapted TusenTac®-app daily and to perform weekly at-home Tac trough finger-prick microsampling. Microsample Tac concentrations were controlled against timed venous samples twice. Medication implementation and persistence adherence were measured with BAASIS© questionnaires, TusenTac®-registrations, Tac trough concentration coefficient of variation (CV%) and self-reporting by interview. For comparison, venous Tac trough CV% were obtained from the year before and after the short-term intervention.

RESULTS

Twenty-two recipients were included, two withdrawals, leaving 20; median age 17.9 (14.5-24.8) years, 12 females (60%). The participants registered their dosage intake 88% (1502/1703) of the expected times, and 90% (106/118) of the microsamples were obtained correctly. At inclusion, 11 recipients (55%) were nonadherent assessed with BAASIS© questionnaire, four of these (36%) turned adherent during the intervention period. At the end, 70% reported improved timing-adherence at the interview. There was no significant change in TacCV% from the year before to the year after the short-term intervention. Home-sampling was reliable and measured Tac concentrations accurately.

CONCLUSIONS

Home-monitoring, combining Tac finger-prick microsampling and a medication-manager app, is feasible in adolescent SOT recipients with 70% perceived improvement in medication timing-adherence. There were no significant long-term changes in TacCV% confirming the need for continuous use and individualized interventions.

Telehealth Experience Among Liver and Kidney Transplant Recipients: A Mixed Methods Study

Telehealth has become widely available to solid organ transplant (SOT) recipients during the COVID-19 pandemic. While evidence suggests that telehealth serves as an acceptable alternative for most SOT recipients, their satisfaction and its context remain unclear. This study used a mixed methods approach to investigate the perspectives of SOT recipients (i.e., liver, kidney, and simultaneous liver-kidney) on the benefits and disadvantages of telehealth. A total of 252 adult SOT recipients completed an online survey that quantitatively assessed telehealth experience and satisfaction. Fifteen of them further shared their perspectives by participating in either a focus group or individual interview. Approximately 70% of online survey participants had previously used telehealth for their transplant care. The quantitative data documented that, while recipients were mostly satisfied with telehealth, especially with its effectiveness and convenience, they were less satisfied with the reliability of navigating the telehealth system. The qualitative data further showed that telehealth could be less effective for SOT recipients who perceived themselves as clinically and/or socially vulnerable, needed urgent care, and were concerned about privacy. These findings suggest that the plan for using telehealth to provide transplant care should prioritize personalization, considering unique needs and preferences of each SOT recipient.

Adherence to Pharmacotherapies After Heart Transplantation in Relation to Multimorbidity and Socioeconomic Position: A Nationwide Register-Based Study

No studies have examined the impact of multimorbidity and socioeconomic position (SEP) on adherence to the pharmacological therapies following heart transplantation (HTx). Using nationwide Danish registers, we tested the hypothesis that multimorbidity and SEP affect treatment patterns and adherence to pharmacological therapies in first-time HTx recipients. Pharmacological management included cost-free immunosuppressants and adjuvant medical treatment (preventive and hypertensive pharmacotherapies; loop diuretics). We enrolled 512 recipients. The median (IQR) age was 51 years (38-58 years) and 393 recipients (77%) were males. In recipients with at least two chronic diseases, prevalence of treatment with antihypertensive pharmacotherapies and loop diuretics was higher. The overall prevalence of adherence to treatment with tacrolimus or mycophenolate mofetil was at least 80%. Prevalence of adherence to preventive pharmacotherapies ranged between 65% and 95% and between 66% and 88% for antihypertensive pharmacotherapies and loop diuretics, respectively. In socioeconomically disadvantaged recipients, both the number of recipients treated with and adherence to cost-free everolimus, lipid modifying agents, angiotensin-converting enzyme/angiotensin II inhibitors, calcium channel blockers, and loop diuretics were lower. In recipients with multimorbidity, prevalence of treatment with antihypertensive pharmacotherapies and loop diuretics was higher. Among socioeconomically disadvantaged recipients, both number of patients treated with and adherence to cost-free everolimus and adjuvant pharmacotherapies were lower.

Patient randomised controlled trial of technology enabled strategies to promote treatment adherence in liver transplantation: rationale and design of the TEST trial

BACKGROUND AND AIMS

Liver transplantation is a life-saving procedure for end-stage liver disease. However, post-transplant medication regimens are complex and non-adherence is common. Post-transplant medication non-adherence is associated with graft rejection, which can have long-term adverse consequences. Transplant centres are equipped with clinical staff that monitor patients post-transplant; however, digital health tools and proactive immunosuppression adherence monitoring has potential to improve outcomes.

METHODS AND ANALYSIS

This is a patient-randomised prospective clinical trial at three transplant centres in the Northeast, Midwest and South to investigate the effects of a remotely administered adherence programme compared with usual care. The programme monitors potential non-adherence largely levering text message prompts and phenotypes the nature of the non-adhere as cognitive, psychological, medical, social or economic. Additional reminders for medications, clinical appointments and routine self-management support are incorporated to promote adherence to the entire medical regimen. The primary study outcome is medication adherence via 24-hour recall; secondary outcomes include additional medication adherence (ASK-12 self-reported scale, regimen knowledge scales, tacrolimus values), quality of life, functional health status and clinical outcomes (eg, days hospitalised). Study implementation, acceptability, feasibility, costs and potential cost-effectiveness will also be evaluated.

ETHICS AND DISSEMINATION

The University of Pennsylvania Review Board has approved the study as the single IRB of record (protocol # 849575, V.1.4). Results will be published in peer-reviewed journals and summaries will be provided to study funders.

TRIAL REGISTRATION NUMBER

NCT05260268.

Prevalence and Modifiable Factors for Holistic Non-Adherence in Renal Transplant Patients: A Cross-Sectional Study

Introduction

In renal transplant recipients, compliance with medical therapy is vital. Non-adherence is considered a risk factor for worst outcomes in kidney recipients, with attributed outcomes of 64% for graft loss and 80% for late acute rejection. Most literature defines adherence as self-based immunosuppression compliance but does not consider other relevant factors such as consult and procedure compliance. Therefore, this study aims to describe adherence prevalence in kidney transplant recipients and the factors related to non-adherence.

