Measuring symptom experience of side-effects of immunosuppressive drugs: the Modified Transplant Symptom Occurrence and Distress Scale

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

RATIONALE & OBJECTIVE

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

STUDY DESIGN

Qualitative interviews for concept elicitation and cognitive debriefing.

SETTING & PARTICIPANTS

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

ANALYTICAL APPROACH

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Symptom Distress Before and After Heart Transplantation - A Longitudinal 5-Year Follow-Up

INTRODUCTION

Symptom distress after heart transplantation (HTx) is a significant problem causing uncertainty, low self-efficacy, and psychological distress. Few studies have addressed self-reported symptoms. The aim was to explore self-reported symptom distress from time on the waiting list to 5 years after HTx and its association with self-reported psychological well-being, chronic pain, and fatigue in order to identify possible predictors of psychological or transplant specific well-being.

METHODS

This multicenter, longitudinal cohort study includes 48 heart recipients (HTRs), 12 women, and 36 men, with a median age of 57 years followed from pretransplant to 5 years post-transplant. Symptom distress was explored by means of four instruments measuring psychological general wellbeing, transplant specific wellbeing, pain, and fatigue.

RESULTS

Transplant specific well-being for the whole improved in a stepwise manner during the first 5 years compared to pretransplant. Heart transplant recipients with poor psychological wellbeing were significantly more burdened by symptom distress, in particular sleep problems and fatigue, for up to 5 years after HTx, and their transplant-specific well-being never improved compared to baseline. The prevalence of pain varied from 40% to 60% and explained a significant proportion of the variance in transplant-specific well-being, while psychological general well-being was mainly predicted by overall symptom distress.

CONCLUSION

The presence of distressing symptoms explains a significant proportion of poor psychological wellbeing both among HTRs reporting chronic pain and those without pain.

Kidney Transplantation Improves Health-Related Quality of Life in Older Recipients

Kidney transplantation is the best treatment for kidney failure in older patients. However, little is known regarding changes in health-related quality of life (HRQoL) from before to after transplantation and determinants of HRQoL in older kidney transplant recipients (KTR). We studied both, using data of older (≥65 years) patients waitlisted for kidney transplantation and older KTR 1 year after transplantation from the TransplantLines Biobank and Cohort Study. HRQoL was assessed using the SF-36 questionnaire. We included 145 older waitlisted patients (68% male, age 70 ± 4 years) and 115 older KTR at 1 year after transplantation (73% male, age 70 ± 4 years). Both mental (48.5 ± 8.4 versus 51.2 ± 7.7, p = 0.009) and physical (47.4 ± 8.5 versus 52.1 ± 7.2, p < 0.001) HRQoL were higher among included KTR, compared to the waitlisted patients. In paired analyses among 46 patients with HRQoL-data both before and after transplantation, there was a trend towards increased mental HRQoL (49.1 ± 8.4 to 51.6 ± 7.5, p = 0.054), and significantly increased physical HRQoL (48.1 ± 8.0 to 52.4 ± 6.7, p = 0.001) after transplantation. Among all assessed factors, the number of patient-reported immunosuppressive drug-related side effects was most strongly negatively associated with both mental and physical HRQoL. In conclusion, HRQoL is significantly higher among older KTR after kidney transplantation compared to older waitlisted patients.

Assessing quality of life in solid organ transplant recipients: A systematic review of the development, content, and quality of available condition- and transplant-specific patient-reported outcome measures

PURPOSE

We aimed to identify the condition- and transplant-specific patient-reported outcome measures (PROMs) available to measure quality of life (QoL) in solid organ transplant (SOT) recipients, examine their development and content, and critically appraise the quality of their measurement properties, to inform recommendations for clinical and research use.

METHODS

We systematically searched MEDLINE, Embase, CINAHL, PsycINFO, Cochrane CENTRAL, and Scopus from inception to 27th January 2023. Search hits were screened for eligibility by two independent reviewers; papers reporting the development and/or validation of condition- and transplant-specific PROMs measuring QoL in adult SOT recipients were considered eligible. We abstracted and synthesised data on PROM characteristics, development (item generation and/or reduction), and content (QoL dimensions). Quality appraisal and synthesis were informed by the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines, and included methodological and quality assessment of measurement properties, GRADE levels of evidence, feasibility and interpretability.

RESULTS

We identified 33 papers reporting 26 QoL PROMs validated in SOT recipients (kidney n = 10 PROMs; liver n = 6; lung n = 3; heart n = 2; pancreas n = 1; multiple organs n = 4). Patient discussions (n = 17 PROMs) and factor analysis (n = 11) were the most common item generation and reduction techniques used, respectively. All PROMs measured ≥3 of nine QoL dimensions (all measured emotional functioning); KDQoL-SF and NIDDK-QA measured all nine. Methodological quality was variable; no PROM had low evidence or better for all measurement properties. All PROMs were COSMIN recommendation category 'B', primarily because none had sufficient content validity.

CONCLUSIONS

There are many condition- and transplant-specific QoL PROMs validated in SOT recipients, particularly kidney. These findings can help inform PROM selection for clinicians and researchers. However, caution is required when adopting measures, due to the substantial heterogeneity in development, content, and quality. Each PROM has potential but requires further research to be recommendable. Greater consideration of patient and professional involvement in PROM development in this setting is needed to ensure sufficient content validity.

The measure of impact: Proposal of quality metrics for solid organ transplant pharmacy practice

As healthcare continues its transition toward value-based care, it is increasingly important for transplant pharmacists to demonstrate their impact on patient care, health-related outcomes, and healthcare costs. Evidence-based quality and performance metrics are recognized as crucial tools for measuring the value of service. Yet, there is a lack of well-developed and agreed-upon specific metrics for many clinical pharmacy specialties, including solid organ transplantation. To address this need, a panel of transplant pharmacy specialists conducted a detailed literature review and engaged in several panel discussions to identify quality metrics to be considered for assessing the value of clinical pharmacy services provided to solid organ transplant recipients and living donors. The proposed metrics are based on the Donabedian model and are categorized to coincide with the typical phases of transplant care. The measures focus on key issues that arise in transplant recipients related to medication therapy, including adverse drug events, nonadherence, and clinical outcomes attributable to medication therapy management. This article proposes a comprehensive set of measures, any number of which transplant pharmacists can adopt and measure over time to objectively gauge the value of services they are providing to transplant recipients, the transplant center, and the overall healthcare system.

Sleep Quality and Related Factors Among Liver Transplant Recipients in Korea: A Cross-Sectional Study

BACKGROUND

Poor sleep quality is common after liver transplantation, which lowers health-related quality of life. However, the detection and management of sleeping difficulties in liver transplant recipients have been limited.

PURPOSE

This study was designed to assess sleep quality in liver transplant recipients in Korea and associated factors, including symptom experience, depression, and family support, using the theory of unpleasant symptoms as a theoretical framework.

