1
|
Chaturvedi S, Ullah S, Hughes Wagadagam JT. Kidney transplantation access and outcomes for Aboriginal and Torres Strait Islander children and young adults, 1963-2020: an ANZDATA registry study. Med J Aust 2024; 221:47-54. [PMID: 38946656 DOI: 10.5694/mja2.52355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 05/08/2024] [Indexed: 07/02/2024]
Abstract
OBJECTIVES To assess differences between Aboriginal and Torres Strait Islander and non-Indigenous Australian children and young adults in access to and outcomes of kidney transplantation. STUDY DESIGN A cohort study based on prospectively collected data; analysis of Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) data. SETTING, PARTICIPANTS Children and young adults aged 0-24 years who commenced kidney replacement therapy in Australia during 1963-2020. MAIN OUTCOME MEASURES Proportions of children and young adults who received kidney transplants within five years of commencing dialysis; 5- and 10-year death-censored graft survival; and 5- and 10-year survival of children and young adults who received kidney transplants or who remained on dialysis. RESULTS During 1963-2020, 3736 children and young adults received kidney replacement therapy in Australia: 213 (5.8%) Aboriginal and Torres Strait Islander and 3523 (94.2%) non-Indigenous children and young adults. During follow-up (median, eight years; interquartile range [IQR], 2.6-15 years), 2762 children and young adults received kidney transplants: 93 Aboriginal and Torres Strait Islander (43.7% of those receiving kidney replacement therapy) and 2669 non-Indigenous children and young adults (75.8%). Smaller proportions of Aboriginal and Torres Strait Islander than of non-Indigenous children and young adults received transplants within five years of commencing dialysis (99, 46% v 2924, 83.0%), received living donor transplants (19, 20% v 1170, 43.9%), or underwent pre-emptive transplantation (one, 1.1% v 363, 13.6%). Five-year graft survival for Aboriginal and Torres Strait Islander recipients was similar to non-Indigenous recipients (61% v 75%; adjusted hazard ratio [aHR], 1.43; 95% confidence interval [CI], 0.02-2.05), but 10-year graft survival was lower (35% v 61%; aHR, 1.69; 95% CI, 1.25-2.28). Five- and 10-year survival after kidney transplantation was similar for Aboriginal and Torres Strait Islander and non-Indigenous people. Among those who remained on dialysis, 10-year survival was poorer for Aboriginal and Torres Strait Islander than non-Indigenous children and young adults (aHR, 1.50; 95% CI, 1.08-2.10). CONCLUSIONS Five-year graft and recipient survival were excellent for Aboriginal and Torres Strait Islander children and young adults who received kidney transplants; however, a lower proportion received transplants within five years of dialysis initiation, than non-Indigenous children and young adults. Improving transplant access within five years of dialysis commencement should be a priority.
Collapse
Affiliation(s)
- Swasti Chaturvedi
- Sydney Children's Hospital, Sydney, NSW
- College of Medicine and Public Health, Flinders University, Adelaide, SA
| | - Shahid Ullah
- College of Medicine and Public Health, Flinders University, Adelaide, SA
| | - Jaquelyne T Hughes Wagadagam
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Darwin, NT
- Royal Darwin Hospital, Darwin, NT
| |
Collapse
|
2
|
Chambord J, Chauveau B, Djabarouti S, Vignaud J, Taton B, Moreau K, Visentin J, Merville P, Xuereb F, Couzi L. Measurement of the Immunosuppressant Possession Ratio by Transplant Clinical Pharmacists Captures a Non-Adherence Associated With Antibody-Mediated Rejection. Transpl Int 2023; 36:11962. [PMID: 38089004 PMCID: PMC10713790 DOI: 10.3389/ti.2023.11962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 11/16/2023] [Indexed: 12/18/2023]
Abstract
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.
Collapse
Affiliation(s)
- Jérémy Chambord
- Service de Pharmacie, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Bertrand Chauveau
- Service d’Anatomopathologie, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- CNRS-UMR 5164 ImmunoConcEpT, Université de Bordeaux, Bordeaux, France
| | - Sarah Djabarouti
- Service de Pharmacie, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- INSERM U1312 BRIEC, Université de Bordeaux, Bordeaux, France
| | - Jean Vignaud
- Service de Pharmacie, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Benjamin Taton
- Service de Néphrologie, Transplantation, Dialyse, Aphérèse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Karine Moreau
- Service de Néphrologie, Transplantation, Dialyse, Aphérèse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Jonathan Visentin
- CNRS-UMR 5164 ImmunoConcEpT, Université de Bordeaux, Bordeaux, France
- Service d’Immunologie et Immunogénétique, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Pierre Merville
- CNRS-UMR 5164 ImmunoConcEpT, Université de Bordeaux, Bordeaux, France
- Service de Néphrologie, Transplantation, Dialyse, Aphérèse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Fabien Xuereb
- Service de Pharmacie, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- INSERM U1034, Université de Bordeaux, Bordeaux, France
| | - Lionel Couzi
- CNRS-UMR 5164 ImmunoConcEpT, Université de Bordeaux, Bordeaux, France
- Service de Néphrologie, Transplantation, Dialyse, Aphérèse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| |
Collapse
|
3
|
Marston MT, Berben L, Dobbels F, Russell CL, de Geest S. Prevalence and Patient-Level Correlates of Intentional Non-Adherence to Immunosuppressive Medication After Heart-Transplantation-Findings From the International BRIGHT Study. Transpl Int 2023; 36:11308. [PMID: 37492859 PMCID: PMC10363605 DOI: 10.3389/ti.2023.11308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 06/15/2023] [Indexed: 07/27/2023]
Abstract
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.
Collapse
Affiliation(s)
- Mark T. Marston
- Nursing Science, Department of Public Health, University of Basel, Basel, Switzerland
- Pediatric Intensive Care Unit, University Children’s Hospital Basel, Basel, Switzerland
| | - Lut Berben
- Nursing Science, Department of Public Health, University of Basel, Basel, Switzerland
- Pediatric Intensive Care Unit, University Children’s Hospital Basel, Basel, Switzerland
| | - Fabienne Dobbels
- Academic Centre for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Cynthia L. Russell
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, MO, United States
| | - Sabina de Geest
- Nursing Science, Department of Public Health, University of Basel, Basel, Switzerland
- Academic Centre for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| |
Collapse
|
4
|
de Zwaan M, Erim Y, Kröncke S, Vitinius F, Buchholz A, Nöhre M. Psychosocial Diagnosis and Treatment Before and After Organ Transplantation. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:413-416. [PMID: 37101343 PMCID: PMC10437037 DOI: 10.3238/arztebl.m2023.0087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 01/06/2023] [Accepted: 03/29/2023] [Indexed: 04/28/2023]
Abstract
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.
Collapse
Affiliation(s)
- Martina de Zwaan
- Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School, Hannover
| | - Yesim Erim
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital of Erlangen, Friedrich-Alexander University Erlangen-Nürnberg
| | - Sylvia Kröncke
- Department of Medical Psychology at the Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Frank Vitinius
- Department of Psychosomatics and Psychotherapy, University Hospital Cologne
| | - Angela Buchholz
- Department of Medical Psychology at the Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Mariel Nöhre
- Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School, Hannover
| |
Collapse
|
5
|
Massart A, Danger R, Olsen C, Emond MJ, Viklicky O, Jacquemin V, Soblet J, Duerinckx S, Croes D, Perazzolo C, Hruba P, Daneels D, Caljon B, Sever MS, Pascual J, Miglinas M, Pirson I, Ghisdal L, Smits G, Giral M, Abramowicz D, Abramowicz M, Brouard S. An exome-wide study of renal operational tolerance. Front Med (Lausanne) 2023; 9:976248. [PMID: 37265662 PMCID: PMC10230038 DOI: 10.3389/fmed.2022.976248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 10/31/2022] [Indexed: 06/03/2023] Open
Abstract
Background Renal operational tolerance is a rare and beneficial state of prolonged renal allograft function in the absence of immunosuppression. The underlying mechanisms are unknown. We hypothesized that tolerance might be driven by inherited protein coding genetic variants with large effect, at least in some patients. Methods We set up a European survey of over 218,000 renal transplant recipients and collected DNAs from 40 transplant recipients who maintained good allograft function without immunosuppression for at least 1 year. We performed an exome-wide association study comparing the distribution of moderate to high impact variants in 36 tolerant patients, selected for genetic homogeneity using principal component analysis, and 192 controls, using an optimal sequence-kernel association test adjusted for small samples. Results We identified rare variants of HOMER2 (3/36, FDR 0.0387), IQCH (5/36, FDR 0.0362), and LCN2 (3/36, FDR 0.102) in 10 tolerant patients vs. 0 controls. One patient carried a variant in both HOMER2 and LCN2. Furthermore, the three genes showed an identical variant in two patients each. The three genes are expressed at the primary cilium, a key structure in immune responses. Conclusion Rare protein coding variants are associated with operational tolerance in a sizable portion of patients. Our findings have important implications for a better understanding of immune tolerance in transplantation and other fields of medicine.ClinicalTrials.gov, identifier: NCT05124444.