Methods

This cross-sectional study included 1030 renal transplant patients followed by Colombiana de Trasplantes between January 2019 and July 2021. Sociodemographic and clinical variables were obtained based on clinical records. The mental-health group diagnosed holistic adherence in a semi-structured interview. The diagnosis considered medication intake failure, frequency and number of failures to medical controls or other procedures, suspicious non-adherence behaviors, and serum levels of immunosuppressants. A bivariate followed a descriptive analysis, and a forward logistic regression was performed for non-adherence.

Results

Patients had a median of 47 years, and 58.1% were male. Non-adherence was presented in 30.7% of patients. The non-adherence patients were younger, with a higher prevalence of males, single, divided transplant care, had a longer time after transplantation, psychopathological diagnosis, and more reinforcement education by only nursing. Older age and multidisciplinary reinforcement education were protective factors. On the other hand, poor social support, psychopathology diagnosis, and longer time after transplant presented as non-adherence risk factors.

Conclusion

Holistic non-adherence was diagnosed in approximately one-third of renal transplant recipients. Its definition included more than just medication non-compliance and could identify more non-adherent patients. Notably, there is a need to consider the related factors in the health follow-up and encourage future research in modifiable factor interventions aiming to increase adherence and achieve better outcomes for renal transplant patients.

Interitem Psychometric Validation of the Stanford Integrated Assessment for Transplant Scale Among Thoracic Transplant Candidates

BACKGROUND

Psychosocial evaluations are mandatory for transplant listing, however the methodology for creating psychosocial risk stratifications is unclear. The Standford Psychosocial Integrated Psychosocial Assessment for Transplant Scale is the most commonly used instrument, however its interitem validity has never been examined.

OBJECTIVE

To investigate the interitem validity of a psychosocial assessment tool for transplant candidates among a sample of thoracic transplant candidates.

METHODS

Clinic data consisting of Stanford Integrated Psychosocial Assessment for Transplant administrations from 173 heart and lung transplant candidates were fit to a partial credit model. Data were subsequently fit to 4 separate partial credit models based on subscale categories, demonstrating the discrimination parameter estimate of each item. Differential item functioning analyses were conducted on the data within each subscale by sex to investigate potential bias produced by each item.

RESULTS

The initial partial credit model using the full scale did not converge, indicating the subscales possibly did not measure the same underlying construct. Subscale discrimination parameter estimates demonstrated that most items were adequately or highly discriminative. The item measuring history of substance use demonstrated poor fit and differential item functioning.

CONCLUSIONS

While the Stanford Integrated Psychosocial Assessment for Transplant has demonstrated strong potential as a standardized framework for psychosocial assessments in transplant, this study identified some areas for improvement in the scoring system. The subscale scores appeared to show greater construct validity when utilized individually than when aggregated to form a total score. The substance use/abuse/dependence item did not fit well into its respective subscale. Future studies should aim to optimize the scoring system and re-asses its construct validity to improve its accuracy in discriminating between high-risk candidates and those needing psychosocial assistance.

Prevalence and Patient-Level Correlates of Intentional Non-Adherence to Immunosuppressive Medication After Heart-Transplantation-Findings From the International BRIGHT Study

After heart transplantation (HTx), non-adherence to immunosuppressants (IS) is associated with poor outcomes; however, intentional non-adherence (INA) is poorly understood regarding its international variability in prevalence, contributing factors and impact on outcomes. We investigated (1) the prevalence and international variability of INA, (2) patient-level correlates of INA, and (3) relation of INA with clinical outcomes. Secondary analysis of data from the BRIGHT study-an international multi-center, cross-sectional survey examining multi-level factors of adherence in 1,397 adult HTx recipients. INA during the implementation phase, i.e., drug holiday and dose alteration, was measured using the Basel Assessment of Adherence to Immunosuppressive Medications Scale© (BAASIS©). Descriptive and inferential analysis was performed with data retrieved through patient interview, patient self-report and in clinical records. INA prevalence was 3.3% (n = 46/1,397)-drug holidays: 1.7% (n = 24); dose alteration: 1.4% (n = 20); both: 0.1% (n = 2). University-level education (OR = 2.46, CI = 1.04-5.83), insurance not covering IS costs (OR = 2.21, CI = 1.01-4.87) and barriers (OR = 4.90, CI = 2.73-8.80) were significantly associated with INA; however, clinical outcomes were not. Compared to other single-center studies, this sample's INA prevalence was low. More than accessibility or financial concerns, our analyses identified patient-level barriers as INA drivers. Addressing patients' IS-related barriers, should decrease INA.

Caregiver Burden in Adult Solid Organ Transplantation

The informal caregiver plays a critical role in supporting patients with various end-stage diseases throughout the solid organ transplantation journey. Caregiver responsibilities include assistance with activities of daily living, medication management, implementation of highly specialized treatments, transportation to appointments and treatments, and health care coordination and navigation. The demanding nature of these tasks has profound impacts across multiple domains of the caregiver's life: physical, psychological, financial, logistical, and social. Few interventions targeting caregiver burden have been empirically evaluated, with the majority focused on education or mindfulness-based stress reduction techniques. Further research is urgently needed to develop and evaluate interventions to improve caregiver burden and outcomes for the patient-caregiver dyad.

Structural equation modeling for associated factors with self-care behavior among young and middle-aged hypertensive patients: a cross-sectional study

BACKGROUND

Self-determination theory (SDT) states that the self-care behaviors of patients with chronic illnesses are affected by an autonomy-supportive healthcare climate, satisfaction of autonomy, competence, and relatedness. Autonomy-supportive healthcare climate means to provide interpersonal conditions that support the person's volition, initiative, and integrity.

OBJECTIVE

The aim of this study was to explore the structural relationships of an autonomy-supportive healthcare climate, as well as the perception of illness consequences, autonomy, competence, and relatedness with self-care behaviors among adult outpatients with hypertension.

DESIGN

A cross-sectional survey was conducted in 2020 across three hospitals outpatient clinics in South Korea.