METHODS

This cross-sectional study of 149 liver transplant recipients in a Korean tertiary hospital was conducted in 2019. Data were obtained using several structured self-report questionnaires, including the Pittsburgh Sleep Quality Index, Modified Transplant Symptom Occurrence and Symptom Distress Scale, Center for Epidemiologic Studies Depression Scale-Revised, and Family Support Scale. Multiple linear regression was used to determine the factors associated with sleep quality.

RESULTS

The prevalence of sleep disturbance was 55% in the sample. Low sleep quality was associated with being female and with having a higher symptom experience, higher depressive symptoms, and lower family support. In the multiple linear regression analysis, depression and symptom experience was shown to significantly affect sleep quality.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The liver transplant recipients in this study reported poor sleep quality. The factors associated with the sleep quality included depression and symptom experience. To enhance sleep quality, interventions designed to reduce depression and symptoms related to liver transplantation should be provided. The results of this study may be used to develop nursing strategies to improve sleep quality in liver transplant recipients.

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.

Understanding Health-Related Quality of Life in Kidney Transplant Recipients: The Role of Symptom Experience and Illness Perceptions

The purpose of our article is to investigate the impact of symptom experience on health related quality of life (HRQOL) in kidney transplant recipients (KTRs) and whether illness perceptions mediated this impact. Symptom experience, illness perceptions, and HRQOL were measured at transplantation and 6 weeks after transplantation in KTRs in an ongoing Dutch cohort study. Multivariable linear regression models were used for the analysis. 90 KTRs were analyzed. Fatigue and lack of energy were the most prevalent and burdensome symptoms at transplantation. Mental HRQOL at 6 weeks after transplantation was comparable to that of the general Dutch population (mean [standard deviation, SD]: 49.9 [10.7]) versus 50.2 [9.2]), while physical HRQOL was significantly lower (38.9 [9.1] versus 50.6 [9.2]). Experiencing more symptoms was associated with lower physical and mental HRQOL, and the corresponding HRQOL reduced by -0.15 (95%CI, -0.31; 0.02) and -0.23 (95%CI, -0.42; -0.04) with each additional symptom. The identified mediation effect suggests that worse symptom experiences could cause more unhelpful illness perceptions and consequently lead to lower HRQOL. Illness perceptions may explain the negative impact of symptom experience on HRQOL. Future studies at later stages after kidney transplantation are needed to further explore the mediation effect of illness perceptions and guide clinical practice to improve HRQOL.

Employment Status and Work Functioning among Kidney Transplant Recipients

BACKGROUND AND OBJECTIVES

To date, employment figures of kidney transplant recipients in Europe are inconsistent. Additionally, little is known about work functioning of employed kidney transplant recipients and work functioning trajectories before and after transplantation.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Data from the ongoing TransplantLines Biobank and Cohort study and from community-dwelling employed adults were used. Health-related work functioning of kidney transplant recipients was assessed with the Work Role Functioning Questionnaire 2.0 and compared with potential kidney donors and community-dwelling employed adults.

RESULTS

We included 668 kidney transplant recipients of working age (59% men, age 51±11 years) at median 3 (interquartile range, 2-10) years after transplantation, 246 potential kidney donors of working age (43% men, age 53±9 years), and 553 community-dwelling employed adults (70% men, age 45±11 years). The proportion of employed kidney transplant recipients was lower compared with potential kidney donors (56% versus 79%). If employed, the work functioning score of kidney transplant recipients was slightly lower compared with employed potential kidney donors yet higher compared with community-dwelling employed adults (medians 91 [interquartile range, 76-98], 94 [interquartile range, 85-99], and 88 [interquartile range, 79-95], respectively). Backward linear regression analyses revealed that lower educational level, having a kidney from a deceased donor, presence of tingling or numbness of hands or feet, presence of concentration/memory problems, presence of anxiety, and presence of severe fatigue were independently associated with lower work functioning among kidney transplant recipients. Additional subgroup analyses showed that work functioning scores were lower before transplantation than at 12 months after transplantation (83 [interquartile range, 66-93] versus 92 [interquartile range, 88-98], respectively; P=0.002).

CONCLUSIONS

Stable employed kidney transplant recipients report to function well at work. In addition, this study shows that self-reported work functioning is higher after successful kidney transplantation compared with before transplantation.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

TransplantLines Biobank and Cohort study, NCT03272841 PODCAST: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_09_26_CJN05560522.mp3.

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.

A Systematized Review of Professional Employment Following Thoracic Transplantation

INTRODUCTION

Acknowledging the evolved landscape in thoracic transplantation, professional employment becomes an important outcome measure to quantify the success of this costly procedure.

OBJECTIVE

We aimed to assess rates of and characterize factors associated with professional employment in patients following thoracic transplantation, and create an evidence-base on the relationship between professional employment and relevant outcome parameters.

METHODS

We systematically searched Medline, Cinahl, and GoogleScholar to identify studies published between 1998 and 2021 reporting on professional employment following heart and lung transplantation.

RESULTS

Twenty-two studies from 11 countries with varying sample sizes (N = 27; 10 066) were included. Employment rates ranged from 19.7% to 69.4% for heart, and from 7.4% to 50.8% for lung transplant recipients. Most frequently reported positively associated factors with employment after transplant were younger age, higher education, and history of pretransplant employment. Longer duration of unemployment prior to transplantation and Medicaid coverage were the most frequently reported negatively associated factors. Relationships between professional employment and clinical outcomes included lower rates of acute and chronic rejection, less infection episodes, and better quality of life among working patients; one study reported a lower 5-year-mortality rate. Reasons not to work were "physical or mental health-related," "employment-related," "financial reasons," and "lifestyle choices."

DISCUSSION

Substantial proportions of patients following thoracic transplantation are not professionally employed, potentially diminishing the success of transplantation on individual and societal levels. Considering adverse clinical outcomes in employed transplant recipients were low, more efforts are needed to identify modifiable factors for employment in these populations.

A randomized crossover study comparing different tacrolimus formulations to reduce intrapatient variability in tacrolimus exposure in kidney transplant recipients

A high intrapatient variability (IPV) in tacrolimus exposure is a risk factor for poor long‐term outcomes after kidney transplantation. The main objective of this trial was to investigate whether tacrolimus IPV decreases after switching patients from immediate‐release (IR)‐tacrolimus to either extended‐release (ER)‐tacrolimus or LifeCyclePharma (LCP)‐tacrolimus. In this randomized, prospective, open‐label, cross‐over trial, adult kidney transplant recipients on a stable immunosuppressive regimen, including IR‐tacrolimus, were randomized for conversion to ER‐tacrolimus or LCP‐tacrolimus, and for the order in which IR‐tacrolimus and the once‐daily formulations were taken. Patients were followed 6 months for each formulation, with monthly tacrolimus predose concentration assessments to calculate the IPV. The IPV was defined as the coefficient of variation (%) of dose corrected predose concentrations. Ninety‐two patients were included for analysis of the primary outcome. No significant differences between the IPV of IR‐tacrolimus (16.6%) and the combined once‐daily formulations (18.3%) were observed (% difference +1.7%, 95% confidence interval [CI] −1.1% to ‒4.5%, p = 0.24). The IPV of LCP‐tacrolimus (20.1%) was not significantly different from the IPV of ER‐tacrolimus (16.5%, % difference +3.6%, 95% CI −0.1% to 7.3%, p = 0.06). In conclusion, the IPV did not decrease after switching from IR‐tacrolimus to either ER‐tacrolimus or LCP‐tacrolimus. These results provide no arguments to switch kidney transplant recipients from twice‐daily (IR) tacrolimus formulations to once‐daily (modified‐release) tacrolimus formulations when the aim is to lower the IPV.