Collapse
Affiliation(s)
- Annick Massart
- Human Genetics Unit, Institut de Recherche Interdisciplinaire en Biologie Humaine et Moléculaire (IRIBHM), Université Libre de Bruxelles (ULB), Brussels, Belgium
- Interuniversity Institute of Bioinformatics in Brussels (IB2), Université Libre de Bruxelles - Vrije Universiteit Brussel (ULB-VUB), Brussels, Belgium
- Department of Nephrology, Antwerp University Hospital and Laboratory of Experimental Medicine, University of Antwerp, Antwerp, Belgium
| | - Richard Danger
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology, CR2TI, UMR 1064, ITUN, Nantes, France
| | - Catharina Olsen
- Interuniversity Institute of Bioinformatics in Brussels (IB2), Université Libre de Bruxelles - Vrije Universiteit Brussel (ULB-VUB), Brussels, Belgium
- Brussels Interuniversity Genomics High Throughput Core (BRIGHTcore), VUB-ULB, Brussels, Belgium
- Center for Medical Genetics, Reproduction and Genetics, Reproduction Genetics and Regenerative Medicine, Vrije Universiteit Brussel, UZ Brussel, Brussels, Belgium
| | - Mary J. Emond
- Department of Biostatistics, University of Washington, Seattle, WA, United States
| | - Ondrej Viklicky
- Transplant Laboratory, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Valérie Jacquemin
- Human Genetics Unit, Institut de Recherche Interdisciplinaire en Biologie Humaine et Moléculaire (IRIBHM), Université Libre de Bruxelles (ULB), Brussels, Belgium
- Interuniversity Institute of Bioinformatics in Brussels (IB2), Université Libre de Bruxelles - Vrije Universiteit Brussel (ULB-VUB), Brussels, Belgium
| | - Julie Soblet
- Interuniversity Institute of Bioinformatics in Brussels (IB2), Université Libre de Bruxelles - Vrije Universiteit Brussel (ULB-VUB), Brussels, Belgium
- Department of Genetics, Hôpital Erasme, ULB Center of Human Genetics, Université Libre de Bruxelles, Brussels, Belgium
- Department of Genetics, Hôpital Universitaire des Enfants Reine Fabiola, ULB Center of Human Genetics, Université Libre de Bruxelles, Brussels, Belgium
| | - Sarah Duerinckx
- Human Genetics Unit, Institut de Recherche Interdisciplinaire en Biologie Humaine et Moléculaire (IRIBHM), Université Libre de Bruxelles (ULB), Brussels, Belgium
- Interuniversity Institute of Bioinformatics in Brussels (IB2), Université Libre de Bruxelles - Vrije Universiteit Brussel (ULB-VUB), Brussels, Belgium
| | - Didier Croes
- Interuniversity Institute of Bioinformatics in Brussels (IB2), Université Libre de Bruxelles - Vrije Universiteit Brussel (ULB-VUB), Brussels, Belgium
- Brussels Interuniversity Genomics High Throughput Core (BRIGHTcore), VUB-ULB, Brussels, Belgium
- Center for Medical Genetics, Reproduction and Genetics, Reproduction Genetics and Regenerative Medicine, Vrije Universiteit Brussel, UZ Brussel, Brussels, Belgium
- Center for Human Genetics, Clinique Universitaires Saint Luc, Brussels, Belgium
| | - Camille Perazzolo
- Human Genetics Unit, Institut de Recherche Interdisciplinaire en Biologie Humaine et Moléculaire (IRIBHM), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Petra Hruba
- Transplant Laboratory, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Dorien Daneels
- Interuniversity Institute of Bioinformatics in Brussels (IB2), Université Libre de Bruxelles - Vrije Universiteit Brussel (ULB-VUB), Brussels, Belgium
- Brussels Interuniversity Genomics High Throughput Core (BRIGHTcore), VUB-ULB, Brussels, Belgium
- Center for Medical Genetics, Reproduction and Genetics, Reproduction Genetics and Regenerative Medicine, Vrije Universiteit Brussel, UZ Brussel, Brussels, Belgium
| | - Ben Caljon
- Brussels Interuniversity Genomics High Throughput Core (BRIGHTcore), VUB-ULB, Brussels, Belgium
- Center for Medical Genetics, Reproduction and Genetics, Reproduction Genetics and Regenerative Medicine, Vrije Universiteit Brussel, UZ Brussel, Brussels, Belgium
| | - Mehmet Sukru Sever
- Istanbul Tip Fakültesi, Istanbul School of Medicine, Internal Medicine, Nephrology, Istanbul, Türkiye
| | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Institute Mar for Medical Research, Barcelona, Spain
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Marius Miglinas
- Nephrology Center, Santaros Klinikos, Medical Faculty, Vilnius University, Vilnius, Lithuania
| | | | - Isabelle Pirson
- Human Genetics Unit, Institut de Recherche Interdisciplinaire en Biologie Humaine et Moléculaire (IRIBHM), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Lidia Ghisdal
- Department of Nephrology, Hospital Centre EpiCURA, Baudour, Belgium
| | - Guillaume Smits
- Interuniversity Institute of Bioinformatics in Brussels (IB2), Université Libre de Bruxelles - Vrije Universiteit Brussel (ULB-VUB), Brussels, Belgium
- Department of Genetics, Hôpital Erasme, ULB Center of Human Genetics, Université Libre de Bruxelles, Brussels, Belgium
| | - Magali Giral
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology, CR2TI, UMR 1064, ITUN, Nantes, France
- CHU Nantes, Centre d'Investigation Clinique en Biothérapie, Centre de Ressources Biologiques (CRB), Nantes, France
- LabEx IGO “Immunotherapy, Graft, Oncology”, Nantes, France
| | - Daniel Abramowicz
- Department of Nephrology, Antwerp University Hospital and Laboratory of Experimental Medicine, University of Antwerp, Antwerp, Belgium
| | - Marc Abramowicz
- Human Genetics Unit, Institut de Recherche Interdisciplinaire en Biologie Humaine et Moléculaire (IRIBHM), Université Libre de Bruxelles (ULB), Brussels, Belgium
- Interuniversity Institute of Bioinformatics in Brussels (IB2), Université Libre de Bruxelles - Vrije Universiteit Brussel (ULB-VUB), Brussels, Belgium
- Department of Genetic Medicine and Development, Faculty of Medicine, Université de Geneve, Geneva, Switzerland
| | - Sophie Brouard
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology, CR2TI, UMR 1064, ITUN, Nantes, France
- CHU Nantes, Centre d'Investigation Clinique en Biothérapie, Centre de Ressources Biologiques (CRB), Nantes, France
- LabEx IGO “Immunotherapy, Graft, Oncology”, Nantes, France
| |
Collapse
|
6
|
Reliability and Validity of the Japanese Version of the Basel Assessment of Adherence to Immunosuppressive Medications Scale in Kidney Transplant Recipients. Transplant Direct 2023; 9:e1457. [PMID: 36860659 PMCID: PMC9970284 DOI: 10.1097/txd.0000000000001457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/22/2022] [Accepted: 01/07/2023] [Indexed: 03/03/2023] Open
Abstract
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.
Collapse
|
7
|
Kuo FC, Wu TH, Loong CC, Lin NC, Ou SM, Chen CY. The strategy of diminishing age gap effect on different donor-recipient combinations in living donor kidney transplantation. J Chin Med Assoc 2023; 86:65-71. [PMID: 36279143 DOI: 10.1097/jcma.0000000000000822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The disparity between kidney donation and the number of uremic patients on the waiting list has increased the demand for older live-donor kidneys (OLK). However, the donor-recipient age gap may have an impact on the recipient's outcome. METHODS Patients who underwent living donor kidney transplantation at our institute between 2005 and 2019 were enrolled and categorized into four donor-recipient groups according to age (≥50 years and <50 years). The Estimated Post-Transplant Survival (EPTS) score was used to quantify the recipient's condition. Adjusted models analyzed recipient outcomes and related risks among the four groups. RESULTS Of the 154 pairs of live donors and recipients, OLK did not influence overall or death-censored graft survival. The four donor-recipient combinations had similar recipient outcomes, except it slightly worsened in the "old donor to young recipient" group. The EPTS score (adjusted HR, 1.02; 95% CI, 1.01-1.04; p = 0.014) and rejection (adjusted HR, 4.26; 95% CI, 1.36-13.37; p = 0.013) were significant risk factors for overall and death-censored graft survival, respectively. Recipients with pretransplant diabetes or prior solid organ transplantation could have amplified risk effects. The main causes of graft loss were death in older recipients and chronic rejection in younger recipients. CONCLUSION OLK is safe for young recipients. Nevertheless, adequate immunosuppression should be maintained to prevent rejection and subsequent graft loss, especially for those receiving second kidney transplantation. In contrast, older recipients should avoid overt immunosuppression and control their comorbidities, such as diabetes-related complications to improve their long-term outcomes.
Collapse
Affiliation(s)
- Fang-Cheng Kuo
- Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Tsai-Hun Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Nephrology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Che-Chuan Loong
- Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Niang-Cheng Lin
- Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Shuo-Ming Ou
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Nephrology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Cheng-Yen Chen
- Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| |
Collapse
|
8
|
Shafiekhani M, Shahabinezhad F, Tavakoli Z, Tarakmeh T, Haem E, Sari N, Nasirabadi S, Dehghani M. Quality of life associated with immunosuppressant treatment adherence in liver transplant recipients: A cross-sectional study. Front Pharmacol 2023; 14:1051350. [PMID: 36909168 PMCID: PMC9998979 DOI: 10.3389/fphar.2023.1051350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 02/13/2023] [Indexed: 02/26/2023] Open
Abstract
Purpose: Transplanted organ survival after solid organ transplantation highly correlates with the adherence levels of the patients to their immunosuppressive drugs. On the other hand, one of the main goals of liver transplantation is to increase the overall quality of life (QOL) for the patient. This study is aimed to analyze the relationship between adherence and QOL in adult liver transplant recipients of the biggest liver transplant center in Asia. Methods: All of the included patients were older than 18 years and at least 6 months had passed from their liver transplantation. The adherence level was measured with BAASIS method and the QOL was assessed by SF-36 questionnaire in real-time interviews. The relationship between adherence and different aspects of QOL in addition to qualitative and quantitative influential factors on these two outcomes was calculated with statistical analysis. Results: Among the 122 included patients, 41% of the were categorized in the non-adherent group. The most important reasons for non-adherence in these patients included forgetfulness (62%), lack of medication (12%), financial problems for drug supply (9%), and side effects (2%). According to the results of the multivariate linear regression model, rejection was the only influential factor in the occurrence of non-adherence among patients (OR = 8.226 CI (1.404-48.196)). The overall mean QOL score of patients was reported 51.09 ± 21.86. The lowest is given to social functioning, while mental health has achieved the highest score. The mean QOL scores in different dimensions in patients with adherence were higher than non-adherents, which was only significant in mental health (p-value = 0.01). Additionally, in total scores related to Physical Composite Score (PSC) and Mental Composite Score (MCS), the mean MSC scores in adherent patients were significantly higher than non-adherent patients (p-value: 0.02). Although adherent patients have an overall greater QOL, the only meaningful effect on QOL total score was from income level. Conclusion: The overall QoL score has been in all parameters higher in the adherent group compared with non-adherent patients. The difference in QoL was most meaningfully significant in mental composite score among other parameters of QoL.
Collapse
Affiliation(s)
- Mojtaba Shafiekhani
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran.,Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Farbod Shahabinezhad
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Tavakoli
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Tahereh Tarakmeh
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Elham Haem
- Department of Biostatistics, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Negar Sari
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shohreh Nasirabadi
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Masoud Dehghani
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| |
Collapse
|
9
|
Taha K, Sharma A, Kroeker K, Ross C, Carleton B, Wishart D, Medeiros M, Blydt-Hansen TD. Noninvasive testing for mycophenolate exposure in children with renal transplant using urinary metabolomics. Pediatr Transplant 2022; 27:e14460. [PMID: 36582125 DOI: 10.1111/petr.14460] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 09/11/2022] [Accepted: 11/18/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Despite the common use of mycophenolate in pediatric renal transplantation, lack of effective therapeuic drug monitoring increases uncertainty over optimal drug exposure and risk for adverse reactions. This study aims to develop a novel urine test to estimate MPA exposure based using metabolomics. METHODS Urine samples obtained on the same day of MPA pharmacokinetic testing from two prospective cohorts of pediatric kidney transplant recipients were assayed for 133 unique metabolites by mass spectrometry. Partial least squares (PLS) discriminate analysis was used to develop a top 10 urinary metabolite classifier that estimates MPA exposure. An independent cohort was used to test pharmacodynamic validity for allograft inflammation (urinary CXCL10 levels) and eGFR ratio (12mo/1mo eGFR) at 1 year. RESULTS Fifty-two urine samples from separate children (36.5% female, 12.0 ± 5.3 years at transplant) were evaluated at 1.6 ± 2.5 years post-transplant. Using all detected metabolites (n = 90), the classifier exhibited strong association with MPA AUC by principal component regression (r = 0.56, p < .001) and PLS (r = 0.75, p < .001). A practical classifier (top 10 metabolites; r = 0.64, p < .001) retained similar accuracy after cross-validation (LOOCV; r = 0.52, p < .001). When applied to an independent cohort (n = 97 patients, 1053 samples), estimated mean MPA exposure over Year 1 was inversely associated with mean urinary CXCL10:Cr (r = -0.28, 95% CI -0.45, -0.08) and exhibited a trend for association with eGFR ratio (r = 0.35, p = .07), over the same time period. CONCLUSIONS This urinary metabolite classifier can estimate MPA exposure and correlates with allograft inflammation. Future studies with larger samples are required to validate and evaluate its clinical application.
Collapse
Affiliation(s)
- Khalid Taha
- Department of Pediatrics, University of British Columbia, BC Children's Hospital Vancouver, Vancouver, British Columbia, Canada
| | - Atul Sharma
- Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital at Health Sciences Center, Winnipeg, Manitoba, Canada
| | - Kristine Kroeker
- Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Colin Ross
- Faculty of Pharmaceutical Sciences, University of British Columbia, BC Children's Hospital Vancouver, Vancouver, British Columbia, Canada
| | - Bruce Carleton
- Department of Pediatrics, University of British Columbia, BC Children's Hospital Vancouver, Vancouver, British Columbia, Canada
| | - David Wishart
- Departments of Computing Science and Biological Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Mara Medeiros
- Departamento de Farmacología, Facultad de Medicina, Universidad Nacional Autónoma de México, Ciudad de México, Mexico
| | - Tom D Blydt-Hansen
- Department of Pediatrics, University of British Columbia, BC Children's Hospital Vancouver, Vancouver, British Columbia, Canada
| |
Collapse
|
10
|
Whittington M, Goggin K, Noel-MacDonnell J, Hathaway D, Remy L, Aholt D, Clark D, Miller C, Ashbaugh C, Wakefield M, Ellis RB, Russell C. Cost-Effectiveness Analysis: Personal Systems Approach in Improving Medication Adherence in Adult Kidney Transplant Patients. J Healthc Qual 2022; 44:240-252. [PMID: 35759613 PMCID: PMC9245085 DOI: 10.1097/jhq.0000000000000327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
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.