METHODS

A questionnaire package containing instruments measuring the perception of autonomy-supportive healthcare climate, autonomy, competence, relatedness, perception of illness consequence, self-care behaviors, sociodemographic data, and disease-related characteristics among the patients. The hypothetical model was derived from the SDT. Data were analyzed to test the hypothetical model and propose the final model.

RESULTS

Complete survey data was provided by 228 participants. Overall, the findings supported the hypothesized model (Goodness-of-Fit Index = 0.90 and Comparative Fit Index = 0.99). An autonomy-supportive healthcare climate and autonomy, competence, and relatedness directly influenced the self-care behaviors of adult hypertensive patients. However, the perception of illness consequences did not have a significant direct effect on self-care behavior.

CONCLUSION

Improving the autonomy-supportive healthcare climate, as well as positive perception of illness consequences, autonomy, competence, and relatedness among patients positively affects self-care behavior. Thus, an authentic partnership between healthcare providers and hypertensive patients is required to enhance trust, cooperation, and adaptation, consequently improving self-care behaviors among patients.

IMPACT STATEMENT

Autonomy-supportive healthcare climate was both directly and indirectly associated with self-care behavior that mediates autonomy, competence, and relatedness among young and middle-aged hypertensive patients.

Psychosocial Diagnosis and Treatment Before and After Organ Transplantation

BACKGROUND

This new clinical practice guideline concerns the psychosocial diagnosis and treatment of patients before and after organ transplantation. Its objective is to establish standards and to issue evidence-based recommendations that will help to optimize decision making in psychosocial diagnosis and treatment.

METHODS

For each key question, the literature was systematically searched in at least two databases (Medline, Ovid, Cochrane Library, and CENTRAL). The end date of each search was between August 2018 and November 2019, depending on the question. The literature search was also updated to capture recent publications, by using a selective approach.

RESULTS

Lack of adherence to immunosuppressant drugs can be expected in 25-30% of patients and increases the odds of organ loss after kidney transplantation (odds ratio 7.1). Psychosocial interventions can significantly improve adherence. Metaanalyses have shown that adherence was achieved 10-20% more frequently in the intervention group than in the control group. 13-40% of patients suffer from depression after transplantation; mortality in this group is 65% higher. The guideline group therefore recommends that experts in psychosomatic medicine, psychiatry, and psychology (mental health professionals) should be involved in patient care throughout the transplantation process.

CONCLUSION

The care of patients before and after organ transplantation should be multidisciplinary. Nonadherence rates and comorbid mental disorders are common and associated with poorer outcomes after transplantation. Interventions to improve adherence are effective, although the pertinent studies display marked heterogeneity and a high risk of bias.

Factors impacting the medication "Adherence Landscape" for transplant patients

BACKGROUND

Medication non-adherence contributes to post-transplant graft rejection and failure; however, limited knowledge about the reasons for non-adherence hinders the development of interventions to improve adherence. We conducted focus groups with solid organ transplant recipients regarding overlooked challenges in the process of transplant medication self-management and examined their adherence strategies and perceptions towards the post-transplant medication regimen.

METHODS

We conducted four focus groups with n = 31 total adult transplant recipients. Participants had received kidney, liver, or combined liver/kidney transplant at Johns Hopkins Hospital between 2014 and 2019. Focus groups were audio-recorded and transcribed. Transcripts were analyzed inductively, using the constant comparative method.

RESULTS

Responses generally fell into two major categories: (1) barriers to adherence and (2) "adherence landscape". We define the former as factors directly labeled as barriers to adherence by participants and the latter as factors that heavily influence the post-transplant medication self-management process.

CONCLUSIONS

We propose a shift in the way healthcare providers and researchers, address the question of medication non-adherence. Rather than asking why patients are non-adherent, we suggest that constructing and understanding patients' "adherence landscape" will provide an optimal way to align the goals of patients and providers and boost health outcomes.

Immunosuppressive Medication Adherence in Patients With Hepatocellular Cancer Who Have Undergo Liver Transplantation: A Case Control Study

BACKGROUND

We aimed to compare the adherence to immunosuppressive medication use in patients who underwent liver transplantation (LT) due to hepatocellular carcinoma (HCC) and non-HCC reasons.

METHODS

The study population was determined as 242 patients with HCC and 1290 patients with non-HCC who had LT performed in our institute between March 2002 and November 2021; all these patients were contacted by phone in March 2022. The sample size was calculated using the MedCalc software program, and the number of patients required in each group was determined as 111 patients. Furthermore, we used the sample.int function, a random integer generator in the R (version 4.1.2) software program. Whereas demographic and clinical parameters were determined as independent variables, the immunosuppressive medication adherence scale (IMAS) score was determined as a dependent variable. Patients were evaluated by the IMAS. This 11-item IMAS scale evaluates the lowest compliance score as 11 and the highest as 55.

RESULTS

Out of a total number of 221 patients, 161 (72%) were men and 60 (27.1%) were women, with a median age of 58 years (IQR: 14); one patient in the non-HCC group was excluded due to lack of data. Among the HCC and non-HCC groups, significant differences were found in terms of the variables of age (P = .003), IMAS score (P < .001), sex (P = .001), working status (P = .004), chronic diseases (P = .008), tacrolimus alone (P < .001), tacrolimus plus everolimus (P < .001), and often medication changes (P < .001). A statistically significant correlation was found between the IMAS score and whether the patients had HCC (P < .001) and frequently changing immunosuppressive drugs (P = .023).

CONCLUSION

This study showed that patients with frequent drug changes or non-HCC etiology had better adherence to immunosuppressive drug use.

Appointment Nonadherence and Graft Outcomes in Living Donor Kidney Transplantation

BACKGROUND

Medication nonadherence is associated with worse graft outcomes but is hard to recognize in clinical settings due to its self-reporting nature. We hypothesized that appointment nonadherence might be associated with worse graft outcomes in living donor kidney transplantation.

METHODS

We included 167 adult living-donor kidney transplants whose grafts survived >2 years from April 2011 to May 2020. Thirty-two cases of appointment nonadherence were identified and compared with the controls (n = 135).