Drug tolerability: How much ambiguity can be tolerated? A systematic review of the assessment of tolerability in clinical studies

AIMS

Drug tolerability refers to the degree to which drugs' overt adverse effects can be tolerated by patients. The tolerability profile is of comparative importance to its efficacy and safety, as it largely determines adherence to treatment and ultimately treatment success or failure. However, the term is frequently used imprecisely, and it is unclear if tolerability is limited to subjective patient-reported symptoms or also covers certain objective signs and findings. The aim of this systematic review was to assess how clinical studies define, evaluate and present drug tolerability.

METHODS

The study consisted of a systematic review of clinical studies in PubMed® reporting the term "tolerability".

RESULTS

Eighty clinical studies were screened and 56 studies reporting drug tolerability were retained. None of the retained studies defined events encompassed by the term tolerability by making a distinction between safety and tolerability. Twenty-five studies claimed to evaluate tolerability, but none of them described how to evaluate tolerability from the patient perspective. Most studies (54 out of 56) concluded that the treatment was well tolerated, apparently implying favourable safety. However, none of them actually presented tolerability in terms of a contrast between safety and tolerability.

CONCLUSIONS

Tolerability is used frequently, albeit incorrectly, to refer to a drug's favourable safety profile. Focused evaluation of drug tolerability (i.e., the patient perspective of adverse drug reactions) should become routine. Presentation in regulatory documents, such as risk management plan summaries, product information and patient leaflets should be a continuation of the process of patient-centred healthcare.

Outcomes after kidney transplantation, let's focus on the patients' perspectives

Graft function and patient survival are traditionally the most used parameters to assess the objective benefits of kidney transplantation. Monitoring graft function, along with therapeutic drug concentrations and transplant complications, comprises the essence of outpatient management in kidney transplant recipients (KTRs). However, the patient's perspective is not always included in this process. Patients' perspectives on their health after kidney transplantation, albeit subjective, are increasingly acknowledged as valuable healthcare outcomes and should be considered in order to provide patient-centred healthcare. Such outcomes are known as patient-reported outcomes (PROs; e.g. health-related quality of life and symptom burden) and are captured using PRO measures (PROMs). So far, PROMs have not been routinely used in clinical care for KTRs. In this review we will introduce PROMs and their potential application and value in the field of kidney transplantation, describe commonly used PROMs in KTRs and discuss structural PROMs implementation into kidney transplantation care.

Discrepancy between self-perceived mycophenolic acid-associated diarrhea and stool water content after kidney transplantation

BACKGROUND

Diarrhea is a well-known side effect of mycophenolic acid (MPA) use in kidney transplant recipients (KTRs). It is unknown whether self-reported diarrhea using the Modified Transplant Symptom Occurrence and Symptom Distress Scale (MTSOSD-59R) corresponds to stool water content and how both relate to MPA usage.

METHODS

MTSOSD-59R questionnaires filled out by 700 KTRs from the TransplantLines Biobank and Cohort Study (NCT03272841) were analyzed and compared with stool water content. Stool samples (N = 345) were freeze-dried, and a water content ≥80% was considered diarrhea.

RESULTS

Self-perceived diarrhea was reported by 46%, while stool water content ≥80% was present in 23% of KTRs. MPA use was not associated with self-perceived diarrhea (odds ratio(OR) 1.32; 95% confidence interval(CI), 0.87-1.99, p = .2), while it was associated with stool water content ≥80% (OR 2.88; 95%CI, 1.41-5.89, p = .004), independent of potential confounders. Adjustment for prior MPA discontinuation because of severe diarrhea, uncovered an association between MPA use and self-perceived diarrhea (OR 1.80; 95%CI, 1.13-2.89, p = .01).

CONCLUSIONS

These results suggest that reporting bias could add to the discrepancy between both methods for diarrhea assessment. We recommend use of objective biomarkers or more extensive questionnaires which assess information on stool frequency and stool consistency, to investigate post-transplantation diarrhea.

Patient-reported outcome measures ( PROMs): making sense of individual PROM scores and changes in PROM scores over time

Patient-reported outcome measures (PROMs) are increasingly being used in nephrology care. However, in contrast to well-known clinical measures such as blood pressure, health-care professionals are less familiar with PROMs and the interpretation of PROM scores is therefore perceived as challenging. In this paper, we provide insight into the interpretation of PROM scores by introducing the different types and characteristics of PROMs, and the most relevant concepts for the interpretation of PROM scores. Concepts such as minimal detectable change, minimal important change and response shift are explained and illustrated with examples from nephrology care.

Restoration of FVIII Function and Phenotypic Rescue in Hemophilia A Mice by Transplantation of MSCs Derived From F8-Modified iPSCs

Hemophilia A (HA), an X-linked recessive congenital bleeding disorder, affects 80%–85% of patients with hemophilia. Nearly half of severe cases of hemophilia are caused by a 0.6-Mb genomic inversion (Inv22) that disrupts F8. Although viral-based gene therapy has shown therapeutic effects for hemophilia B (HB), this promising approach is not applicable for HA at the present stage; this limitation is mainly due to the large size of F8 cDNA, which far exceeds the adeno-associated virus (AAV) packaging capacity. We previously reported an in situ genetic correction of Inv22 in HA patient-specific induced pluripotent stem cells (HA-iPSCs) by using TALENs. We also investigated an alternative strategy for targeted gene addition, in which cDNA of the B-domain deleted F8 (BDDF8) was targeted at the rDNA locus of HA-iPSCs using TALENickases to restore FVIII function. Mesenchymal stem cells (MSCs) have low immunogenicity and can secrete FVIII under physiological conditions; in this study, MSCs were differentiated from F8-corrected iPSCs, BDDF8-iPSCs, and HA-iPSCs. Differentiated MSCs were characterized, and FVIII expression efficacy in MSCs was verified in vitro. The three types of MSCs were introduced into HA mice via intravenous injection. Long-term engraftment with restoration of FVIII function and phenotypic rescue was observed in HA mice transplanted with F8-corrected iMSCs and BDDF8-iMSCs. Our findings suggest that ex vivo gene therapy using iMSCs derived from F8-modified iPSCs can be feasible, effective, and promising for the clinical translation of therapeutic gene editing of HA and other genetic birth defects, particularly those that involve large sequence variants.