Collapse
|
11
|
Deng Y, Zhang Z, Hong Y, Feng L, Su Y, Xu D. Schisandrin A alleviates mycophenolic acid-induced intestinal toxicity by regulating cell apoptosis and oxidative damage. Toxicol Mech Methods 2022; 32:580-587. [PMID: 35321622 DOI: 10.1080/15376516.2022.2057263] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The gastrointestinal side effects of mycophenolic acid affect its efficacy in kidney transplant patients, which may be due to its toxicity to the intestinal epithelial mechanical barrier, including intestinal epithelial cell apoptosis and destruction of tight junctions. The toxicity mechanism of mycophenolic acid is related to oxidative stress-mediated the activation of mitogen-activated protein kinases (MAPK). Schisandrin A (Sch A), one of the main active components of the Schisandra chinensis, can protects intestinal epithelial cells from deoxynivalenol-induced cytotoxicity and oxidative damage by antioxidant effects. The aim of this study was to investigate the protective effect and potential mechanism of Sch A on mycophenolic acid-induced damage in intestinal epithelial cell. The results showed that Sch A significantly reversed the mycophenolic acid-induced cell viability reduction, restored the expression of tight junction protein ZO-1, occludin and reduced cell apoptosis. In addition, Sch A inhibited mycophenolic acid-mediated MAPK activation and reactive oxygen species (ROS) increase. Collectively, our study showed that Sch A protected intestinal epithelial cells from mycophenolic acid intestinal toxicity, at least in part, by reducing oxidative stress and inhibiting MAPK signaling pathway.
Collapse
Affiliation(s)
- Yiyun Deng
- School of Pharmacy, Anhui Medical University, Hefei, China
| | - Zhe Zhang
- School of Pharmacy, Anhui Medical University, Hefei, China
| | - Yuanyuan Hong
- School of Pharmacy, Anhui Medical University, Hefei, China
| | - Lijuan Feng
- The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Yong Su
- The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Dujuan Xu
- School of Pharmacy, Anhui Medical University, Hefei, China.,The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| |
Collapse
|
12
|
Graft Failure Due to Nonadherence among 150 Prospectively-Followed Kidney Transplant Recipients at 18 Years Post-transplant: Our Results and Review of the Literature. J Clin Med 2022; 11:jcm11051334. [PMID: 35268424 PMCID: PMC8911343 DOI: 10.3390/jcm11051334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 01/15/2023] Open
Abstract
Background: We previously reported that graft failure due to nonadherence (GFNA) was a major cause of graft loss in kidney transplantation. Here, among 150 prospectively-followed kidney transplant recipients at 18 years post-transplant, we provide: updated (longer-term) estimates of cause-specific graft loss probabilities, risk factors for developing GFNA, and detailed characterizations of patients’ overt nonadherent (NA) behavior, including timing, extent, and clinical consequences. Methods: Determination of the patient becoming NA in taking his/her immunosuppressive medications, and the underlying cause of graft loss, were determined prospectively by the attending physicians. For never-functioning-graft, GFNA, GF due to causes other than NA (Other GF), and death with a functioning graft (DWFG), cumulative incidence functions were used to estimate the cumulative probabilities of cause-specific graft loss. Cox stepwise regression was used to determine significant multivariable predictors for the hazard rate of developing GFNA. Results: GFNA was a major cause of graft loss (22/150 patients), particularly among African-American and Hispanic recipients <50 years of age-at-transplant (20/56 experienced GFNA), with estimated percentages of such patients ever developing GFNA ranging between 36.9 and 41.5%. These patients were also at a higher risk of developing Other GF. For the remaining patients (2/94 experienced GFNA), estimated percentages of ever-developing GFNA were much lower (range: 0.0−6.7%). The major cause of graft loss among recipients ≥50 years of age was DWFG; GFNA rarely occurred among older recipients. In 21/22 GFNA patients, NA behavior lasted continuously from the time of developing NA until GFNA. In total, 28/150 patients became NA, and 67.9% (19/28) occurred beyond 36 months post-transplant. A total of 25 of 28 NA patients (89.3%) developed biopsy-proven acute rejection and/or chronic rejection that was directly attributed to the NA behavior. Lastly, 25/28 admitted to NA behavior, with financial and psychological components documented in 71.4% (20/28) and 96.4% (27/28) of NA cases, respectively. Conclusions: These results highlight the importance of performing serial monitoring of patients for overt NA behavior throughout their post-transplant follow-up. Financial and psychological components to NA behavior need to be simultaneously addressed with the goal of achieving complete avoidance/elimination of NA behavior among higher risk patients.
Collapse
|
13
|
Dabirzadeh A, Dahhou M, Zhang X, Sapir-Pichhadze R, Cardinal H, White M, Johnston O, Blydt-Hansen TD, Tibbles LA, Hamiwka L, Urschel S, Birk P, Bissonnette J, Matsuda-Abedini M, Harrison J, Schiff J, Phan V, De Geest S, Allen U, Mital S, Foster BJ. Care processes and structures associated with higher medication adherence in adolescent and young adult transplant recipients. Pediatr Transplant 2021; 25:e14106. [PMID: 34339090 DOI: 10.1111/petr.14106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 07/19/2021] [Accepted: 07/24/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND We aimed to identify care processes and structures that were independently associated with higher medication adherence among young transplant recipients. METHODS We conducted a prospective, observational cohort study of 270 prevalent kidney, liver, and heart transplant recipients 14-25 years old. Patients were ≥3 months post-transplant, ≥2 months post-discharge, and followed in one of 14 pediatric or 14 adult transplant programs in Canada. Patients were enrolled between June 2015 and March 2018 and followed for 6 months. Adherence was assessed at baseline, 3, and 6 months using the BAASIS© self-report tool. Patients were classified as adherent if no doses were missed in the prior 4 weeks. Transplant program directors and nurses completed questionnaires regarding care organization and processes. RESULTS Of the 270 participants, 99 were followed in pediatric programs and 171 in adult programs. Median age was 20.3 years, and median time since transplant was 5 years. At baseline, 71.5% were adherent. Multivariable mixed effects logistic regression models with program as a random effect identified two program-level factors as independently associated with better adherence: minimum number of prescribed blood draws per year for those >3 years post-transplant (per 1 additional) (OR 1.12 [95% CI 1.00, 1.26]; p = .047), and average time nurses spend with patients in clinic (per 5 additional minutes) (OR 1.15 [1.03, 1.29]; p = .017). CONCLUSION Program-level factors including protocols with a greater frequency of routine blood testing and more nurse time with patients were associated with better medication adherence. This suggests that interventions at the program level may support better adherence.
Collapse
Affiliation(s)
| | - Mourad Dahhou
- Research Institute of The McGill University Health Centre, Montreal, QC, Canada
| | - Xun Zhang
- Research Institute of The McGill University Health Centre, Montreal, QC, Canada
| | - Ruth Sapir-Pichhadze
- Research Institute of The McGill University Health Centre, Montreal, QC, Canada.,Department of Medicine, McGill University, Montreal, QC, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Heloise Cardinal
- Department of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Michel White
- Institut de Cardiologie, Université de Montréal, Montreal, QC, Canada
| | - Olwyn Johnston
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Tom D Blydt-Hansen
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Lee Anne Tibbles
- Department of Medicine and Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lorraine Hamiwka
- Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Simon Urschel
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Patricia Birk
- Section of Pediatric Nephrology, University of Manitoba, Winnipeg, MB, Canada
| | | | - Mina Matsuda-Abedini
- Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Toronto, ON, Canada
| | - Jennifer Harrison
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.,Multi-Organ Transplant Program, Toronto General Hospital, Toronto, ON, Canada
| | - Jeffrey Schiff
- Multi-Organ Transplant Program, Toronto General Hospital, Toronto, ON, Canada
| | - Veronique Phan
- CHU Ste-Justine, Université de Montréal, Montréal, QC, Canada
| | - Sabina De Geest
- Department Public Health, Institute of Nursing Science, University of Basel, Basel, Switzerland.,Academic Center of Nursing and Midwifery, Department of Primary Care and Public Health, KU Leuven, Leuven, Belgium
| | - Upton Allen
- Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Toronto, ON, Canada
| | - Seema Mital
- Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Toronto, ON, Canada
| | - Bethany J Foster
- Research Institute of The McGill University Health Centre, Montreal, QC, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada.,Department of Pediatrics, McGill University, Montreal, QC, Canada
| |
Collapse
|
14
|
Kostalova B, Ribaut J, Dobbels F, Gerull S, Mala-Ladova K, Zullig LL, De Geest S. Medication adherence interventions in transplantation lack information on how to implement findings from randomized controlled trials in real-world settings: A systematic review. Transplant Rev (Orlando) 2021; 36:100671. [PMID: 34773910 DOI: 10.1016/j.trre.2021.100671] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/19/2021] [Accepted: 09/19/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Growing numbers of randomized controlled trials (RCTs) are showing the effectiveness of interventions to improve medication adherence in transplantation recipients. However, real-world implementation is still a major challenge. This systematic review assesses the range of information available in RCTs supporting these interventions' clinical adoption in adult transplant populations. METHODS We included RCTs of interventions that a) targeted any phase of medication adherence in solid organ or allogeneic stem cell transplantation recipients and b) were published between January 2015 and November 2020. We excluded study protocols, conference abstracts and studies focusing only on pediatric populations. We identified relevant database and trial registries as well as traced references backward and citations forward. Implementation-relevant information was evaluated using adapted versions of Peters' ten criteria: 1. healthcare/organizational context; 2. social/economic/policy context; 3. patient involvement; 4. other stakeholder involvement; 5. sample representativeness; 6. trial conducted in a real-world-setting; 7. presence of feasibility study; 8. implementation strategy; 9. process evaluation; 10. implementation outcomes, using a stoplight color-rating system. RESULTS Screening 17'004 titles/abstracts resulted in 23 eligible RCTs, including 2'339 patients (n = 19-209/study). All included studies focused on the implementation phase of medication adherence. The best-reported criteria were feasibility study (43%), representative sample (17%) and conducted in a real-world-setting (17%). Least reported were context (9%), implementation strategies (4%), process evaluation (4%). CONCLUSIONS RCTs testing medication adherence interventions tend to report limited implementation-relevant information. This hinders their translation to real-world transplant settings. Integrating implementation science principles early in the conceptualization of RCTs would fuel real-world-translation, reducing research waste.
Collapse
Affiliation(s)
- Barbora Kostalova
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Kralove, Charles University, Akademika Heyrovskeho 1203, 500 05 Hradec Kralove, Czech Republic.
| | - Janette Ribaut
- Institute of Nursing Science, Department of Public Health, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland; Department of Theragnostic, Hematology, University Hospital of Basel, Petersgraben 4, 4031 Basel, Switzerland.
| | - Fabienne Dobbels
- Institute of Nursing Science, Department of Public Health, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland; Academic Center for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 35 blok d, box 7001, 3000 Leuven, Belgium.
| | - Sabine Gerull
- Department of Theragnostic, Hematology, University Hospital of Basel, Petersgraben 4, 4031 Basel, Switzerland; Department of Hematology, Cantonal Hospital of Aarau, Tellstrasse 25, 5001 Aarau, Switzerland.
| | - Katerina Mala-Ladova
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Kralove, Charles University, Akademika Heyrovskeho 1203, 500 05 Hradec Kralove, Czech Republic.
| | - Leah L Zullig
- Department of Population Health Science, Duke University, 215 Morris St, Durham, NC 27701, USA; Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 508 Fulton St, Durham, NC 27705, USA.
| | - Sabina De Geest
- Institute of Nursing Science, Department of Public Health, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland; Academic Center for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 35 blok d, box 7001, 3000 Leuven, Belgium.
| |
Collapse
|
15
|
Tang J, Kerklaan J, Wong G, Howell M, Scholes-Robertson N, Guha C, Kelly A, Tong A. Perspectives of solid organ transplant recipients on medicine-taking: Systematic review of qualitative studies. Am J Transplant 2021; 21:3369-3387. [PMID: 33866675 DOI: 10.1111/ajt.16613] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/16/2021] [Accepted: 04/02/2021] [Indexed: 01/25/2023]
Abstract
Medicine-taking among transplant recipients is a complex and ubiquitous task with significant impacts on outcomes. This study aimed to describe the perspectives and experiences of medicine-taking in adult solid organ transplant recipients. Electronic databases were searched to July 2020, and thematic synthesis was used to analyze the data. From 119 studies (n = 2901), we identified six themes: threats to identity and ambitions (impaired self-image, restricting goals and roles, loss of financial independence); navigating through uncertainty and distrust (lacking tangible/perceptible benefits, unprepared for side effects, isolation in decision-making); alleviating treatment burdens (establishing and mastering routines, counteracting side effects, preparing for the unexpected); gaining and seeking confidence (clarity with knowledge, reassurance through collective experiences, focusing on the future outlook); recalibrating to a new normal posttransplant (adjusting to ongoing dependence on medications, in both states of illness and health, unfulfilled expectations); and preserving graft survival (maintaining the ability to participate in life, avoiding rejection, enacting a social responsibility of giving back). Transplant recipients take medications to preserve graft function, but dependence on medications jeopardizes their sense of normality. Interventions supporting the adaptation to medicine-taking and addressing treatment burdens may improve patient satisfaction and capacities to take medications for improved outcomes.