RESULTS

Younger age, male sex, higher body weight, and parent donor were significantly observed in the appointment nonadherence group. The appointment nonadherence group was significantly associated with worse graft survival (5 years: 82.3% vs 98.9%, P < .001, 10 years: 67.2% vs 89.6%, P < .001), de novo donor-specific antibody production, acute rejection, as well as the decline of graft function. Furthermore, appointment nonadherence had a 4-fold higher risk of graft loss after an adjustment with recipient age, sex, body weight, and donor type (adjusted hazard ratio: 3.93, 95% CI: 1.15-13.42, P = .029).

CONCLUSIONS

Appointment nonadherence might be an alternative predictor for worse graft outcomes after living donor kidney transplantation.

MyKidneyCoach, Patient Activation, and Clinical Outcomes in Diverse Kidney Transplant Recipients: A Randomized Control Pilot Trial

Kidney transplant (KT) recipients who are not actively engaged in their care and lack self-management skills have poor transplant outcomes, which are disproportionately observed among Black KT recipients. This pilot study aimed to determine whether the MyKidneyCoach app, an mHealth intervention that provides self-management monitoring and coaching, improved patient activation, engagement, and nutritional behaviors in a diverse KT population.

Methods

This was a randomized, age-stratified, parallel-group, attention-control, pilot study in post-KT patients. Participants were randomized into the attention-control with access to MyKidneyCoach for education and self-management (n = 9) or the intervention with additional tailored nurse coaching (n = 7). Feasibility, acceptability, and clinical outcomes were assessed.

Results

The acceptability of MyKidneyCoach by System Usability Scale was 67.5 (95% confidence interval [CI], 59.1-75.9). Completion rates based on actively using MyKidneyCoach were 81% (95% CI, 57%-93%) and study retention rate of 73%. Patient activation measure significantly increased overall by a mean of 11 points (95% CI, 3.2-18.8). Additionally, Black patients (n = 7) had higher nutrition self-efficacy scores of 80.5 (95% CI, 74.4-86.7) compared with 75.6 (95% CI, 71.1-80.1) in non-Black patients (n = 9) but lower patient activation measure scores of 69.3 (95% CI, 56.3-82.3) compared with 71.8 (95% CI, 62.5-81) in non-Black patients after 3 mo.

Conclusions

MyKidneyCoach was easy to use and readily accepted with low attrition, and improvements were demonstrated in patient-reported outcomes. Both Black and non-Black participants using MyKidneyCoach showed improvement in self-management competencies; thus, this intervention may help reduce healthcare inequities in KT.

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.

The effect of illness perception levels of liver transplant patients receiving immunosuppressive therapy on their rational drug use levels

Objective

Since 50% of drug use all over the world is used other than rational drug use, rational drug use, which is associated with the perception of the disease, is important for the course of the disease. This study aimed to determine the effect of disease perception levels on rational drug use in liver transplant patients receiving immunosuppressive therapy.

Methods

This descriptive and cross-sectional study was conducted with patients who came to the outpatient clinic for control between May-September 2022 with the participation of patients who underwent liver transplantation and followed up in a liver transplant institute in eastern Turkey. In the collection of the study data, "sociodemographic information form" prepared by the researchers, "Brief Illness Perception Questionnaire", and "Rational Drug Use Scale" were employed.

Results

In this study conducted with 206 patients, the mean age of patients with liver transplantation was 48.66 ± 9.4 years, 59.7% were male, 80.1% were married, and 33.5% were high school graduates. It was determined that the disease perception levels and rational drug use levels of the patients who underwent liver transplantation were moderate. It was also determined that as the education levels of the liver transplant patients increased, their levels of illness perception and rational drug use also statistically significantly increased (p < 0.05). It was found that there was a significant and moderate relationship between illness perception and rational drug use, and that as their level of illness perception increased, their level of rational drug use also increased (r:0.622, p < 0.05). It was observed that the disease perception level explained 38.7% of the change in rational drug use (R²:387, p < 0.05).

Conclusions

In the study, it was observed that high illness perception levels of liver transplant patients increased their levels of rational drug use. It is important to raise the awareness of patients in order for them to cope with illnesses and to have a high level of illness perception.

Differences in medication adherence by sex and organ type among adolescent and young adult solid organ transplant recipients

BACKGROUND

Identification of differences in medication adherence by sex or organ type may help in planning interventions to optimize outcomes. We compared immunosuppressive medication adherence between males and females, and between kidney, liver and heart transplant recipients.

METHODS

This multicenter study of prevalent kidney, liver and heart transplant recipients 14-25 years assessed adherence 3 times (0, 3, 6 months post-enrollment) with the BAASIS self-report tool. At each visit, participants were classified as adherent if they missed no doses in the prior 4 weeks and non-adherent otherwise. Adherence was also assessed using the coefficient of variation (CV) of tacrolimus trough levels; CV < 30% was classified as adherent. We used multivariable mixed effects logistic regression models adjusted for potential confounders to compare adherence by sex and by organ.

RESULTS

Across all visits, males (n = 150, median age 20.4 years, IQR 17.2-23.3) had lower odds of self-reported adherence than females (n = 120, median age 19.8 years, IQR 17.1-22.7) (OR 0.41, 95% CI 0.21-0.80) but higher odds of adherence by tacrolimus CV (OR 2.50, 95% CI 1.30-4.82). No significant differences in adherence (by self-report or tacrolimus CV) were noted between the 184 kidney, 58 liver, and 28 heart recipients.

CONCLUSION

Females show better self-reported adherence than males but greater variability in tacrolimus levels. Social desirability bias, more common in females than males, may contribute to better self-reported adherence among females. Higher tacrolimus variability among females may reflect biologic differences in tacrolimus metabolism between males and females rather than sex differences in adherence. There were no significant differences in adherence by organ type.

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

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

Reliability and Validity of the Japanese Version of the Basel Assessment of Adherence to Immunosuppressive Medications Scale in Kidney Transplant Recipients

A valid and reliable instrument that can measure adherence is needed to identify nonadherent patients and to improve adherence. However, there is no validated Japanese self-report instrument to evaluate adherence to immunosuppressive medications for transplant patients. The purpose of this study was to determine the reliability and validity of the Japanese version of the Basel Assessment of Adherence to Immunosuppressive Medications Scale (BAASIS).