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

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

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

INTRODUCTION

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Screening Performance of Edmonton Symptom Assessment System in Kidney Transplant Recipients

An average prevalence of 35% for psychiatric comorbidity has been reported in kidney transplant recipients (KTRs) and an even higher prevalence of other psychosocial syndromes, as defined by the Diagnostic Criteria for Psychosomatic Research (DCPR), has also been found in this population. Consequently, an easy, simple, rapid psychiatric tool is needed to measure physical and psychological symptoms of distress in KTRs. Recently, the Edmonton Symptom Assessment System (ESAS), a pragmatic patient-centred symptom assessment tool, was validated in a single cohort of KTRs. The aims of this study were: to test the screening performances of ESAS for the International Classification of Diseases-10th Revision (ICD-10) psychiatric diagnoses in KTRs; to investigate the optimal cut-off points for ESAS physical, psychological and global subscales in detecting ICD-10 psychiatric diagnoses; and to compare ESAS scores among KTR with ICD-10 diagnosis and DCPR diagnosis. 134 KTRs were evaluated and administered the MINI International Neuropsychiatric Interview 6.0 and the DCPR Interview. The ESAS and Canadian Problem Checklist (CPC) were given as self-report instruments to be filled in and were used to examine the severity of physical and psychological symptoms and daily-life problems. The physical distress sub-score (ESAS-PHYS), psychological distress sub-score (ESAS-PSY) and global distress score (ESAS-TOT) were obtained by summing up scores of six physical symptoms, four psychological symptoms and all single ESAS symptoms, respectively. Routine biochemistry, immunosuppressive agents, socio-demographic and clinical data were collected. Receiving Operating Characteristic (ROC) analysis was used to examine the ability of the ESAS emotional distress (DT) item, ESAS-TOT, ESAS-PSY and ESAS-PHYS, to detect psychiatric cases defined by using MINI6.0. The area under the ROC curve for ESAS-TOT, ESAS-PHYS, ESAS-PSY and DT item were 0.85, 0.73, 0.89, and 0.77, respectively. The DT item, ESAS-TOT and ESAS-PSY optimal cut-off points were ≥4 (sensitivity 0.74, specificity 0.73), ≥20 (sensitivity 0.85, specificity 0.74) and ≥12 (sensitivity 0.85, specificity 0.80), respectively. No valid ESAS-PHYS cut-off was found (sensitivity <0.7, specificity <0.7). Thirty-nine (84.8%) KTRs with ICD-10 diagnosis did exceed both ESAS-TOT and ESAS-PSY cut-offs. Higher scores on the ESAS symptoms (except shortness of breath and lack of appetite) and on the CPC problems were found for ICD-10 cases and DCRP cases than for ICD-10 no-cases and DCPR no-cases. This study shows that ESAS had an optimal screening performance (84.8%) to identify ICD-10 psychiatric diagnosis, evaluated with MINI; furthermore, ESAS-TOT and ESAS-PSY cut-off points could provide a guide for clinical symptom management in KTRs.

Development and Preliminary Validation of the Lung Transplant Quality of Life (LT-QOL) Survey

RATIONALE

Although lung transplantation aims to improve health-related quality of life (HRQL), existing instruments fail to include health domains considered important in this population.

OBJECTIVES

We aimed to develop a comprehensive lung transplant-specific instrument to address this shortcoming.

METHODS

We developed a pool of 126 candidate items addressing domains previously identified as important by lung transplant recipients. Through cognitive interviews conducted in 43 transplant recipients, items deemed irrelevant or redundant were dropped. The 84 remaining items were field tested in lung transplant recipients. Exploratory and confirmatory factor analyses were used to evaluate the factor structure, and scales were evaluated for internal consistency and construct validity.

MEASUREMENTS AND MAIN RESULTS

The 84-item preliminary survey was administered to 201 lung transplant recipients with a mean age of 57.9 (±12.7) years; 46% were female. After factor analyses and internal consistency evaluation, we retained 60 items comprising the Lung Transplant Quality of Life (LT-QOL) Survey. The LT-QOL contains 10 scales that measure symptoms, health perceptions, functioning, and well-being. The confirmatory factor analysis model had good approximate fit (comparative fit index = 0.990; standardized root-mean-square residual = 0.062). Cronbach αs for the 10 scales ranged from 0.75 to 0.95. Interscale correlations were consistent with hypothesized relationships. Subjects with severe chronic lung allograft dysfunction (n = 13) reported significantly worse HRQL than subjects without chronic lung allograft dysfunction (n = 168) on 6 of the 10 LT-QOL scales.

CONCLUSIONS

The LT-QOL is a new, multidimensional instrument that characterizes and quantifies HRQL in lung transplant recipients.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Adverse effects of mycophenolic acid in renal transplant recipients: gender differences

Background Mycophenolic acid is widely used immunosuppressive drug, associated with adverse effects which increase patient morbidity and decrease medication adherence. Objective To evaluate the adverse effects in renal transplant recipients under mycophenolate treatment with respect to gender. Setting University Clinical Centre of Nis, Clinic of Nephrology, Serbia. Method This research included 96 renal transplant recipients, who received immunosuppressive regimen, based on tacrolimus or cyclosporin A, prednisone and mycophenolic acid. The high-performance liquid chromatography method combined with protein precipitation was used for the analysis of mycophelate concentration in human plasma. Drug concentration and dose-adjusted concentration were determined with respect to the patients' gender. An adverse effect scoring system developed by nephrologists within the University of Buffalo Nephrology/Transplant Program was used to monitor adverse effects of therapy. Main outcome measure Individual and scores of adverse effects in relation to the dosing regimen and gender. Results Results showed statistically lower dose and concentrations in men compared to the women in our investigation group. Also, female patients demonstrated higher mean scores (cumulative and subscores) within the same dosing regimens of mycophenolic acid. The gastrointestinal score was significantly higher in women who received a dose greater than 720 mg compared to men (0.20 ± 0.12 vs 0.12 ± 0.12). Women demonstrated higher individual adverse effects such as diarrhea and skin changes (41.7 vs 17.0; p = 0.038 and 62.5 vs 30.2; p = 0.037, respectively). Conclusions The results of our research showed that recipients' gender may play an important role in pharmacokinetic profile of mycophenolic acid, suggesting that women had higher concentration of mycophenolic acid and more serious side effects.