Collapse
Affiliation(s)
- James Tang
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Jasmijn Kerklaan
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia.,Department of Pediatric Nephrology, Academic Medical Center, Emma Children's Hospital, Amsterdam, the Netherlands
| | - Germaine Wong
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia
| | - Martin Howell
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Nicole Scholes-Robertson
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Chandana Guha
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Ayano Kelly
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| |
Collapse
|
16
|
Samojlik MM, Stabler CL. Designing biomaterials for the modulation of allogeneic and autoimmune responses to cellular implants in Type 1 Diabetes. Acta Biomater 2021; 133:87-101. [PMID: 34102338 DOI: 10.1016/j.actbio.2021.05.039] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 05/05/2021] [Accepted: 05/20/2021] [Indexed: 12/15/2022]
Abstract
The effective suppression of adaptive immune responses is essential for the success of allogeneic cell therapies. In islet transplantation for Type 1 Diabetes, pre-existing autoimmunity provides an additional hurdle, as memory autoimmune T cells mediate both an autoantigen-specific attack on the donor beta cells and an alloantigen-specific attack on the donor graft cells. Immunosuppressive agents used for islet transplantation are generally successful in suppressing alloimmune responses, but dramatically hinder the widespread adoption of this therapeutic approach and fail to control memory T cell populations, which leaves the graft vulnerable to destruction. In this review, we highlight the capacity of biomaterials to provide local and nuanced instruction to suppress or alter immune pathways activated in response to an allogeneic islet transplant. Biomaterial immunoisolation is a common approach employed to block direct antigen recognition and downstream cell-mediated graft destruction; however, immunoisolation alone still permits shed donor antigens to escape into the host environment, resulting in indirect antigen recognition, immune cell activation, and the creation of a toxic graft site. Designing materials to decrease antigen escape, improve cell viability, and increase material compatibility are all approaches that can decrease the local release of antigen and danger signals into the implant microenvironment. Implant materials can be further enhanced through the local delivery of anti-inflammatory, suppressive, chemotactic, and/or tolerogenic agents, which serve to control both the innate and adaptive immune responses to the implant with a benefit of reduced systemic effects. Lessons learned from understanding how to manipulate allogeneic and autogenic immune responses to pancreatic islets can also be applied to other cell therapies to improve their efficacy and duration. STATEMENT OF SIGNIFICANCE: This review explores key immunologic concepts and critical pathways mediating graft rejection in Type 1 Diabetes, which can instruct the future purposeful design of immunomodulatory biomaterials for cell therapy. A summary of immunological pathways initiated following cellular implantation, as well as current systemic immunomodulatory agents used, is provided. We then outline the potential of biomaterials to modulate these responses. The capacity of polymeric encapsulation to block some powerful rejection pathways is covered. We also highlight the role of cellular health and biocompatibility in mitigating immune responses. Finally, we review the use of bioactive materials to proactively modulate local immune responses, focusing on key concepts of anti-inflammatory, suppressive, and tolerogenic agents.
Collapse
Affiliation(s)
- Magdalena M Samojlik
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA
| | - Cherie L Stabler
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA; University of Florida Diabetes Institute, Gainesville, FL, USA; Graduate Program in Biomedical Sciences, College of Medicine, University of Florida, Gainesville, FL, USA.
| |
Collapse
|
17
|
Bekker CL, Aslani P, Chen TF. The use of medication adherence guidelines in medication taking behaviour research. Res Social Adm Pharm 2021; 18:2325-2330. [PMID: 34393079 DOI: 10.1016/j.sapharm.2021.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 08/10/2021] [Accepted: 08/10/2021] [Indexed: 10/20/2022]
Abstract
Medication nonadherence continues to be a serious issue in a range of long-term medical conditions and has been studied extensively over the past few decades. However, despite the plethora of research studies on medication adherence, poor methodological rigour in many studies has contributed to limited generalisability of the positive findings, limited impact on patients' medication adherence, and inability to compare between studies. This paper focuses on current guidelines designed specifically for research on medication adherence. It discusses key elements to consider during study design, selection of adherence measurements, and reporting on medication adherence research, to ensure a higher quality of research in medication adherence. Overall, there appears to be variations in adherence terminology reported in the literature despite improvements in defining medication taking behaviour and the availability of taxonomies. In addition, limited guidance exists on how best to measure adherence. Recommendations are provided on appropriate adherence measures for the adherence behaviour being investigated, including careful consideration of adherence concepts, validity of adherence instruments, appropriate instrument selection, definition of nonadherence threshold, and how to report medication adherence. Improving adherence research requires greater clarity and standardisation of descriptions of nonadherence behaviour, increased methodological rigour in study designs, better selection of adherence measurements, and comprehensive reporting.
Collapse
Affiliation(s)
- Charlotte L Bekker
- Radboud University Medical Center, Research Institute for Health Sciences, Department of Pharmacy, Nijmegen, the Netherlands.
| | - Parisa Aslani
- The University of Sydney School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
| | - Timothy F Chen
- The University of Sydney School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
| |
Collapse
|
18
|
Prospective Measures of Adherence by Questionnaire, Low Immunosuppression and Graft Outcome in Kidney Transplantation. J Clin Med 2021; 10:jcm10092032. [PMID: 34068497 PMCID: PMC8125965 DOI: 10.3390/jcm10092032] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/20/2021] [Accepted: 04/28/2021] [Indexed: 01/05/2023] Open
Abstract
Background: Non-adherence with immunosuppressant medication (MNA) fosters development of de novo donor-specific antibodies (dnDSA), rejection, and graft failure (GF) in kidney transplant recipients (KTRs). However, there is no simple tool to assess MNA, prospectively. The goal was to monitor MNA and analyze its predictive value for dnDSA generation, acute rejection and GF. Methods: We enrolled 301 KTRs in a multicentric French study. MNA was assessed prospectively at 3, 6, 12, and 24 months (M) post-KT, using the Morisky scale. We investigated the association between MNA and occurrence of dnDSA at year 2 post transplantation, using logistic regression models and the association between MNA and rejection or graft failure, using Cox multivariable models. Results: The initial percentage of MNA patients was 17.7%, increasing to 34.6% at 24 months. Nineteen patients (8.4%) developed dnDSA 2 to 3 years after KT. After adjustment for recipient age, HLA sensitization, HLA mismatches, and maintenance treatment, MNA was associated neither with dnDSA occurrence, nor acute rejection. Only cyclosporine use and calcineurin inhibitor (CNI) withdrawal were strongly associated with dnDSA and rejection. With a median follow-up of 8.9 years, GF occurred in 87 patients (29.0%). After adjustment for recipient and donor age, CNI trough level, dnDSA, and rejection, MNA was not associated with GF. The only parameters associated with GF were dnDSA occurrence, and acute rejection. Conclusions: Prospective serial monitoring of MNA using the Morisky scale does not predict dnDSA occurrence, rejection or GF in KTRs. In contrast, cyclosporine and CNI withdrawal induce dnDSA and rejection, which lead to GF.
Collapse
|
19
|
Chambord J, Couzi L, Merville P, Moreau K, Xuereb F, Djabarouti S. Benefit of a pharmacist-led intervention for medication management of renal transplant patients: a controlled before-and-after study. Ther Adv Chronic Dis 2021; 12:20406223211005275. [PMID: 33868624 PMCID: PMC8024450 DOI: 10.1177/20406223211005275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 03/03/2021] [Indexed: 11/16/2022] Open
Abstract
Aims To assess the effect of a pharmacist-led intervention, using Barrows cards method, during the first year after renal transplantation, on patient knowledge about their treatment, medication adherence and exposure to treatment in a French cohort. Methods We conducted a before-and-after comparative study between two groups of patients: those who benefited from a complementary pharmacist-led intervention [intervention group (IG), n = 44] versus those who did not [control group (CG), n = 48]. The pharmacist-led intervention consisted of a behavioral and educational interview at the first visit (visit 1). The intervention was assessed 4 months later at the second visit (visit 2), using the following endpoints: treatment knowledge, medication adherence [proportion of days covered (PDC) by immunosuppressive therapy] and tacrolimus exposure. Results At visit 2, IG patients achieved a significantly higher knowledge score than CG patients (83.3% versus 72.2%, p = 0.001). We did not find any differences in treatment exposure or medication adherence; however, the intervention tended to reduce the proportion of non-adherent patients with low knowledge scores. Using the PDC by immunosuppressive therapy, we identified 10 non-adherent patients (10.9%) at visit 1 and six at visit 2. Conclusions Our intervention showed a positive effect on patient knowledge about their treatment. However, our results did not show any improvement in overall medication adherence, which was likely to be because of the initially high level of adherence in our study population. Nevertheless, the intervention appears to have improved adherence in non-adherent patients with low knowledge scores.
Collapse
Affiliation(s)
| | - Lionel Couzi
- Department of Nephrology and Renal Transplantation, CHU Bordeaux, Bordeaux, Aquitaine, France
| | - Pierre Merville
- Department of Nephrology and Renal Transplantation, CHU Bordeaux, Bordeaux, Aquitaine, France
| | - Karine Moreau
- Department of Nephrology and Renal Transplantation, CHU Bordeaux, Bordeaux, Aquitaine, France
| | - Fabien Xuereb
- CHU Bordeaux, Pharmacy, Bordeaux, Pessac, France Univ. Bordeaux, INSERM U1034, Bordeaux, France
| | - Sarah Djabarouti
- CHU Bordeaux, Pharmacy, Bordeaux, Pessac, France Univ. Bordeaux, INSERM U1034, Bordeaux, France
| |
Collapse
|
20
|
Association between medication adherence and intrapatient variability in tacrolimus concentration among stable kidney transplant recipients. Sci Rep 2021; 11:5397. [PMID: 33686160 PMCID: PMC7940492 DOI: 10.1038/s41598-021-84868-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 02/18/2021] [Indexed: 02/04/2023] Open
Abstract
This study analyzed the association between medication adherence and the intrapatient variability (IPV) of tacrolimus concentrations among kidney transplant recipients through a post hoc analysis of the dataset from a recently conducted randomized controlled trial. Among 138 patients enrolled in the original trial, 92 patients with ≥ 5 months of medication event monitoring system (MEMS) use and ≥ 4 tacrolimus trough values were included in this post hoc analysis. The variability of tacrolimus trough levels was calculated using coefficient variation (CV) and mean absolute deviation. Adherence was assessed using MEMS and self-report via the Basal Assessment of Adherence to Immunosuppressive Medication Scale. There were no statistically significant differences in the CV [median 16.5% [interquartile range 11.6–25.5%] and 16.0% [11.5–23.5%], respectively, P = .602] between the nonadherent (n = 59) and adherent groups (n = 33). There was also no significant correlation between the CV and adherence detected by MEMS (taking adherence, ρ = − 0.067, P = .527; dosing adherence, ρ = − 0.098, P = .352; timing adherence, ρ = − 0.113, P = .284). Similarly, adherence measured by self-report did not significantly affect the IPV (P = .452). In this post hoc analysis, nonadherent behavior, measured through electronic monitoring or self-report, did not affect the IPV.
Collapse
|
21
|
Lushin EN, McDermott JK, Truax C, Lourenco LM, Mariski M, Melaragno JI, Potter LM. A multicenter case series documenting Medicare Part D plan denials of immunosuppressant drug coverage for organ transplant recipients. Am J Transplant 2021; 21:889-896. [PMID: 32976706 DOI: 10.1111/ajt.16321] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/28/2020] [Accepted: 09/04/2020] [Indexed: 01/25/2023]
Abstract
Medicare Part D plans make coverage decisions according to FDA-labeled indications and off-label uses endorsed by two CMS-recognized compendia. Patients who rely on Medicare Part D for immunosuppressive drug coverage are at risk for denied coverage when these medications are prescribed off-label. The purpose of this multicenter collaboration was to assemble a case series documenting situations where immunosuppressive therapies prescribed for transplant patients were denied by Medicare Part D prescription drug plans. This case series documents 66 instances in 39 patients where immunosuppressive drug claims were denied coverage due to off-label use not endorsed by the compendia. Patients were recipients of lung (n = 28, 72%), heart (n = 7, 18%), or liver (n = 4, 10%) transplants. Denied claims were for mycophenolate mofetil (n = 22, 33%), azathioprine (n = 18, 27%), sirolimus (n = 15, 23%), mycophenolate sodium (n = 5, 8%), everolimus (n = 5, 8%), and belatacept (n = 1, 1%). Most denials were upheld across all the levels of attempted appeal, including those escalated to a Medicare Administrative Law Judge. This case series demonstrates a critical flaw in the construct of the Medicare Prescription Drug Benefit. The currently referenced compendia are not up to date and do not reflect best practices in organ transplantation.