Methods

We translated the BAASIS into Japanese and developed the Japanese version of the BAASIS (J-BAASIS) according to the International Society of Pharmacoeconomics and Outcomes Research task force guidelines. We analyzed the reliability (test-retest reliability and measurement error) and validity of the J-BAASIS (concurrent validity with the medication event monitoring system and the 12-item Medication Adherence Scale) referring to the COSMIN Risk of Bias checklist.

Results

A total of 106 kidney transplant recipients were included in this study. In the analysis of test-retest reliability, Cohen's kappa coefficient was found to be 0.62. In the analysis of measurement error, the positive and negative agreement were 0.78 and 0.84, respectively. In the analysis of concurrent validity with the medication event monitoring system, sensitivity and specificity were 0.84 and 0.90, respectively. In the analysis of concurrent validity with the 12-item Medication Adherence Scale, the point-biserial correlation coefficient for the "medication compliance" subscale was 0.38 (P < 0.001).

Conclusions

The J-BAASIS was determined to have good reliability and validity. Using the J-BAASIS to evaluate adherence can help clinicians to identify medication nonadherence and institute appropriate corrective measures to improve transplant outcomes.

Self-management in adults after solid-organ transplantation: a scoping review protocol

INTRODUCTION

After solid-organ transplantation (SOTx), recipients must adhere to a lifelong medical regimen, change their lifestyle and cope with physiological and psychosocial challenges. This requires active participation in their care and self-management abilities. The concept of self-management after SOTx has only been described regarding specific organs and focused on adherence to medical treatment. A comprehensive conceptualisation of self-management entailing all solid organs and beyond medical aspects does not exist. This might lead to unmet self-management support needs of SOTx recipients and hinder a more holistic and integrative approach in self-management support. Therefore, a better understanding of the concept of self-management after SOTx is needed to facilitate a comprehensive evidence base for healthcare providers and researchers. The purpose of this scoping review is to explore existing evidence on self-management in adults after SOTx.

METHODS AND ANALYSIS

To identify relevant evidence, six electronic databases and three study registers will be searched, supplemented by handsearches, reference checking and expert recommendations. Screening and selection of available evidence will be carried out in a two-step process by two independent reviewers. International evidence published in English or German reporting on adults after heart, lung, liver, pancreas, kidney or small bowel transplantation will be considered. To meet inclusion criteria, articles have to focus on either: self-management, self-management support or recipients' or healthcare providers' perspectives of challenges and needs potentially addressable by self-management. Data extraction will be performed by two reviewers independently using a structured form. Data will be analysed descriptively and using content analysis procedures. Findings will be summarised narratively and presented in tabular format.

ETHICS AND DISSEMINATION

The consultation and approval of an ethics committee is not required for this scoping review. Findings of the scoping review will be published in a peer-reviewed open-access journal and presented at conferences.

Improved Medication Adherence with the Use of Extended-Release Tacrolimus in Liver Transplant Recipients: A Pilot Randomized Controlled Trial

Background

Nonadherence to immunosuppression in liver transplant recipients (LTRs) leads to deterioration in health outcomes. Once-dailyextended-release tacrolimus (TAC-ER) may improve adherence when compared to twice-dailyimmediate-release tacrolimus (TAC-IR).

Methods

We conducted a randomized controlled study to evaluate medication adherence, clinical efficacy, and safety of TAC-ER in stable LTR. All patients >18 years who underwent liver transplantation before 6 months were eligible. Patients were randomized 1 : 1 to continued TAC-IR or conversion to TAC-ER. The primary outcome was change in medication adherence from baseline to 9 months, assessed using BAASIS. Secondary outcomes were tacrolimus trough levels, safety, and quality of life.

Results

Thirty-one patients were consented and randomized to either of the two groups: conversion to TAC-ER (n = 15) or continued TAC-IR (n = 16). Six patients in the TAC-ER group withdrew after randomization due to apprehension about switching medication (n = 2), unwillingness to travel (n = 2), and increased liver tests after conversion (n = 2, both were acute rejections despite therapeutic tacrolimus levels and were considered unrelated to TAC-ER). We compared the results of nine patients in the TAC-ER group that completed the study with those of sixteen in the TAC-IR group. At baseline, there was no difference in tacrolimus trough levels between groups. Improved adherence was observed in the TAC-ER group as 100% of patients reported at least one period of full adherence during the study period (100% vs. 62.6%, p = 0.035). Tacrolimus trough levels and liver tests were comparable between groups throughout the study. There were no differences in eGFR, HbA1c, or QoL between the groups.

Conclusion

TAC-ER improved medication adherence while maintaining comparable trough levels, liver function, and QoL as TAC-IR in LTR.

[Medication adherence in renal transplantation: Evaluation, predictive factors and impact on humoral alloreactivity]

OBJECTIVES

The aims of this study were to assess medication adherence to immunosuppressive treatment in kidney transplanted patients, to identify predictive factors of medication non-adherence and to analyse its impact on the development of Donor Specific Antibodies (DSA) de novo, biomarkers of rejection in transplant recipients.

METHODS

A cross-sectional single-centre study was conducted to assess medication adherence to immunosuppressive treatment with the BAASIS (Basel Assessment of Adherence Scale for Immunosuppressives) self-report questionnaire. Univariate and multivariate analyses were performed to determine non-adherence predictive factors and its role in the development of DSA de novo.

RESULTS

A total of 212 renal transplanted patients completed the BAASIS questionnaire: 36,3 % were non-adherent to their immunosuppressive treatment. Patient's age and taking azathioprine were independent predictors of non-adherence and "married or living together" family status was a protective factor in the multivariate analysis. Medication non-adherence was associated with DSA de novo development in the multivariate model and it multiplied their risk of development by 3.

CONCLUSIONS

This study, which detected a large proportion of patients who did not adhere to immunosuppressive treatment, highlighted non-adherence predictors and showed the association between non-adherence and development of DSA de novo. In case of non-adherent behavior, it is crucial to set up a personalised support for patients with a multidisciplinary approach of therapeutic education, in which the clinical pharmacist has a role.