A Scoping Review of Key Health Items in Self-Report Instruments Used Among Solid Organ Transplant Recipients

The overall aim of this scoping review of the literature is twofold: (1) to provide an overview of all instruments that have been used to assess health-related quality of life (HRQoL) after solid organ transplantation and (2) to provide a list of health items they include to support future studies on the development of a new-generation HRQoL instrument. All studies that administered any form of HRQoL instrument to post-transplant solid organ recipients were identified in a comprehensive search of PubMed (MEDLINE), Embase, and Web of Science, with a cut-off date of May 2018. The search used various combinations of the following keywords: lung, heart, liver, kidney, or pancreas transplantation; quality of life; well-being; patient-reported outcome; instrument; questionnaire; and health survey. In total, 8013 distinct publications were identified and 1218 of these were selected for review. Among the instruments applied, 53 measured generic, 51 organ-specific, 271 domain-specific, and 43 transplant-specific HRQoL. A total of 78 distinct health items grouped into 16 sub-domains were identified and depicted graphically. The majority of publications did not report a logical rationale for the choice of specific HRQoL instrument. The most commonly used types of instruments were generic health instruments, followed by domain-specific instruments. Despite the availability of transplant-specific instruments, few studies applied these types of instruments. Based on the 78 items, further research is planned to develop a patient-centered, transplant-specific HRQoL instrument that is concise, easy to apply (mobile application), and specifically related to the health issues of solid organ recipients.

The importance of drug safety and tolerability in the development of new immunosuppressive therapy for transplant recipients: The Transplant Therapeutics Consortium's position statement

The Transplant Therapeutics Consortium (TTC) is a public-private partnership between the US Food and Drug Administration and the transplantation community including the transplantation societies and members of the biopharmaceutical industry. The TTC was formed to accelerate the process of developing new medical products for transplant patients. The initial goals of this collaboration are the following: (a) To define which aspects of the kidney transplant drug-development process have clear needs for improvement from an industry and regulatory perspective; (b) to define which of the unmet needs in the process could be positively impacted through the development of specific drug-development tools based on available data; and (c) to determine the most appropriate pathway to achieve regulatory acceptance of the proposed process-accelerating tools. The TTC has identified 2 major areas of emphasis: new biomarkers or endpoints for determining the efficacy of new therapies and new tools to assess the safety or tolerability of new therapies. This article presents the rationale and planned approach to develop new tools to assess safety and tolerability of therapies for transplant patients. We also discuss how similar efforts might support the continued development of patient-reported outcome measures in the future.

Rationale and design of TransplantLines: a prospective cohort study and biobank of solid organ transplant recipients

INTRODUCTION

In the past decades, short-term results after solid organ transplantation have markedly improved. Disappointingly, this has not been accompanied by parallel improvements in long-term outcomes after transplantation. To improve graft and recipient outcomes, identification of potentially modifiable risk factors and development of biomarkers are required. We provide the rationale and design of a large prospective cohort study of solid organ transplant recipients (TransplantLines).

METHODS AND ANALYSIS

TransplantLines is designed as a single-centre, prospective cohort study and biobank including all different types of solid organ transplant recipients as well as living organ donors. Data will be collected from transplant candidates before transplantation, during transplantation, at 3 months, 6 months, 1 year, 2 years and 5 years, and subsequently every 5 years after transplantation. Data from living organ donors will be collected before donation, during donation, at 3 months, 1 year and 5 years after donation, and subsequently every 5 years. The primary outcomes are mortality and graft failure. The secondary outcomes will be cause-specific mortality, cause-specific graft failure and rejection. The tertiary outcomes will be other health problems, including diabetes, obesity, hypertension, hypercholesterolaemia and cardiovascular disease, and disturbances that relate to quality of life, that is, physical and psychological functioning, including quality of sleep, and neurological problems such as tremor and polyneuropathy.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the relevant local ethics committee. The TransplantLines cohort study is designed to deliver pioneering insights into transplantation and donation outcomes. The study design allows comprehensive data collection on perioperative care, nutrition, social and psychological functioning, and biochemical parameters. This may provide a rationale for future intervention strategies to more individualised, patient-centred transplant care and individualisation of treatment.

TRIAL REGISTRATION NUMBER

NCT03272841.

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

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

Pilot testing a model of psychological care for heart transplant recipients

BACKGROUND

Anxiety and depression are common after heart transplantation. This study aimed to pilot test the feasibility of a clinical model of psychological care for heart transplant recipients. The model of care involved nurse-led screening for anxiety and depression followed by referral for a course of telephone-delivered cognitive behaviour therapy as well as co-ordination of communication with on-going specialist and primary care services.

METHODS

A pilot randomised controlled trial was conducted. Heart transplant recipients who self-reported at least mild anxiety or depressive symptoms were randomised (defined as a score higher than 5 on the Patient Health Questionnaire-9 or the Generalized Anxiety Disorder-7 [GAD-7], or a score higher than 20 on the Kessler Psychological Distress Scale [K10]). The primary outcome was assessment of feasibility of conducting a larger trial, which included identification of recruitment and attrition rates as well as the acceptability of the intervention. Follow-up was conducted at 9 weeks and 6 months.

RESULTS

One hundred twenty-two of the 126 (97 %) heart transplant recipients assessed on their attendance at the outpatient clinic met the study eligibility criteria. Of these patients, 88 (72 %) agreed to participate. A moderate proportion of participants (n = 20; 23 %) reported at least mild symptoms of anxiety or depression. Five participants were excluded because they were currently receiving psychological counselling, two withdrew before randomisation and the remaining 13 were randomised (seven to intervention and six to usual care). The majority of the randomised participants were male (n = 9; 69 %) and aged over 60 (range 35-73). Median length of time post-transplant was 9.5 years (ranging from 1 to 19 years). On enrolment, 3 randomised participants were taking anti-depressants. One intervention group participant withdrew and a further 3 (50 %) declined the telephone-delivered CBT sessions; all because of restrictions associated with physical illnesses. Attrition was 30 % at the 6 month follow-up time-point.

CONCLUSIONS

Due to the poor acceptability of telephone-delivered cognitive behavioural therapy observed in our sample, changes to intervention components are indicated and further pilot testing is required.

TRIAL REGISTRATION

ACTRN12613000740796 Date registered: 03/07/2013.

Depression and Pain in Heart Transplant Recipients

Characterizing how physical and psychological symptoms interact in heart transplant recipients may lead to advances in therapeutic options. This study examined associations between pain and major depression.

Method:

A cross-sectional study was conducted with adult heart transplant recipients. Pain was measured with the bodily pain domain of the Short Form-36 Health Survey and psychological distress with the Kessler Psychological Distress Scale (K-10). The Mini International Neuropsychiatric Interview, version 6.0, was used to identify participants meeting the criteria for major depression. Hierarchical linear regression was used to determine if there was an association between pain and major depression, controlling for pharmacological treatment of depression, severity of psychological distress, and clinical characteristics including immunosuppression medication which may induce pain as a side effect.

Results:

Average pain score of the 48 heart transplant recipients was 43 ( SD ± 10, range 0–100, lower scores indicate worse pain), with moderate pain reported by 39% ( n = 19). Major depression was associated with worse pain ( R2 change = 36%, β = −16, 95% confidence interval [CI] = [−30, −4], p = .012). Pharmacological treatment for depression was associated with better pain scores ( R2 change = 1.5%, β = 13, 95% CI [4, 23], p = .006).