Collapse
Affiliation(s)
- Erin N Lushin
- Department of Pharmacy, Indiana University Health, Indianapolis, Indiana
| | | | - Crystal Truax
- Department of Pharmacy, University of Utah Health, Salt Lake City, Utah
| | - Laura M Lourenco
- Department of Pharmacy Services, University of Chicago Medicine, Chicago, Illinois
| | - Mark Mariski
- Department of Pharmacy, University of California San Diego Health, San Diego, California
| | - Jennifer I Melaragno
- Department of Pharmacy, University of Rochester Medical Center, Rochester, New York
| | - Lisa M Potter
- Department of Pharmacy Services, University of Chicago Medicine, Chicago, Illinois
| |
Collapse
|
22
|
Jyothindrakumar J, Dhanasekaran R, Natarajan G, Thanigachalam D, Rajendran P. Diarrhea in renal transplant recipients – Retrospective observational study from a center in South India. INDIAN JOURNAL OF TRANSPLANTATION 2021. [DOI: 10.4103/ijot.ijot_123_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
23
|
Kostalova B, Mala-Ladova K, Kubena AA, Horne R, Dusilova Sulkova S, Maly J. Changes in Beliefs About Post-Transplant Immunosuppressants Over Time and Its Relation to Medication Adherence and Kidney Graft Dysfunction: A Follow-Up Study. Patient Prefer Adherence 2021; 15:2877-2887. [PMID: 35002225 PMCID: PMC8725840 DOI: 10.2147/ppa.s344878] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 12/07/2021] [Indexed: 12/14/2022] Open
Abstract
PURPOSE The main aim was to evaluate the changes in beliefs about immunosuppressants over a 3-year period in patients after kidney transplantation. The second aim was to investigate the relationship between beliefs, medication adherence, and selected clinical outcomes such as graft functioning. PATIENTS AND METHODS This observational follow-up study was conducted in the outpatient post-transplant clinic at the University Hospital Hradec Kralove in the Czech Republic. Adult patients, at least 4 weeks after kidney transplantation, were invited for the structured interview, which was followed by a self-administered questionnaire survey during their regularly scheduled visits at the clinic. Appropriate paired tests were used to compare two measurements of beliefs about immunosuppressants by BMQ-CZ© in 2016 (baseline) and in 2019 (follow-up). Self-reported adherence was measured by two validated tools (MARS-CZ© and BAASIS©) capturing implementation and discontinuation phases. A generalized linear model was used to investigate the relation between beliefs and the consecutive estimated glomerular filtration rate. RESULTS The study involved 134 patients. Over time, their perceived treatment necessity beliefs of immunosuppressants decreased, while their treatment-related concerns increased. Overall self-reported non-adherence (ie, taking, dosing and discontinuation of immunosuppressants) was reported by 12% of the patients in both observation periods. In the follow-up period, timing non-adherence was reported by 52 (38.8%) patients. Higher baseline treatment concerns were associated with poor adherence whereas higher baseline treatment necessity beliefs corresponded with better kidney functioning, even after adjusting for age. CONCLUSION Higher treatment necessity beliefs corresponded with better kidney functioning, whereas higher treatment concerns were related to non-adherence to immunosuppressants at the beginning of the observed period. Still, most patients accepted their medicines that do not come without risk. Nevertheless, decreasing treatment necessity beliefs on one hand, and increasing treatment concerns on the other, should be considered in clinical practice.
Collapse
Affiliation(s)
- Barbora Kostalova
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Katerina Mala-Ladova
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
- Correspondence: Katerina Mala-Ladova Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Kralove, Charles University, Ak. Heyrovskeho 1203/8, Hradec Kralove, 500 05, Czech RepublicTel +420 495 067 486 Email
| | - Ales Antonin Kubena
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Rob Horne
- Centre for Behavioural Medicine, UCL School of Pharmacy, University College London, London, UK
| | | | - Josef Maly
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| |
Collapse
|
24
|
Keys AE, Pilch NA, Perez C, Patel N, Meadows H, Fleming JN, Taber DJ. Patient‐reported medication adherence and tolerability: Results of a prospective observational study. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Alison E Keys
- College of Pharmacy Medical University of South Carolina Charleston South Carolina USA
| | - Nicole A. Pilch
- College of Pharmacy Medical University of South Carolina Charleston South Carolina USA
| | - Caroline Perez
- Department of Pharmacy Medical University of South Carolina Charleston South Carolina USA
| | - Neha Patel
- Department of Pharmacy Medical University of South Carolina Charleston South Carolina USA
| | - Holly Meadows
- Department of Pharmacy Medical University of South Carolina Charleston South Carolina USA
| | - James N. Fleming
- Department of Surgery, Division of Transplant Surgery Medical University of South Carolina Charleston South Carolina USA
| | - David J. Taber
- Department of Surgery, Division of Transplant Surgery Medical University of South Carolina Charleston South Carolina USA
| |
Collapse
|
25
|
van Gelder T, Meziyerh S, Swen JJ, de Vries APJ, Moes DJAR. The Clinical Impact of the C 0/D Ratio and the CYP3A5 Genotype on Outcome in Tacrolimus Treated Kidney Transplant Recipients. Front Pharmacol 2020; 11:1142. [PMID: 32848756 PMCID: PMC7411304 DOI: 10.3389/fphar.2020.01142] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 07/13/2020] [Indexed: 01/08/2023] Open
Abstract
Tacrolimus is metabolized by CYP3A4 and CYP3A5 enzymes. Patients expressing CYP3A5 (in Caucasian patients about 15% of the population but more frequent in African Americans and Asians) have a dose requirement that is around 50% higher than non-expressers to reach the target concentration. CYP3A5 expressers can be considered fast metabolizers. The trough concentration/dose (C0/D) ratio of tacrolimus has recently been proposed as a prognostic marker for poor outcome after kidney transplantation. Patients with a low C0/D ratio (also referred to as fast metabolizers) seem to have more tacrolimus-related nephrotoxicity, more BK-viremia, and a lower graft survival. At first sight, the expression of CYP3A5 and a low C0/D ratio seem to be overlapping factors, both pointing towards patients in whom a higher tacrolimus dose is needed to reach the tacrolimus target concentration. However, there are important differences, and these differences may explain why the impact of the C0/D ratio on long term outcome is stronger than for CYP3A5 genotype status. Patients with a low C0/D ratio require a high tacrolimus dose and are exposed to high tacrolimus peak concentrations. The higher peak exposure to tacrolimus (and/or its metabolites) may explain the higher incidence of nephrotoxicity, BK-viremia and graft loss. A potential confounder is the concurrent maintenance treatment of corticosteroids, as steroids are sometimes continued in patients at high immunological risk. Steroids induce the metabolism of tacrolimus via pregnane X receptor mediated increased CYP3A4 expression, resulting in lower tacrolimus C0/D ratio in high risk patients. Also non-adherence may result in lower C0/D ratio which is also associated with poor outcome. The C0/D ratio of tacrolimus does seem to identify a group of patients with increased risk of poor outcome after kidney transplantation. Our recommendation is to monitor tacrolimus peak concentrations in these patients, and if these are high then target slightly lower pre-dose concentrations. Another possibility would be to switch to a prolonged release formulation or to dose the drug more frequently, in smaller doses, to avoid high peak concentrations.
Collapse
Affiliation(s)
- Teun van Gelder
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, Netherlands
| | - Soufian Meziyerh
- Department of Internal Medicine, Division of Nephrology, Leiden University Medical Center, Leiden, Netherlands.,Leiden Transplant Center, Leiden University Medical Center, Leiden, Netherlands
| | - Jesse J Swen
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, Netherlands
| | - Aiko P J de Vries
- Department of Internal Medicine, Division of Nephrology, Leiden University Medical Center, Leiden, Netherlands.,Leiden Transplant Center, Leiden University Medical Center, Leiden, Netherlands
| | - Dirk Jan A R Moes
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, Netherlands
| |
Collapse
|
26
|
Terranella SL, Poirier J, Chan EY, Hertl M, Olaitan OK. Should Pre-Transplant Hemoglobin A1c Be Used to Predict Post-Transplant Compliance in End-Stage Renal Disease Patients Undergoing Kidney Transplantation? Ann Transplant 2020; 25:e924061. [PMID: 32587234 PMCID: PMC7339972 DOI: 10.12659/aot.924061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background Patient compliance with immunosuppressive therapy after transplant has impacts on both graft and patient outcomes. For diabetic end-stage renal disease (ESRD) patients who are undergoing evaluation for kidney transplantation in our program, hemoglobin A1c (HbA1c) level of >10% is used as a flag that the patient may be at risk for noncompliance and that more comprehensive psychosocial screening is needed prior to transplant. We evaluated the association between pre-transplant HbA1c level and post-transplant compliance, as no study to date has looked at this in the transplant population. Material/Methods The charts of 392 patients who received a kidney transplant at a single institution between July 2008 and June 2012 were retrospectively reviewed. One hundred and sixty-five diabetic patients who received a kidney transplant alone were included in the final analysis. Our predictive variable was HbA1c level greater than 7.7% based on previous reports in the diabetic population. Outcome measures were graft survival, rejection episodes, unexplained low immunosuppressant levels, and documented noncompliance. Results There were no statistically significant differences between the HbA1c groups of ≤7.7% and >7.7% in outcomes of failed grafts (22.0% and 17.8%, p=0.2), rejection episodes (15.0% and 6.7%, p=0.3), unexplained low immunosuppressant level (46.6% and 37.9%, p=0.3), and documented noncompliance (25.0% and 16.7%, p=0.4). Conclusions In diabetic ESRD patients selected for renal transplantation, elevated pre-transplant HbA1c levels, defined as HbA1c >7.7%, are not predictive of post-transplant medication compliance. We advocate that this group of patients should not be denied transplant solely on their elevated pre-transplant HbA1c.
Collapse
Affiliation(s)
| | - Jennifer Poirier
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Edie Y Chan
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Martin Hertl
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | | |
Collapse
|
27
|
Chisholm-Burns MA, Spivey CA, Potukuchi PK, Streja E, Kalantar-Zadeh K, Kovesdy CP, Molnar MZ. Association between Posttransplant Opioid Use and Immunosuppressant Therapy Adherence among Renal Transplant Recipients. Nephron Clin Pract 2020; 144:321-330. [PMID: 32434210 DOI: 10.1159/000507257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 03/14/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Little is known about the effect of posttransplant opioid use on adherence to immunosuppressant therapy (IST) among adult renal transplant recipients (RTRs). OBJECTIVE The aim of this study was to examine the relationship between opioid use and IST adherence among adult RTRs during the first year posttransplant. METHODS Longitudinal data were analyzed from a retrospective cohort study examining US veterans undergoing renal transplant from October 1, 2007, through March 31, 2015. Data were collected from the US Renal Data System, Centers for Medicare and Medicaid Services Data (Medicare Part D), and Veterans Affairs pharmacy records. Dose of opioid prescriptions was collected and divided based on annual morphine milligram equivalent within a year of transplant. Proportion of days covered of greater than or equal to 80% indicated adherence to tacrolimus. Unadjusted and multivariable-adjusted logistic regression analyses were performed. RESULTS A study population of 1,229 RTRs included 258 with no opioid use, while 971 opioid users were identified within the first year after transplantation. Compared to RTRs without opioid usage, RTRs with opioid usage had a lower probability of being adherent to tacrolimus in unadjusted logistic regression (odds ratio [OR] (95% confidence interval [CI]): 0.22 [0.07-0.72]) and adjusted logistic regression (OR [95% CI]: 0.11 [0.03-0.44]). These patterns generally remained consistent in unadjusted and adjusted main and sensitivity analyses. CONCLUSIONS Findings indicate RTRs who use prescription opioids during the first year posttransplant, regardless of the dosage/amount, are less likely to be adherent to tacrolimus. Future studies are needed to better understand underlying causes of the association between opioid use and tacrolimus nonadherence.