Kidney-transplanted Adolescents—Nonadherence and Graft Outcomes During the Transition Phase: A Nationwide Analysis, 2000–2020

BACKGROUND

The transition from pediatric to young adult care is a vulnerable period for the renal transplant patient. We aimed to identify medication nonadherence (noninitiation, nonimplementation, and nonpersistence) and graft loss rates among adolescents and young adults and elucidate the influence of the transition phase on transplant outcomes.

METHODS

A retrospective nationwide cohort analysis of all renal transplantations in Norway from 2000 to 2020 was performed. Data were retrieved from the Norwegian Renal Registry, and adherence data from hospital charts. Patients transplanted aged <50 y, with functioning graft at 6 mo, were included. Recipients transplanted aged <26 y were compared with recipients transplanted aged 26-50 y. Graft loss, acute rejection, and development of de novo donor-specific antibodies were assessed in relation to the transition phase, defined as 14-26 y.

RESULTS

Data from 1830 kidney recipients were included: 371 (20%) transplanted <26 y (64% male, 68% living donor) versus 1459 transplanted 26-50 y (63% male, 44% living donor). There were 298 graft losses, 78 (21%) in the <26-y group versus 220 (15%) in the 26- to 50-y group. During the transition phase, 36 grafts were lost, 29 (81%) after transfer to the adult service. Medication nonadherence was the reason for 58% (21 of 36) of the losses during the transition phase, versus 12% (27 of 220) in the 26- to 50-y group ( P < 0.001). The 5-y graft survival rate was 89% (95% confidence interval, 85%-92%) and 94% (92%-95%), respectively ( P = 0.01).

CONCLUSIONS

Nonadherence was verified as the main cause of kidney graft loss in the transition phase.

Digital health technologies to support medication adherence in chronic kidney disease

Non-adherence to medications is a critical challenge in the management of people with chronic kidney disease (CKD). This review explores the complexities of adherence in this population, the unique barriers and enablers of good adherence behaviours, and the role of emerging digital health technologies in bridging the gap between evidence-based treatment plans and the real-world standard of care. We present the current evidence supporting the use of digital health interventions among CKD populations, identifying the key research questions that remain unanswered, and providing practical strategies for clinicians to support medication adherence in a digital age.

A comparison of outcomes after lung transplantation between European and North American centers

BACKGROUND

With advancements in basic science and clinical medicine, lung transplantation (LT) has evolved rapidly over the last three decades. However, it is unclear if significant regional variations exist in long-term outcomes after LT.

METHODS

To investigate potential differences, we performed a retrospective, comparative cohort analysis of adult patients undergoing deceased donor single or double LT in North America (NA) or Europe between January 2006 and December 2016. Data up to April 2019 were abstracted from the International Society for Heart and Lung Transplantation (ISHLT) Thoracic Organ Registry. We compared overall survival (OS) between North American and European LT centers in a propensity score matched analysis.

RESULTS

In 3,115 well-matched pairs, though 30-day survival was similar between groups (NA 96.2% vs Europe 95.4%, p = 0.116), 5-year survival was significantly higher in European patients (NA 60.1% vs Europe 70.3%, p < 0.001).

CONCLUSIONS

This survival difference persisted in a sensitivity analysis excluding Canadian patients. Prior observations suggest that these disparities are at least partly related to better access to care via universal healthcare models prevalent in Europe. Future studies are warranted to confirm our findings and explore other causal mechanisms. It is likely that potential solutions will require concerted efforts from healthcare providers and policymakers.

Interventions for increasing immunosuppressant medication adherence in solid organ transplant recipients

BACKGROUND

Non-adherence to immunosuppressant therapy is a significant concern following a solid organ transplant, given its association with graft failure. Adherence to immunosuppressant therapy is a modifiable patient behaviour, and different approaches to increasing adherence have emerged, including multi-component interventions. There has been limited exploration of the effectiveness of interventions to increase adherence to immunosuppressant therapy.

OBJECTIVES

This review aimed to look at the benefits and harms of using interventions for increasing adherence to immunosuppressant therapies in solid organ transplant recipients, including adults and children with a heart, lung, kidney, liver and pancreas transplant.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 14 October 2021 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

All randomised controlled trials (RCTs), quasi-RCTs, and cluster RCTs examining interventions to increase immunosuppressant adherence following a solid organ transplant (heart, lung, kidney, liver, pancreas) were included. There were no restrictions on language or publication type.

DATA COLLECTION AND ANALYSIS

Two authors independently screened titles and abstracts of identified records, evaluated study quality and assessed the quality of the evidence using the GRADE approach. The risk of bias was assessed using the Cochrane tool. The ABC taxonomy for measuring medication adherence provided the analysis framework, and the primary outcomes were immunosuppressant medication initiation, implementation (taking adherence, dosing adherence, timing adherence, drug holidays) and persistence. Secondary outcomes were surrogate markers of adherence, including self-reported adherence, trough concentration levels of immunosuppressant medication, acute graft rejection, graft loss, death, hospital readmission and health-related quality of life (HRQoL). Meta-analysis was conducted where possible, and narrative synthesis was carried out for the remainder of the results.