Conclusions:

Heart transplant recipients with major depression had worse pain after controlling for pharmacological treatment of depression, severity of psychological distress, and clinical characteristics. Thus, it is imperative that clinicians devising a treatment regimen for pain in heart transplant recipients take into account co-occurring depression and vice versa.

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

PURPOSE

The purpose of this study was to investigate the relationship between immunosuppressant-related symptom experience (SE) and adherence to immunosuppressant regimens among kidney transplant (KT) recipients.

METHODS

A total of 239 KT recipients on an immunosuppressant regimen who were followed up after transplantation participated in this study. Data was collected through a self-reported questionnaire survey (medication adherence, SE, and quality of life) and medical record review.

RESULTS

Low adherence in the immunosuppressant group was associated with longer time since KT, less comorbidity (<3), and a higher rehospitalization rate. Low adherence among KT recipients showed significantly greater overall symptom occurrence (P = .001) and symptom distress (P = .002) levels than patients with high or medium adherence after adjusting for a number of covariates. The most common symptom both in terms of occurrence (96.4%) and distress (91.1%) among poorly adherent KT recipients was tiredness.

CONCLUSION

Low adherence to an immunosuppressant regimen was significantly associated with high SE among KT recipients. Strategies to decrease immunosuppressant-related SE are needed to improve adherence to immunosuppressants.

What influences persistence with medicines? A multinational discrete choice experiment of 2549 patients

AIM

The aim was to examine patients' stated preferences to persist with medicines and to explore the influence of psychosocial and sociocognitive factors.

METHODS

Community-dwelling, hypertensive patients recruited from nine European countries were invited to complete a discrete choice experiment (DCE) with attributes for treatment benefits, mild yet common adverse drug reactions (ADRs), rare but potentially life-threatening ADRs and dosing frequency. Patients responded to the binary choice of which medicine would they be most likely to continue taking. Data were analyzed using a random effects logit model.

RESULTS

Two thousand five hundred and forty-nine patients from Austria (n = 321), Belgium (n = 175), England (n = 315), Germany (n = 266), Greece (n = 288), Hungary (n = 322), the Netherlands (n = 231), Poland (n = 312) and Wales (n = 319) completed the DCE. All attributes significantly influenced patients' stated preference to persist with medications (P < 0.05). Patients were willing to accept decreases in treatment benefits of 50.6 percentage points (95% CI 46.1, 57.9) for a very rare (as opposed to rare) risk of severe ADR, 28.3 percentage points (95% CI 25.2, 33.1) for a once daily instead of twice daily dosing and 0.74 percentage points (95% CI 0.67, 0.85) for a 1% point reduction in mild ADRs. Models accounting for psychosocial and sociocognitive characteristics were significantly different from the base case.

CONCLUSION

Patients' intention to persist with treatment was associated with their willingness to trade potential benefits, harms and dosing frequency. Psychosocial and sociocognitive factors influenced the extent of trading. The utility model may have value in assessing patients' likelihood of persisting with medicines and to tailor treatment to maximize persistence.

Effect of tolerance versus chronic immunosuppression protocols on the quality of life of kidney transplant recipients

BACKGROUND

Kidney transplant patients on tolerance protocols avoid the morbidity associated with the use of conventional chronic immunosuppressive regimens. However, the impact of tolerance versus conventional regimens on the quality of life (QOL) of kidney transplant patients is unknown.

METHODS

Five patients who achieved long-term immunosuppression-free renal allograft survival after combined kidney and bone marrow transplantation (tolerant group) were compared with thirty-two comparable kidney transplant recipients on conventional immunosuppression (conventional group). QOL was compared with 16 conventional recipients using the Kidney Disease Quality of Life Short Form 36 (KDQOL SF-36) and the Modified Transplant Symptom Occurrence and Symptom Distress Scale (MTSOSD-59R).

RESULTS

Patients in the tolerant group required significantly less treatment after transplant for hypertension and no medications for diabetes (P < 0.01). There was no incidence of diabetes, dyslipidemia, or malignancies in the tolerant group, while these were observed in 12.5%, 40.6%, and 11.8% of the conventional group, respectively. Tolerant patients experienced better overall health (P < 0.01) and scored higher on kidney transplant-targeted scales and healthy survey scales than patients in the conventional group according to the KDQOL SF-36 (P < 0.05). Tolerant patients were less likely to experience depression, dyspnea, excessive appetite/thirst, flatulence, hearing loss, itching, joint pain, lack of energy, muscle cramps, and lack of libido than conventional patients according to the MTSOSD-59R (P < 0.05).

CONCLUSION

Kidney transplant recipients who achieved tolerance experience significantly fewer incidences of complications, improved QOL, and fewer comorbid symptoms compared with patients on conventional immunosuppression. These results support the expanded use of tolerance protocols in kidney transplantation.

A systematic review of health-related quality of life and psychological outcomes after lung transplantation

BACKGROUND

Lung transplantation (LTx) aims to reduce physical disability and mental distress, extend survival, and improve health-related quality of life (HRQoL). In this systematic review we aimed to: (1) augment evidence regarding measures to assess HRQoL and psychological outcomes after LTx; and (2) summarize HRQoL and psychological outcomes after LTx.

METHODS

Validated and standardized instruments with well-known psychometric properties used for assessing HRQoL and psychological outcomes after LTx were identified by means of comprehensive literature searches of PsychINFO and Medline/PubMed, up through March 2014, using the following search terms in various combinations: lung transplantation; physical functioning; symptom experience; mental health; anxiety; depression; distress; social functioning; life satisfaction; and health-related quality of life.

RESULTS

The search strategy identified 371 titles and abstracts. Of these, 279 were retrieved for further assessment and 63 articles selected for final review. Thirty-nine studies were found for HRQoL, 15 for physical functioning, 5 for mental health and 4 for social functioning. A total of 50 psychometric instruments were encountered.

CONCLUSIONS

Considerable heterogeneity exists in methodology, operational concepts and applied outcome measures in the existing literature on HRQoL and psychological outcomes after LTx. Nevertheless, the studies generally point to significant improvements in both mental health and HRQoL post-transplant. Further research is warranted utilizing consistent outcome measures, including LTx-specific measures and longitudinal study designs.

Adherence of patients to long-term medication: a cross-sectional study of antihypertensive regimens in Austria

OBJECTIVE

The objective of this study was to evaluate adherence and causes for non-adherence to antihypertensive therapy in Austrian patients. A special focus was placed on social parameters and behavioural theories.

METHODS

Patients were invited via advertisements in community pharmacies in Austria to complete an online survey. Inclusion criteria were an age of 18 years or older, a diagnosis of arterial hypertension and a current prescription of antihypertensive medication. Adherence was measured by the four-item Morisky scale. Non-adherence was defined by at least one point in the Morisky scale. Several demographic, social and behavioural parameters were analysed as potential co-variables associated with adherence.