Collapse
Affiliation(s)
- Marie A Chisholm-Burns
- College of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee, USA,
| | - Christina A Spivey
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Praveen K Potukuchi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Elani Streja
- Division of Nephrology, University of California, Irvine, California, USA
| | | | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA
| | - Miklos Z Molnar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Methodist University Hospital Transplant Institute, Memphis, Tennessee, USA.,Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| |
Collapse
|
28
|
Boucquemont J, Pai ALH, Dharnidharka VR, Hebert D, Zelikovsky N, Amaral S, Furth SL, Foster BJ. Association between day of the week and medication adherence among adolescent and young adult kidney transplant recipients. Am J Transplant 2020; 20:274-281. [PMID: 31507087 PMCID: PMC6940530 DOI: 10.1111/ajt.15590] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 07/30/2019] [Accepted: 08/11/2019] [Indexed: 01/25/2023]
Abstract
Disruption of usual routines may hinder adherence, increasing the risk of rejection. We aimed to compare weekend versus weekday medication adherence among adolescent and young adult kidney transplant recipients, hypothesizing poorer adherence on weekends. We examined data from the Teen Adherence in Kidney transplant Effectiveness of Intervention Trial (TAKE-IT). We assessed the 3-month run-in period (no intervention) and the 12-month intervention interval, considering a potential interaction between weekend/weekday and treatment group. Adherence was monitored using electronic pillboxes in participants 11-24 years followed in eight transplant centers in Canada and the United States. We used logistic regression with generalized estimating equations to estimate the association between weekends/weekdays and each of perfect taking (100% of prescribed doses taken) and timing (100% of prescribed doses taken on time) adherence. Taking (OR = 0.72 [95% CI 0.65-0.79]) and timing (OR = 0.66 [95% CI 0.59-0.74]) adherence were poorer on weekends than weekdays in the run-in (136 participants) and the intervention interval (taking OR = 0.74 [0.67-0.81] and timing OR = 0.71 [95% CI 0.65-0.77]). There was no interaction by treatment group (64 intervention and 74 control participants). Weekends represent a disruption of regular routines, posing a threat to adherence. Patients and families should be encouraged to develop strategies to maintain adherence when routines are disrupted. TAKE-IT registration number: Clinicaltrials.gov registration: NCT01356277 (May 17, 2011).
Collapse
Affiliation(s)
- Julie Boucquemont
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Ahna LH Pai
- Center for Adherence and Self-Management, Cincinnati Children’s Hospital Medical Center, Cincinnati Ohio,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Ohio
| | - Vikas R Dharnidharka
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri,St. Louis Children’s Hospital, St. Louis, Missouri
| | - Diane Hebert
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nataliya Zelikovsky
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sandra Amaral
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Susan L Furth
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bethany J Foster
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada,Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| |
Collapse
|
29
|
Bertram A, Fuge J, Suhling H, Tudorache I, Haverich A, Welte T, Gottlieb J. Adherence is associated with a favorable outcome after lung transplantation. PLoS One 2019; 14:e0226167. [PMID: 31846463 PMCID: PMC6917262 DOI: 10.1371/journal.pone.0226167] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 11/20/2019] [Indexed: 02/07/2023] Open
Abstract
Non-adherence to therapy is associated with impaired outcome in solid organ allograft recipients. Outcome data are limited after lung transplantation. In a single-center cohort study, adherence was assessed in 427 patients undergoing lung transplantation from 2010 to 2013. Objective criteria of adherence were judged by health care workers on every visit on a five item Likert scale including trough level monitoring, home spirometry and contact with an overall rating of adherence between 0 and 100%. Cut-off values for good vs. suboptimal adherence were defined retrospectively. Primary outcome was allograft survival, secondary outcomes were patient survival, prevalence of chronic lung allograft dysfunction, hospitalizations, renal function and quality of life. Follow-up ended on 31st December 2018. Median adherence was 86% on 6,623 visits, this cut-off was used as a discriminator between good and suboptimal adherers. Patients with good adherence within the first three years showed better 5-year allograft (74% vs. 60%, p = 0.003) and patient survival (79% vs. 64%, p<0.001) and lower prevalence of chronic allograft dysfunction (33% vs. 45%, p = 0.011) after 5 years compared to patients with suboptimal adherence. A multidimensional adherence score proved to be a simple tool to assess adherence in clinical practice. Suboptimal adherence was associated with impaired outcome in lung transplant patients.
Collapse
Affiliation(s)
- Anna Bertram
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
- * E-mail:
| | - Jan Fuge
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Gießen, Germany
| | - Hendrik Suhling
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Gießen, Germany
| | - Igor Tudorache
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Gießen, Germany
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Gießen, Germany
| | - Jens Gottlieb
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Gießen, Germany
| |
Collapse
|
30
|
Meaney CJ, Sudchada P, Consiglio JD, Wilding GE, Cooper LM, Venuto RC, Tornatore KM. Influence of Calcineurin Inhibitor and Sex on Mycophenolic Acid Pharmacokinetics and Adverse Effects Post-Renal Transplant. J Clin Pharmacol 2019; 59:1351-1365. [PMID: 31062373 PMCID: PMC7375007 DOI: 10.1002/jcph.1428] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 04/05/2019] [Indexed: 12/15/2022]
Abstract
Tacrolimus or cyclosporine is prescribed with mycophenolic acid posttransplant and contributes to interpatient variability in mycophenolic acid pharmacokinetics and response. Cyclosporine inhibits enterohepatic circulation of the metabolite mycophenolic acid glucuronide, which is not described with tacrolimus. This study investigated mycophenolic acid pharmacokinetics and adverse effects in stable renal transplant recipients and the association with calcineurin inhibitors, sex, and race. Mycophenolic acid and mycophenolic acid glucuronide area under the concentration-time curve from 0 to 12 hours (AUC0-12h ) and apparent clearance were determined at steady state in 80 patients receiving cyclosporine with mycophenolate mofetil and 67 patients receiving tacrolimus with mycophenolate sodium. Gastrointestinal adverse effects and hematologic parameters were evaluated. Statistical models evaluated mycophenolic acid pharmacokinetics and adverse effects. Mycophenolic acid AUC0-12h was 1.70-fold greater with tacrolimus (68.9 ± 30.9 mg·h/L) relative to cyclosporine (40.8 ± 17.6 mg·h/L); P < .001. Target mycophenolic acid AUC0-12h of 30-60 mg·h/L was achieved in 56.3% on cyclosporine compared with 34.3% receiving tacrolimus (P < .001). Mycophenolic acid clearance was 48% slower with tacrolimus (10.6 ± 4.7 L/h) relative to cyclosporine (20.5 ± 10.0 L/h); P < .001. Enterohepatic circulation occurred less frequently with cyclosporine (45%) compared with tacrolimus (78%); P < 0.001; with a 2.9-fold greater mycophenolic acid glucuronide AUC0-12h to mycophenolic acid AUC0-12h ratio (P < .001). Race did not affect mycophenolic acid pharmacokinetics. Gastrointestinal adverse effect scores were 2.2-fold higher with tacrolimus (P < .001) and more prominent in women (P = .017). Lymphopenia was more prevalent with tacrolimus (52.2%) than cyclosporine (22.5%); P < 0.001. Calcineurin inhibitors and sex contributed to interpatient variability in mycophenolic acid pharmacokinetics and adverse effects post-renal transplant, which could be attributed to differences in enterohepatic circulation.
Collapse
Affiliation(s)
- Calvin J. Meaney
- Immunosuppressive Pharmacology Research Program,
Translational Pharmacology Research Core, Buffalo, NY, USA
- Department of Pharmacy Practice, School of Pharmacy and
Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Patcharaporn Sudchada
- Immunosuppressive Pharmacology Research Program,
Translational Pharmacology Research Core, Buffalo, NY, USA
| | - Joseph D. Consiglio
- Department of Biostatistics, School of Public Health and
Health Professions, University at Buffalo, Buffalo, NY, USA
| | - Gregory E. Wilding
- Department of Biostatistics, School of Public Health and
Health Professions, University at Buffalo, Buffalo, NY, USA
| | - Louise M. Cooper
- Immunosuppressive Pharmacology Research Program,
Translational Pharmacology Research Core, Buffalo, NY, USA
- Department of Pharmacy Practice, School of Pharmacy and
Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Rocco C. Venuto
- Department of Medicine; Nephrology Division, Jacobs School
of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Kathleen M. Tornatore
- Immunosuppressive Pharmacology Research Program,
Translational Pharmacology Research Core, Buffalo, NY, USA
- Department of Pharmacy Practice, School of Pharmacy and
Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Medicine; Nephrology Division, Jacobs School
of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| |
Collapse
|
31
|
Rubik J, Debray D, Kelly D, Iserin F, Webb NJA, Czubkowski P, Vondrak K, Sellier-Leclerc AL, Rivet C, Riva S, Tönshoff B, D'Antiga L, Marks SD, Reding R, Kazeem G, Undre N. Efficacy and safety of prolonged-release tacrolimus in stable pediatric allograft recipients converted from immediate-release tacrolimus - a Phase 2, open-label, single-arm, one-way crossover study. Transpl Int 2019; 32:1182-1193. [PMID: 31325368 PMCID: PMC6852421 DOI: 10.1111/tri.13479] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 01/21/2019] [Accepted: 07/11/2019] [Indexed: 12/11/2022]
Abstract
There are limited clinical data regarding prolonged‐release tacrolimus (PR‐T) use in pediatric transplant recipients. This Phase 2 study assessed the efficacy and safety of PR‐T in stable pediatric kidney, liver, and heart transplant recipients (aged ≥5 to ≤16 years) over 1 year following conversion from immediate‐release tacrolimus (IR‐T), on a 1:1 mg total‐daily‐dose basis. Endpoints included the incidence of acute rejection (AR), a composite endpoint of efficacy failure (death, graft loss, biopsy‐confirmed AR, and unknown outcome), and safety. Tacrolimus dose and whole‐blood trough levels (target 3.5–15 ng/ml) were also evaluated. Overall, 79 patients (kidney, n = 48; liver, n = 29; heart, n = 2) were assessed. Following conversion, tacrolimus dose and trough levels remained stable; however, 7.6–17.7% of patients across follow‐up visits had trough levels below the target range. Two (2.5%) patients had AR, and 3 (3.8%) had efficacy failure. No graft loss or deaths were reported. No new safety signals were identified. Drug‐related treatment‐emergent adverse events occurred in 28 patients (35.4%); most were mild, and all resolved. This study suggests that IR‐T to PR‐T conversion is effective and well tolerated over 1 year in pediatric transplant recipients and highlights the importance of therapeutic drug monitoring to maintain target tacrolimus trough levels.
Collapse
Affiliation(s)
- Jacek Rubik
- Department of Nephrology, Kidney Transplantation and Hypertension, The Children's Memorial Health Institute, Warsaw, Poland
| | - Dominique Debray
- Pediatric Hepatology Unit, APHP-Hôpital Universitaire Necker, Paris, France
| | - Deirdre Kelly
- The Liver Unit, Birmingham Women's & Children's Hospital, Birmingham, UK
| | - Franck Iserin
- Pediatric Cardiology Unit, APHP-Hôpital Universitaire Necker, Paris, France
| | - Nicholas J A Webb
- Department of Pediatric Nephrology, NIHR/Wellcome Trust Manchester Clinical Research Facility, Manchester Academic Health Science Centre, Royal Manchester Children's Hospital, University of Manchester, Manchester, UK
| | - Piotr Czubkowski
- Department of Gastroenterology, Hepatology, Nutritional Disturbances and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Karel Vondrak
- Department of Pediatrics, Second School of Medicine, University Hospital Motol, Charles University, Prague, Czech Republic
| | - Anne-Laure Sellier-Leclerc
- Department of Nephrology, Rheumatology, and Dermatology, Center for Rare Diseases, Civil Hospice of Lyon, 'Woman-Mother-Child' Hospital, Bron Cedex, France
| | - Christine Rivet
- Pediatric Hepatology, Gastroenterology and Transplantation, Civil Hospice of Lyon, Lyon, France
| | - Silvia Riva
- Department of Pediatrics, ISMETT-IRCCS, Palermo, Italy
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Lorenzo D'Antiga
- Pediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Stephen D Marks
- Department of Pediatric Nephrology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Raymond Reding
- Unité de Chirurgie et Transplantation Pédiatrique, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Gbenga Kazeem
- BENKAZ Consulting Ltd, Cambridge, UK.,Astellas Pharma Europe Ltd, Chertsey, UK
| | | |
Collapse
|
32
|
Manickavasagar R, Wong G, Alexander SI, Francis A, Prestidge C, Larkins NG, Le Page A, Lim WH. Allograft outcome following repeat transplantation of patients with non-adherence-related first kidney allograft failure: a population cohort study. Transpl Int 2019; 32:1247-1258. [PMID: 31408545 DOI: 10.1111/tri.13492] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/11/2019] [Accepted: 08/08/2019] [Indexed: 11/30/2022]
Abstract
Nonadherence is an important risk factor for premature allograft failure after kidney transplantation, but outcomes after re-transplantation remain uncertain. Using data from the Australian and New Zealand Dialysis and Transplant registry, the associations between causes of first allograft failure and acute rejection-related and non-adherence-related allograft failure following re-transplantation were examined using competing risk analyses, treating the respective alternative causes of allograft failure and death with functioning graft as competing events. Fifty-nine of 2450 patients (2%) lost their first allografts from nonadherence. Patients who lost their first kidney allograft from nonadherence were younger at the time of first kidney allograft failure but waited longer for a second allograft (>5 years: 54% vs. 20%, P < 0.001) compared with other causes. Compared with patients who lost their first allograft from causes other than nonadherence, the adjusted subdistribution hazard ratio (HR and 95% CI) for acute rejection-related second allograft failure was 0.58 (0.08, 4.07; P = 0.582) for patients with allograft failure attributed to nonadherence and was 6.30 (1.34, 29.67; P = 0.020) for non-adherence-related second allograft failure. In this cohort of transplant recipients who have received second allografts, first allograft failure secondary to nonadherence was associated with a marginally greater risk of allograft failure attributed to nonadherence in subsequent transplantation.