MAIN RESULTS

Forty studies involving 3896 randomised participants (3718 adults and 178 adolescents) were included. Studies were heterogeneous in terms of the type of intervention and outcomes assessed. The majority of studies (80%) were conducted in kidney transplant recipients. Two studies examined paediatric solid organ transplant recipients. The risk of bias was generally high or unclear, leading to lower certainty in the results. Initiation of immunosuppression was not measured by the included studies. There is uncertain evidence of an association between immunosuppressant medication adherence interventions and the proportion of participants classified as adherent to taking immunosuppressant medication (4 studies, 445 participants: RR 1.09, 95% CI 0.95 to 1.20; I² = 78%). There was very marked heterogeneity in treatment effects between the four studies evaluating taking adherence, which may have been due to the different types of interventions used. There was evidence of increasing dosing adherence in the intervention group (8 studies, 713 participants: RR 1.14, 95% CI 1.03 to 1.26, I² = 61%).  There was very marked heterogeneity in treatment effects between the eight studies evaluating dosing adherence, which may have been due to the different types of interventions used. It was uncertain if an intervention to increase immunosuppressant adherence had an effect on timing adherence or drug holidays. There was limited evidence that an intervention to increase immunosuppressant adherence had an effect on persistence. There was limited evidence that an intervention to increase immunosuppressant adherence had an effect on secondary outcomes. For self-reported adherence, it is uncertain whether an intervention to increase adherence to immunosuppressant medication increases the proportion of participants classified as medically adherent to immunosuppressant therapy (9 studies, 755 participants: RR 1.21, 95% CI 0.99 to 1.49; I² = 74%; very low certainty evidence). Similarly, it is uncertain whether an intervention to increase adherence to immunosuppressant medication increases the mean adherence score on self-reported adherence measures (5 studies, 471 participants: SMD 0.65, 95% CI -0.31 to 1.60; I² = 96%; very low certainty evidence). For immunosuppressant trough concentration levels, it is uncertain whether an intervention to increase adherence to immunosuppressant medication increases the proportion of participants who reach target immunosuppressant trough concentration levels (4 studies, 348 participants: RR 0.98, 95% CI 0.68 to 1.40; I² = 40%; very low certainty evidence). It is uncertain whether an intervention to increase adherence to immunosuppressant medication may reduce hospitalisations (5 studies, 460 participants: RR 0.67, 95% CI 0.44 to 1.02; I² = 64%; low certainty evidence). There were limited, low certainty effects on patient-reported health outcomes such as HRQoL. There was no clear evidence to determine the effect of interventions on secondary outcomes, including acute graft rejection, graft loss and death. No harms from intervention participation were reported.

AUTHORS' CONCLUSIONS

Interventions to increase taking and dosing adherence to immunosuppressant therapy may be effective; however, our findings suggest that current evidence in support of interventions to increase adherence to immunosuppressant therapy is overall of low methodological quality, attributable to small sample sizes, and heterogeneity identified for the types of interventions. Twenty-four studies are currently ongoing or awaiting assessment (3248 proposed participants); therefore, it is possible that findings may change with the inclusion of these large ongoing studies in future updates.

Cost-Effectiveness Analysis: Personal Systems Approach in Improving Medication Adherence in Adult Kidney Transplant Patients

ABSTRACT

Interventions to improve medication nonadherence in transplantation have recently moved from a focus on motivation and intention, to a focus on person-level quality improvement strategies. These strategies link adherence to established daily routines, environmental cues, and supportive people. The objective of this evaluation was to estimate the cost of implementation and the cost-effectiveness of a person-level intervention shown to increase medication adherence. To estimate the intervention costs, a direct measure microcosting approach was used after key informant interviews with project champions and a review of implementation expenditures. Cost-effectiveness was calculated by comparing the incremental implementation costs and healthcare costs associated with nonadherence to the incremental percent adherent, defined as the percent of patients who took greater or equal to 85% of their medication doses, for each pairwise comparison. The intervention was low-resource to implement, costing approximately $520 to implement per patient, and was associated with significant improvements in medication adherence. These implementation costs were more than outweighed by the expected healthcare savings associated with improvements in adherence. This person-level intervention is a low-cost, efficacious intervention associated with significant statistical and clinical improvements in medication adherence in adult kidney transplant recipients.

Information and Communication Technologies in Lung Transplantation: Perception of Patients and Medical Teams

Optimal therapeutic management is a major determinant of patient prognosis and healthcare costs. Information and communication technologies (ICTs) represent an opportunity to enhance therapeutic management in complex chronic diseases, such as lung transplantation (LT). The objective of this study was to assess the preferences of LT patients and healthcare professionals regarding ICTs in LT therapeutic management. A cross-sectional opinion survey was conducted among lung transplant patients and healthcare professionals from the French lung transplantation centers. Five ICTs were defined (SMS, email, phone, internet, and smartphone application) in addition to face-to-face communication. An unsupervised approach by Principal Component Analysis (PCA) identified lung transplant patient profiles according to their preferences for ICTs. Fifty-three lung transplant patients and 15 healthcare professionals of the French LT centers were included. Both expected ICTs for treatment management and communication. Phone call, face-to-face, and emails were the most preferred communication tools for treatment changes and initiation. PCA identified four ICTs-related profiles (“no ICT”, “email”, “SMS”, and “oral communication”). “Email” and “oral communication” profiles are mainly concerned with treatment changes and transmission of new prescriptions. The “SMS” profile expected reminders for healthcare appointments and optimizing therapeutic management. This study provides practical guidance to enhance LT therapeutic management by ICT intervention. The type of ICT used should take into account patient profiles to improve adherence and thereby the prognosis. A combination of strategies including information, education by a multidisciplinary team, and reminders is a promising approach to ensure an optimal management of our patients.

Health Facts Medication Adherence in Transplantation (H-MAT) Study: A Secondary Analysis of Determinants and Outcomes of Medication Nonadherence in Adult Kidney Transplant Recipients

Aims

To explore the relationship between determinants and posttransplant medication nonadherence (MNA) in adult kidney transplant recipients, and to examine the relationship between posttransplant MNA and clinical outcomes.

Methods

Using the World Health Organization's model, this retrospective, multicenter, correlational study examined the relationship between determinants, posttransplant MNA, and clinical outcomes in 16,671 adult kidney transplant recipients from the Cerner Health Facts national data warehouse.

Results

With 12% MNA, those who were nonadherent were more likely to have the social/economic factors of being younger, single, Caucasian versus Hispanic race, have the condition-related factor of mental health/substance use disorder, and have the healthcare system-related factor of government/health maintenance organization/managed care insurance (p′s < 0.05). Bivariate correlations indicated both age (OR = 1.006, p=0.01) and mental health or substance use disorder diagnosis (OR = 1.26, p=0.04) were significant predictors of MNA. Patients were 0.6% more likely to be medication adherent for each year they increased in age and 26% more likely to be MNA if they were diagnosed with a mental health/substance use disorder. Nonadherent patients were less likely to be readmitted, but more likely to have complications after transplant and medication side effects (p′s < 0.01).