RESULTS

A total of 323 patients completed the online survey, of which 109 (33.7%) met the criteria for non-adherence. In a multivariable model, self-efficacy and age were associated with adherence, whereas intention and barriers were linked to non-adherence; 56 patients (17.3%) were classified as intentionally non-adherent.

CONCLUSION

This study demonstrates that non-adherence affects an important proportion of patients in the treatment of arterial hypertension. Young age was a particularly important risk factor for non-adherence, and this patient population is, therefore, in need of special attention. Modifiable risk factors were identified that could help improving the treatment of arterial hypertension and potentially other chronic conditions.

Effects of a Support Group Intervention on Physical, Psychological, and Social Adaptation of Liver Transplant Recipients

OBJECTIVES

Liver transplant recipients must adapt to a new life after transplant. We report the effects of a support group on physical and psychosocial adaptation of liver transplant recipients.

MATERIALS AND METHODS

The study used a quasi-experimental design, comparing an intervention group and a control group. Data were collected between January 2011 and May 2012 with 73 liver transplant recipients. A patient identification form, Modified Transplant Symptom Occurrence and Symptom Distress Scale - 58, and SF-36 were used for data collection. The intervention group attended support group meetings, while the control group received a routine follow-up. Data were analyzed with t test and The Repeated Measures ANOVA with 1 between-group factor.

RESULTS

The results indicated that the support group intervention increases physical, psychological, and social adaptation of liver transplant recipients. Specifically, this effect of the support group was accrued after support group intervention and decreased 3 months after intervention.

CONCLUSIONS

A support group intervention can have a positive effect on liver transplant recipients' physical, psychological, and social adaptations.

Prevalence of psychological problems and associated transplant-related variables at different time periods after liver transplantation

After liver transplantation, recipients often experience psychological problems that are influenced by demographic, personal, and transplant-related variables. However, because previous studies have mostly reported on psychological problems and their influencing factors in the first years after transplantation, less is known about their prevalence and influence in the long run. The aims of this study were to examine point-prevalence rates of symptoms of anxiety, depression, and posttraumatic stress (PTS) at different time periods after transplantation and to examine the transplant-related variables associated with these problems. A cross-sectional survey was performed among 373 liver transplant recipients who received transplants between 1979 and 2009 at our center. Five clinically relevant time periods were identified: 0.5 to <2 years, 2 to <5 years, 5 to <10 years, 10 to <15 years, and ≥15 years after transplantation. The response rate was 75% (n=281). Overall, 33.4% of the respondents experienced clinically relevant symptom levels of anxiety (28.7%), depression (16.5%), or PTS (10.0%). Symptoms of anxiety and depression were more prevalent in the first 2 years and in the long term after transplantation. PTS symptoms were more prevalent in the first 5 years after transplantation. However, the prevalence rates did not differ significantly between time periods. Viral hepatitis and the number of side effects of the immunosuppressive (IS) medication were found to be associated with all psychological problems. Alcoholic liver disease was associated with anxiety and depression in the short term after transplantation. In conclusion, a significant subset of transplant recipients experience psychological problems, both shortly after transplantation and in the long run. These problems are often associated with side effects from the IS medication. Therefore, the monitoring of psychological problems, the offering of psychological counseling, and the management of the medication's side effects should be part of the routine care of transplant recipients.

Beneficial effect of belatacept on health-related quality of life and perceived side effects: results from the BENEFIT and BENEFIT-EXT trials

BACKGROUND

Patient-reported outcomes are increasingly incorporated in drug evaluation trials. Whether new immunosuppressive drugs result in an improved health-related quality of life (HRQoL) and a reduced side effect experiences remains unknown. Moreover, the relationship between HRQoL and kidney function has never been investigated in kidney transplant recipients.

METHODS

Using the BENEFIT and BENEFIT-EXT trials, we investigated the following: (a) evolution of HRQoL, assessed by the Medical Outcomes Short Form Health Survey (SF-36) in the first 3 years (baseline, 12, 24, and 36 months) after kidney transplantation; (b) association among kidney function (chronic kidney disease stage), HRQoL, and patient-reported side effects (Modified Transplant Symptom Occurrence and Symptom Distress Scale-59R; BENEFIT trial only); and (c) impact of belatacept and cyclosporine on side effect experience and HRQoL.

RESULTS

In the BENEFIT trial, all subjects reported clinically meaningful improvements compared with baseline and returned to general population scores, both for physical composite score (PCS) and mental composite score Short Form (36) Health Survey at 12 to 36 months after transplantation. In the BENEFIT-EXT trial, this was observed for PCS only. Belatacept-treated patients reported better absolute PCSs compared with cyclosporine-treated patients. The differences were small but statistically significant at all times. Belatacept-treated patients tended to experience less side effects compared with cyclosporine-treated patients, except for dry skin. Worsening kidney function was associated with a significant decrease in HRQoL.

CONCLUSION

Worsening in kidney function was associated with lower HRQoL. Compared with cyclosporine, belatacept was associated with improved HRQoL, suggesting that use of non-nephrotoxic immunosuppressants may affect the patient's side effect experience and improve their HRQoL.

Predictors of self-reported adherence to antihypertensive medicines: a multinational, cross-sectional survey

BACKGROUND

Nonadherence to antihypertensive medicines limits their effectiveness, increases the risk of adverse health outcome, and is associated with significant health care costs. The multiple causes of nonadherence differ both within and between patients and are influenced by patients' care settings.

OBJECTIVES

The objective of this article was to identify determinants of patient nonadherence to antihypertensive medicines, drawing from psychosocial and economic models of behavior.

METHODS

Outpatients with hypertension from Austria, Belgium, England, Germany, Greece, Hungary, The Netherlands, Poland, and Wales were recruited to a cross-sectional online survey. Nonadherence to medicines was assessed using the Morisky Medication Adherence Scale (primary outcome) and the Medication Adherence Rating Scale. Associations with adherence and nonadherence were tested for demographic, clinical, and psychosocial factors.

RESULTS

A total of 2595 patients completed the questionnaire. The percentage of patients classed as nonadherent ranged from 24% in The Netherlands to 70% in Hungary. Low age, low self-efficacy, and respondents' perceptions of their illness and cost-related barriers were associated with nonadherence measured on the Morisky Medication Adherence Scale across several countries. In multilevel, multivariate analysis, low self-efficacy (odds ratio = 0.73; 95% confidence interval 0.70-0.77) and a high number of perceived barriers to taking medicines (odds ratio = 1.70; 95% confidence interval 1.38-2.09) were the main significant determinants of nonadherence. Country differences explained 11% of the variance in nonadherence.

CONCLUSIONS

Among the variables measured, patients' adherence to antihypertensive medicines is influenced primarily by their self-efficacy, illness beliefs, and perceived barriers. These should be targets for interventions for improving adherence, as should an appreciation of differences among the countries in which they are being delivered.