Collapse
Affiliation(s)
| | - Germaine Wong
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia.,University of Sydney, Sydney, NSW, Australia
| | - Stephen I Alexander
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia.,University of Sydney, Sydney, NSW, Australia
| | - Anna Francis
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia.,University of Sydney, Sydney, NSW, Australia
| | | | - Nicholas G Larkins
- Perth Children's Hospital, Perth, WA, Australia.,School of Paediatrics and Child Health, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Amelia Le Page
- Department of Nephrology, Monash Children's Hospital, Melbourne, Vic., Australia.,Department of Paediatrics, School of Clinical Sciences, Monash University, Melbourne, Vic., Australia
| | - Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia.,School of Medicine, University of Western Australia, Perth, WA, Australia
| |
Collapse
|
33
|
McGillicuddy J, Chandler J, Sox L, Mueller M, Nemeth L, Baliga P, Treiber F. "Smartphone Medication Adherence Saves Kidneys" for Kidney Transplantation Recipients: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2019; 8:e13351. [PMID: 31228175 PMCID: PMC6611329 DOI: 10.2196/13351] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 04/17/2019] [Accepted: 05/02/2019] [Indexed: 12/31/2022] Open
Abstract
Background Kidney transplant recipients’ poor medication adherence and poor control of comorbidities, particularly hypertension, are risk factors for graft rejection, graft loss, and death. Few randomized controlled trials (RCTs) have been successful in improving sustained medication adherence and blood pressure control among kidney transplantation recipients. We provide rationale for an RCT evaluating a mobile health medical self-management system for kidney transplantation recipients called Smartphone Medication Adherence Saves Kidneys (SMASK). Objective Our objective is to determine whether SMASK is efficacious in improving medication adherence and sustaining blood pressure control among kidney transplantation recipients with uncontrolled hypertension and poor medication adherence compared to an enhanced standard care. Methods This two-arm, 6-month, phase II single-site efficacy RCT will involve 80 kidney transplantation recipients. Participants will be randomly assigned to the SMASK intervention arm or control arm. SMASK includes multilevel components: automated reminders from an electronic medication tray; tailored text messages and motivational feedback, guided by the self-determination theory; and automated summary reports for providers. Evaluations will be conducted preintervention, at 3 and 6 months, and posttrial at 12 months. Specific aims are to test the hypotheses that compared to standard care, the SMASK cohort will demonstrate significantly improved changes at 3, 6, and 12 months in the primary outcome variables medication adherence (proportion with electronic monitor-derived score >0.90) and blood pressure control (proportion meeting and sustaining adherence to the Kidney Disease Improving Global Outcomes [KDIGO] guidelines for blood pressure control); the secondary outcome variables provider adherence to KDIGO guidelines, measured by timing of medication changes and changes in self-determination theory constructs; and the exploratory outcome variables estimated glomerular filtration rate, variability in calcineurin inhibitor trough levels, and proportion of patients meeting and sustaining the 24-hour ambulatory blood pressure below 130/80 mm Hg. After the 6-month evaluation, interviews with a random sample of SMASK subjects (n=20) and health care providers (n=3-5) will assess user reactions including acceptability, usability, and aids/barriers to sustainability. Data from the RCT and interviews will be triangulated to further refine and optimize SMASK and prepare for a multisite effectiveness RCT. Results The SMASK project received funding from National Institute of Diabetes and Digestive and Kidney Diseases in June 2016, obtained institutional review board approval in April 2016, and began data collection in July 2016. As of July 2018, we completed enrollment with a total of 80 participants. Conclusions This study will provide data regarding the efficacy of SMASK to improve medication adherence and blood pressure control in a cohort of hypertensive kidney transplant recipients. An efficacious SMASK intervention will pave the way for a larger, multicenter, effectiveness RCT powered sufficiently to evaluate clinical events in a real-world setting and with the potential to demonstrate improved outcomes at lower cost than standard care. International Registered Report Identifier (IRRID) DERR1-10.2196/13351
Collapse
Affiliation(s)
- John McGillicuddy
- College of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Jessica Chandler
- College of Nursing, Medical University of South Carolina, Charleston, SC, United States
| | - Luke Sox
- College of Nursing, Medical University of South Carolina, Charleston, SC, United States
| | - Martina Mueller
- College of Nursing, Medical University of South Carolina, Charleston, SC, United States
| | - Lynne Nemeth
- College of Nursing, Medical University of South Carolina, Charleston, SC, United States
| | - Prabhakar Baliga
- College of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Frank Treiber
- College of Nursing, Medical University of South Carolina, Charleston, SC, United States
| |
Collapse
|
34
|
Potter L, Lushin EN, Hofmeyer B, Ensor C, Wilson N, Tremblay S, Campara M. Discharge medication procurement and education after kidney transplantation. Clin Transplant 2019; 33:e13627. [PMID: 31162711 DOI: 10.1111/ctr.13627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 05/27/2019] [Accepted: 05/30/2019] [Indexed: 11/30/2022]
Abstract
Adherence to immunosuppressant medications is a key determinant of success following organ transplantation. Medication procurement and education are precursory. In March 2018, Medicare announced a rule change interpreted to prohibit delivery of Part B-covered immunosuppressive drugs to hospitals. A subsequent Medicare announcement clarified that immunosuppressive drug delivery to hospitals is acceptable, effective April 2019. To promulgate the perceived importance of medication delivery to hospitals among key providers of transplant discharge education, a 25-question descriptive survey was distributed between May and July 2018 to pharmacists affiliated with each active US kidney transplant program (n = 238). Survey goals were to describe discharge medication procurement practices, discharge medication teaching practices, and attitudes toward the value of medication education. A total of 155 responses were received from 115 different transplant centers. A majority (93%) of respondents require discharge medications to be onsite prior to hospital discharge. A majority (81%) of respondents use discharge medications during medication education. Acquisition of immunosuppressant medications and their delivery to the inpatient environment prior to discharge for the purpose of medication education is a common practice, is viewed as important, and serves to enhance discharge education, ensure safe transitions of care, and encourage medication adherence.
Collapse
Affiliation(s)
- Lisa Potter
- Department of Pharmacy, University of Chicago Medicine, Chicago, Illinois
| | - Erin N Lushin
- Indiana University Health Methodist Hospital, Indianapolis, Indiana
| | - Brooke Hofmeyer
- Department of Pharmacy, Mercy Hospital Iowa City, Iowa City, Iowa
| | | | - Nikita Wilson
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Simon Tremblay
- Departments of Surgery and Environmental Health, University of Cincinnati, Cincinnati, Ohio
| | - Maya Campara
- Departments of Pharmacy Practice and Surgery, University of Illinois at Chicago, Chicago, Illinois
| | | |
Collapse
|
35
|
Almardini R, Taybeh EO, Alsous MM, Hawwa AF, McKeever K, Horne R, McElnay JC. A multiple methods approach to determine adherence with prescribed mycophenolate in children with kidney transplant. Br J Clin Pharmacol 2019; 85:1434-1442. [PMID: 30845359 DOI: 10.1111/bcp.13911] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Revised: 02/07/2019] [Accepted: 02/09/2019] [Indexed: 12/22/2022] Open
Abstract
AIMS The aim of this study was, to use a multiple methods approach, including, for the first time, dried blood spot (DBS) sampling with population pharmacokinetic interpretation, to assess adherence to mycophenolate in children with kidney transplant. A second aim was to identify patient/parental factors that influenced adherence and to link adherence behaviour to clinical outcomes. METHODS A convenience sample of 33 children with kidney transplant (age ≤ 18 years) who had been prescribed mycophenolate for at least 3 months were recruited from participating outpatient clinics in the UK and Jordan. Medication adherence was determined via self-report questionnaires, medication refill data from dispensing records, and via mycophenolic acid concentrations in plasma and DBS samples obtained from children during a clinic visit. RESULTS Through triangulation of results from the different methodological approaches a total of 12 children (36.4%) were deemed to be nonadherent with their prescribed mycophenolate treatment. Logistic regression analysis indicated that nonadherence was significantly associated with the presence of mycophenolate side effects. Poor adherence was positively linked to measures of poor clinical outcomes (hospitalisation and the need for kidney biopsy). CONCLUSIONS Despite the imperative regarding medication adherence to help prevent organ rejection, a significant proportion of children are not fully adherent with their therapy. Side-effects appear to be an important factor leading to nonadherence. Measurement of mycophenolate in DBS samples, coupled with the use of population pharmacokinetics modelling, was a convenient direct approach to assessing adherence in children with kidney transplant and has the potential to be introduced into routine practice.
Collapse
Affiliation(s)
- Reham Almardini
- Department of Pediatric Nephrology, King Hussien Medical Center, Amman, Jordan
| | - Esra' O Taybeh
- Department of Applied Pharmaceutical Sciences, School of Pharmacy, Isra University, Amman, Jordan.,Clinical and Practice Research Group, School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - Mervat M Alsous
- Department of Pharmacy Practice, School of Pharmacy, Yarmouk University, Irbid, Jordan
| | - Ahmed F Hawwa
- Clinical and Practice Research Group, School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - Karl McKeever
- Department of Paediatric Nephrology, Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Rob Horne
- Centre for Behavioural Medicine, UCL School of Pharmacy, University College London, London, UK
| | - James C McElnay
- Clinical and Practice Research Group, School of Pharmacy, Queen's University Belfast, Belfast, UK
| |
Collapse
|
36
|
Kuo AC, Raghunathan K, Lartigue AM, Bryan WE, Pepin MJ, Takemoto S, Wallace AW. Freedom From Opioids After Total Knee Arthroplasty. J Arthroplasty 2019; 34:893-897. [PMID: 30777627 DOI: 10.1016/j.arth.2019.01.054] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 01/21/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND In the United States, opioids are commonly prescribed to treat knee pain after total knee arthroplasty (TKA). While surgery leads to decreased pain in most patients, a sizable minority continue to experience severe pain and consume opioids chronically after TKA. We sought to determine the population-level effect of TKA on opioid consumption by detailing the pattern of opioid prescriptions before and after surgery. METHODS We retrospectively identified US Veterans Health Administration TKA patients from 2010 to 2015. Outpatient opioid prescriptions were identified from 18 months before to 18 months after surgery, and mean daily opioid doses were calculated. Our primary end point was the achievement of opioid-freedom, defined as a period of at least 6 months without opioids. We compared the percentage of patients who were opioid-free preoperatively to the percentage who were opioid-free 18 months after surgery (no prescriptions after postoperative month 12). We identified factors associated with opioid-freedom. RESULTS In a cohort of 33,927 patients, 41% were opioid-free in the month before surgery compared to 54% 18 months after surgery (P < .001). Preoperative freedom from opioids (odds ratio, 4.59; 95% confidence interval, 4.34 to 4.85; P < .001) was more strongly associated with postoperative freedom from opioids than patient medical and social factors. CONCLUSION TKA was associated with an increase in postoperative freedom from opioids. Low preoperative dose of opioids was more strongly associated with postoperative opioid-freedom than patient characteristics, suggesting that opioid prescription patterns are a chief driver of opioid use after surgery. LEVEL OF EVIDENCE III Retrospective cohort study.