Conclusions

Using one of the largest samples of adult kidney transplant patients, our findings support the WHO model and move the body of medication adherence intervention research forward by clarifying the importance of focusing interventions not only on the patient but on multilevel determinants. Consistent with previous studies, MNA negatively impacts transplant outcomes.

Describing Predictors Of Regimen Nonadherence Among Kidney Recipients Using Multiple Measures

Introduction: Many kidney recipients struggle with medication adherence and are at greater risk for adverse post-transplant outcomes. Historically, research has focused on single immunosuppressants alone, though all medications within a prescribed regimen are essential for positive outcomes. Research question: Explore predictors of medication regimen nonadherence among a diverse sample of adult kidney recipients by using multiple measures of adherence. Design: A cross-sectional analysis was performed using data from an ongoing clinical trial that enrolled 234 kidney recipients from a large transplant center. We used linear and logit regression models to examine associations of demographic characteristics, social determinants of health, and clinical characteristics with (a) self-reported regimen adherence, measured by the Adherence Starts with Knowledge 12 scale, and (b) immunosuppressant adherence, captured by calculated risk score based on Tacrolimus measurements. Results: Kidney recipients with limited health literacy, overall poorer health, and higher levels of depression demonstrated significantly poorer regimen adherence. Recipients who had dual public/private insurance, took a greater number of medications, and had shorter time since transplant demonstrated significantly poorer immunosuppressant adherence. Conclusion: Social determinants (health literacy and insurance status), and clinical characteristics (overall health status, depression, number of medications, and time since transplant) played significant roles in regimen and immunosuppressant adherence among kidney recipients in our sample. Self-reported adherence, particularly in relation to full medication regimens, can highlight modifiable barriers that might otherwise be overlooked by focusing on adherence to a single immunosuppressant. Depression and health literacy can be assessed and addressed to improve adherence among adult kidney recipients.

Patient-Reported Outcomes as Endpoints in Clinical Trials of Kidney Transplantation Interventions

Patient-reported outcomes (PROs) that assess individuals' perceptions of life participation, medication adherence, disease symptoms, and therapy side effects are extremely relevant in the context of kidney transplantation. All PROs are potentially suitable as primary or secondary endpoints in interventional trials that aim to improve outcomes for transplant recipients. Using PRO measures (PROMs) in clinical trials facilitates assessment of the patient's perspective of their health, but few measures have been developed and evaluated in kidney transplant recipients; robust methodologies, which use validated instruments and established frameworks for reporting, are essential. Establishing a core PROM for life participation in kidney transplant recipients is a critically important need, which is being developed and validated by the Standardized Outcomes in Nephrology (SONG)-Tx Initiative. Measures involving electronic medication packaging and smart technologies are gaining traction for monitoring adherence, and could provide more robust information than questionnaires, interviews, and scales. This article summarizes information on PROs and PROMs that was included in a Broad Scientific Advice request on clinical trial design and endpoints in kidney transplantation. This request was submitted to the European Medicines Agency (EMA) by the European Society for Organ Transplantation in 2016. Following modifications, the EMA provided its recommendations in late 2020.

Exploration of Adherence to the Immunosuppressive Medication in Kidney Transplant Recipients Based on Theory of Planned Behavior

To investigate adherence to immunosuppressive medication (IM) in kidney transplant recipients (KTRs) and analyze the associated factors using the Theory of Planned Behavior (TPB). Data were collected at Time1 (T1) and 3 months later (T2). T1: the elements of the TPB, past behavior, beliefs about medicines, perceived social support were measured. T2: IM adherence was measured. Structural equation modeling was applied to analyze the associated factors of medication adherence. A total of 246 KTRs were included. The average IM adherence score of KTRs' was 4.86 (SD = 1.63). Of the recipients, 39.43% had one aspect of non-adherence to IM. The model could explain 28.7% of the variance in adherence to IM (R² = .287, p = .006). TPB is a useful tool for understanding adherence to IM in KTRs. Caregivers can provide effective interventions during follow-up, which should focus on improving medication beliefs as well as provision of other external support especially from outside.

A Multifaceted Intervention to Improve Medication Adherence in Kidney Transplant Recipients: An Exploratory Analysis of the Fidelity of the TAKE IT Trial

BACKGROUND

Inadequate adherence to prescribed immunosuppressive medication regimens among kidney transplant recipients is common, yet interventions are needed to support patients in sustaining adequate adherence to prescribed regimens and achieving optimal transplant outcomes.

OBJECTIVE

We examined the preliminary fidelity of a transplant center-based, multifaceted adherence monitoring strategy known as TAKE IT.

METHODS

The TAKE IT strategy includes: (1) routine, online, monthly patient self-report adherence assessments; (2) care alerts directed to nurses; (3) quarterly reports monitoring tacrolimus values and adherence trends; (4) support tools tailored to specific adherence concerns. A 2-arm, patient-randomized trial is underway at two large transplant centers (N=449). To evaluate the initial fidelity of TAKE IT, we investigated patient uptake of monthly adherence assessments during the course of a 3-month period, whether any disparities emerged, and the nature of any reported adherence concerns.

RESULTS

Among 202 patients randomized and exposed to TAKE IT for 3-months or more, 81% (164/202) completed an adherence assessment, 73% (148/202) completed at least two, and 57% (116/202) completed all monthly assessments. Overall, 50% (82/164) of kidney transplant recipients reported at least one adherence concern over the 3-month assessment period. The most common barriers were classified as regimen-related (eg, regimen complexity), cognitive (eg, forgetfulness), and medical (eg, side effects). Higher-income participants were more likely to complete all surveys compared to lower-income participants (P=.01).

CONCLUSIONS

TAKE IT demonstrated 81% (164/202) completion of an adherence assessment, 73% (148/202) completion of at least two, and 57% (116/202) completion of all monthly assessments during this brief, initial observation period. Among those that did respond to the online assessments, the majority demonstrated sustained engagement. Additional monitoring modalities could also be offered to meet patient preferences to ensure all patients' medication use can be properly monitored.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03104868; https://clinicaltrials.gov/ct2/show/NCT03104868.