Immunosuppressive Medication Adherence, Therapeutic Adherence, School Performance, Symptom Experience, and Depression Levels in Patients Having Undergone a Liver Transplant During Childhood

OBJECTIVES

This study sought to investigate immunosuppressive medication adherence, therapeutic adherence, school performance, symptom experiences, and depression levels of patients having undergone liver transplant during childhood.

MATERIALS AND METHODS

We performed a retrospective, cross-sectional, case-controlled study to compare the depression levels of subjects with those of their healthy peers. Data were collected between June 23, 2014, and July 10, 2014, from 0- to 18-year-old patients having undergone a liver transplant between 1996 and 2014 (n = 27; the participant's mean age, 17.59 y [SD = 4.29, min-max = 8-28 y]). The mean score for the immunosuppressant therapy adherence was 11.18. To collect the data, the Demographic and Clinical Characteristics Form, Immunosuppressant Therapy Adherence Scale, Therapeutic Regimen Adherence Assessment Questionnaire, School Performance Assessment Questionnaire, Modified Transplant Symptom Occurrence and Symptom Distress Scale-58, and Beck Depression Inventory were used. To analyze the data, descriptive statistics (frequencies, mean, and standard deviation), Mann-Whitney U test, and ridit scoring were used.

RESULTS

While the rate of adherence with clinical appointments was 55.5%, it was 33.3% with the diet (prescribed regimen) and 44.4% with exercise. While 33.3% of the participants repeated a grade or were held back, 44.4% of them missed more than 20 school days. Of the symptoms, the recipients mostly experienced anxiety, restlessness, nervousness, fatigue, and difficulty in concentrating. The patients' mean depression score was 7.77 when they were compared to their healthy peers, the difference was not statistically significant (P > .05).

CONCLUSIONS

In our study, the recipients' adherence with immunosuppressive therapy and clinical appointment was high. This study will provide data for the literature about pediatric liver transplant recipients' adherence with diet and exercise, and physiological and psychological symptoms such as fatigue and anxiety.

Depicting Changes in Multiple Symptoms Over Time

Ridit analysis, an acronym for Relative to an Identified Distribution, is a method for assessing change in ordinal data and can be used to show how individual symptoms change or remain the same over time. The purposes of this article are to (a) describe how to use ridit analysis to assess change in a symptom measure using data from a longitudinal study, (b) give a step-by-step example of ridit analysis, (c) show the clinical relevance of applying ridit analysis, and (d) display results in an innovative graphic. Mean ridit effect sizes were calculated for the frequency and distress of 64 symptoms in lung transplant patients before and after transplant. Results were displayed in a bubble graph. Ridit analysis allowed us to maintain the specificity of individual symptoms and to show how each symptom changed or remained the same over time. The bubble graph provides an efficient way for clinicians to identify changes in symptom frequency and distress over time.

The development and validation of the treatment of autoimmune bullous disease quality of life questionnaire, a tool to measure the quality of life impacts of treatments used in patients with autoimmune blistering disease

BACKGROUND

Treatments for autoimmune blistering diseases have significant risk of medical complications and quality of life impacts during treatment, and it is difficult to differentiate these impacts from disease burden or the effects of treatment.

OBJECTIVES

To develop a quality of life instrument specific to the effects of treatments used in patients with autoimmune bullous disease (AIBD).

METHODS

A comprehensive item generation process was used to build a 45-item pilot Autoimmune Bullous Disease Quality of Life (ABQOL) questionnaire, distributed to 70 patients with AIBD. Experts in bullous disease refined the pilot ABQOL, selecting only those questions pertaining to the treatment effects. This pilot Treatment of Autoimmune Bullous Disease Quality of Life (TABQOL) questionnaire was administered to 70 patients, before factor analysis was performed to yield the final questionnaire of 17 questions. Validity and reliability were evaluated across a range of indices.

RESULTS

Face and content validity were established through a comprehensive patient interview process, expert review and summaries of treatments used. The questionnaire was found to have appropriate correlation with the Dermatology Life Quality Index (r = 0.64) and the level of treatments used (P < 0.01), and was found to be responsive to overall variations in treatment burden. The TABQOL was also found to be a reliable instrument as evaluated by internal consistency (Cronbach α = 0.892) and test-retest reliability (r = 0.99).

CONCLUSIONS

We have shown that the TABQOL questionnaire is a valid and reliable instrument that may to be used to measure treatment burden in AIBD and serve as an end point in clinical trials.

Validity and reliability of a novel immunosuppressive adverse effects scoring system in renal transplant recipients

Background

After renal transplantation, many patients experience adverse effects from maintenance immunosuppressive drugs. When these adverse effects occur, patient adherence with immunosuppression may be reduced and impact allograft survival. If these adverse effects could be prospectively monitored in an objective manner and possibly prevented, adherence to immunosuppressive regimens could be optimized and allograft survival improved. Prospective, standardized clinical approaches to assess immunosuppressive adverse effects by health care providers are limited. Therefore, we developed and evaluated the application, reliability and validity of a novel adverse effects scoring system in renal transplant recipients receiving calcineurin inhibitor (cyclosporine or tacrolimus) and mycophenolic acid based immunosuppressive therapy.

Methods

The scoring system included 18 non-renal adverse effects organized into gastrointestinal, central nervous system and aesthetic domains developed by a multidisciplinary physician group. Nephrologists employed this standardized adverse effect evaluation in stable renal transplant patients using physical exam, review of systems, recent laboratory results, and medication adherence assessment during a clinic visit. Stable renal transplant recipients in two clinical studies were evaluated and received immunosuppressive regimens comprised of either cyclosporine or tacrolimus with mycophenolic acid. Face, content, and construct validity were assessed to document these adverse effect evaluations. Inter-rater reliability was determined using the Kappa statistic and intra-class correlation.

Results

A total of 58 renal transplant recipients were assessed using the adverse effects scoring system confirming face validity. Nephrologists (subject matter experts) rated the 18 adverse effects as: 3.1 ± 0.75 out of 4 (maximum) regarding clinical importance to verify content validity. The adverse effects scoring system distinguished 1.75-fold increased gastrointestinal adverse effects (p = 0.008) in renal transplant recipients receiving tacrolimus and mycophenolic acid compared to the cyclosporine regimen. This finding demonstrated construct validity. Intra-class correlation was 0.81 (95% confidence interval: 0.65-0.90) and Kappa statistic of 0.68 ± 0.25 for all 18 adverse effects and verified substantial inter-rater reliability.

Conclusions

This immunosuppressive adverse effects scoring system in stable renal transplant recipients was evaluated and substantiated face, content and construct validity with inter-rater reliability. The scoring system may facilitate prospective, standardized clinical monitoring of immunosuppressive adverse drug effects in stable renal transplant recipients and improve medication adherence.