Collapse
Affiliation(s)
- Alfred C Kuo
- Department of Orthopaedic Surgery, University of California, San Francisco, CA; Orthopaedic Section, San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - Karthik Raghunathan
- Department of Anesthesiology, Duke University Medical Center, Durham, NC; The Patient Safety Center of Inquiry, Durham Veterans Affairs Medical Center, Durham, NC
| | - Alain M Lartigue
- Anesthesiology Service, San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - William E Bryan
- Pharmacy Service, Durham Veterans Affairs Health Care System, Durham, NC
| | - Marc J Pepin
- Pharmacy Service, Durham Veterans Affairs Health Care System, Durham, NC
| | - Steven Takemoto
- The Patient Safety Center of Inquiry, Durham Veterans Affairs Medical Center, Durham, NC; Anesthesiology Service, San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - Arthur W Wallace
- Anesthesiology Service, San Francisco Veterans Affairs Medical Center, San Francisco, CA
| |
Collapse
|
37
|
Leino AD, King EC, Jiang W, Vinks AA, Klawitter J, Christians U, Woodle ES, Alloway RR, Rohan JM. Assessment of tacrolimus intrapatient variability in stable adherent transplant recipients: Establishing baseline values. Am J Transplant 2019; 19:1410-1420. [PMID: 30506623 DOI: 10.1111/ajt.15199] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 11/14/2018] [Accepted: 11/26/2018] [Indexed: 01/25/2023]
Abstract
The purpose of this study was to determine the intrapatient (within the same patient) variability of tacrolimus in adherent patients. Daily tacrolimus trough levels were obtained at home using dried blood spot technology in kidney and liver transplant recipients. Patients were randomized to receive 3 formulations of tacrolimus, each for two 1-week periods. Adherence was monitored by patient diary, pill counts, and use of the Medication Event Monitoring System (MEMS). Variability was quantified as the coefficient of variation (CV). Comparison of CV between groups was by independent t test or one-way ANOVA as appropriate. The population was found to be adherent with a rate of 99.9% with a mean interval between the evening and morning dose of tacrolimus of 11.86 hours. The median CV for the entire population was 15.2% (range 4.8%-110%). There were no differences in CV by allograft type or tacrolimus formulation. The multivariate analysis did not identify any demographic characteristics associated with a CV > 30%. In a highly adherent population, tacrolimus did not display high intrapatient variability. Given the association between IPV and poor allograft outcomes, future studies are needed to quantitate the influence of adherence and establish target IPV goals.
Collapse
Affiliation(s)
- Abbie D Leino
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Eileen C King
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Division of Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Wenlei Jiang
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food & Drug Administration, Silver Spring, Maryland
| | - Alexander A Vinks
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jost Klawitter
- iC42 Clinical Research and Development, University of Colorado, Aurora, Colorado
| | - Uwe Christians
- iC42 Clinical Research and Development, University of Colorado, Aurora, Colorado
| | - E Steve Woodle
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Rita R Alloway
- Division of Nephrology, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jennifer M Rohan
- Division of Hematology and Oncology, Children's Hospital of Richmond, Richmond, Virginia
| |
Collapse
|
38
|
Ntatsaki E, Vassiliou VS, Velo-Garcia A, Salama AD, Isenberg DA. Renal transplantation for lupus nephritis: non-adherence and graft survival. Lupus 2019; 28:651-657. [PMID: 30982400 DOI: 10.1177/0961203319842641] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Poor adherence to immunosuppressive treatment is common in patients with systemic lupus erythematosus and may identify those with lupus nephritis (LN) who have a poorer prognosis. Non-adherence has also been reported to be a potential adverse outcome predictor in renal transplantation (rTp). We investigated whether non-adherence is associated with increased rTp graft rejection and/or failure in patients with LN. METHODS Patients with LN undergoing rTp in two major London hospitals were retrospectively included. Medical and electronic records were reviewed for documented concerns of non-adherence as well as laboratory biochemical drug levels. The role of non-adherence and other potential predictors of graft rejection/failure including demographics, comorbidities, age at systemic lupus erythematosus and LN diagnosis, type of LN, time on dialysis prior to rTp and medication use were investigated using logistic regression. RESULTS Out of 361 patients with LN, 40 had rTp. During a median follow-up of 8.7 years, 17/40 (42.5%) of these patients had evidence of non-adherence. A total of 12 (30.0%) patients experienced graft rejection or failure or both. In the adherent group 2/23 (8.7%) had graft rejection, whilst in the non-adherent this rose to 5/17 (29.4%, p = 0.11). Graft failure was seen in 5/23 (21.7%) patients from the adherent group and 4/17 (23.5%) in the non-adherent group ( p = 0.89). Non-adherent patients had a trend towards increased graft rejection, hazard ratio 4.38, 95% confidence interval = 0.73-26.12, p = 0.11. Patients who spent more time on dialysis prior to rTp were more likely to be adherent to medication, p = 0.01. CONCLUSION Poor adherence to immunosuppressive therapy is common and has been shown to associate with a trend towards increased graft failure in patients with LN requiring rTp. This is the first paper to report that shorter periods on dialysis prior to transplantation might lead to increased non-adherence in lupus patients.
Collapse
Affiliation(s)
- E Ntatsaki
- 1 Centre for Rheumatology, Division of Medicine, University College London, London, United Kingdom.,2 Rheumatology Department, Ipswich Hospital, Ipswich, United Kingdom
| | - V S Vassiliou
- 3 Norwich Medical School, University of East Anglia, Norwich, United Kingdom.,4 Department of Medicine, Imperial College London, London, United Kingdom
| | - A Velo-Garcia
- 1 Centre for Rheumatology, Division of Medicine, University College London, London, United Kingdom.,5 Internal Medicine Department, University Hospital Complex of Pontevedra, Pontevedra, Spain
| | - A D Salama
- 6 Centre for Nephrology, University College London, London, United Kingdom
| | - D A Isenberg
- 1 Centre for Rheumatology, Division of Medicine, University College London, London, United Kingdom
| |
Collapse
|
39
|
Kong I, Law MC, Ng GS. Clinical practice guidelines for the provision of renal service in Hong Kong: Renal Nursing Practice. Nephrology (Carlton) 2019; 24 Suppl 1:77-97. [DOI: 10.1111/nep.13504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Irene Kong
- Renal Unit, Department of Medicine and GeriatricsPrincess Margaret Hospital Hong Kong
| | - Man Ching Law
- Renal Unit, Department of Medicine and TherapeuticsPrince of Wales Hospital Hong Kong
| | - Gar Shun Ng
- Renal Dialysis CentreHong Kong Sanatorium and Hospital Hong Kong
| |
Collapse
|
40
|
Moradi O, Karimzadeh I, Davani-Davari D, Shafiekhani M, Sagheb MM. Pattern and associated factors of adherence to immunosuppressive medications in kidney transplant recipients at a referral center in Iran. Patient Prefer Adherence 2019; 13:729-738. [PMID: 31190755 PMCID: PMC6514256 DOI: 10.2147/ppa.s198967] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 03/12/2019] [Indexed: 12/02/2022] Open
Abstract
Purpose: Ever increasing number of patients who receive kidney transplantation as a therapeutic option, approaches to increase graft survival as well as to identify factors that reduce the treatment outcomes should be taken into account. One of the heightened concerns after transplantation is non-adherence to immunosuppressive medications, which increases the risk of kidney failure or even rejection. The aim of this study was to evaluate factors associated with immunosuppressant medications adherence in kidney transplant recipients. Patients and methods: Data were collected from 100 eligible kidney transplant patients referring to Shiraz Motahhari clinic and a private office of an attending nephrologist during 18 months. Adherence to immunosuppressive medications was assessed by Basel assessment of adherence to immunosuppressive medication scale at 2 time points. Results: According to the findings, 55% of patients did not adhere to their post-transplantation immunosuppressive medications. The rate of adherence to immunosuppressive medications was not either statistically or clinically significant between time points zero and six months. None of the investigated factors including demographic, clinical and social-economical-cultural factors were significantly associated with patients' adherence to immunosuppressive regimen. Furthermore, there was no statistically significant association between immunosuppressive medication adherence and acute kidney rejection. Conclusion: The rate of non-adherence to immunosuppressive medications was high. These data can be exploited by both physicians and policymakers to improve the rate of adherence to immunosuppressive medications amongst kidney transplant recipients.
Collapse
Affiliation(s)
- Omid Moradi
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Iman Karimzadeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
- Correspondence: Iman KarimzadehDepartment of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Karafarin street, P O Box 7146864685, Shiraz, IranTel +98 713 242 4128Fax +98 713 242 4126Email
| | - Dorna Davani-Davari
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mojtaba Shafiekhani
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Mahdi Sagheb
- Nephrology-Urology Research Center and Department of Internal Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| |
Collapse
|
41
|
Kenawy AS, Gheith O, Al-Otaibi T, Othman N, Abo Atya H, Al-Otaibi M, Nagy MS. Medication compliance and lifestyle adherence in renal transplant recipients in Kuwait. Patient Prefer Adherence 2019; 13:1477-1486. [PMID: 31564836 PMCID: PMC6722433 DOI: 10.2147/ppa.s209212] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 07/25/2019] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION AND AIM Kidney transplantation is the optimal treatment choice for end stage renal disease; this option needs a major change in the recipients' lifestyle and requires strict adherence to medications. The study aim was to assess the compliance of renal transplant patients to medications and lifestyle modifications in the Hamed Al-Essa Organ Transplant Center in Kuwait. PATIENTS AND METHODS One-hundred and twenty renal transplant patients were interviewed for their lifestyle behaviors after transplantation, including transplant adherence to their medications, healthy meals, personal hygiene, physical activity, regular out-patient follow up visits, and preventive measures against infection and cancer, in addition to sexual function. The questionnaire used was created by staff of the Faculty of Medicine, Mansura University, Egypt. RESULTS Sixty percent of the renal transplant patients were compliant with medications and lifestyle. Risk factors associated with poor medication compliance were being Kuwaiti citizens, women, and having had unrelated living donors (p<0.05). Compliance with medications was associated with less transplant related complications (p=0.003). Only 15% of the participants were compliant with low-salt diet, 8% with low-fat, and 11% with low-carb. One fourth of patients were compliant with a daily shower and 20% were physically active. More than 70% of the patients were regularly visiting the out-patient clinic. Compliance to preventive measures against infection was observed in 85% of patients but only 5% were avoiding direct sun exposure. Half of the male patients had sexual dysfunction but only half of them were consulting their nephrologists about it. CONCLUSION Kidney transplant patients in Kuwait had moderate compliance with medications and lifestyle modifications. Closer assessment is needed to identify the risk factors before and after transplantation to avoid any complications associated with non-compliance.
Collapse
Affiliation(s)
- Ahmed Saleh Kenawy
- Hamed Al-Essa Organ Transplant Center, Ibn Sina Group of Hospitals, Ministry of Health, Kuwait City, Kuwait
- Correspondence: Ahmed Saleh KenawyHamed Al-Essa Organ Transplant Center, Ibn Sina Group of Hospitals, Pharmacy Department, Sabah Medical Area, Shuwikh, PO Box 25427, Kuwait City, Safat13115, KuwaitTel +965 9 755 7486Email
| | - Osama Gheith
- Hamed Al-Essa Organ Transplant Center, Ibn Sina Group of Hospitals, Ministry of Health, Kuwait City, Kuwait
| | - Torky Al-Otaibi
- Hamed Al-Essa Organ Transplant Center, Ibn Sina Group of Hospitals, Ministry of Health, Kuwait City, Kuwait
| | - Nashwa Othman
- Dasman Diabetes Institute, Ministry of Health, Kuwait City, Kuwait
| | - Hasaneen Abo Atya
- Hamed Al-Essa Organ Transplant Center, Ibn Sina Group of Hospitals, Ministry of Health, Kuwait City, Kuwait
| | - Mohamed Al-Otaibi
- Hamed Al-Essa Organ Transplant Center, Ibn Sina Group of Hospitals, Ministry of Health, Kuwait City, Kuwait
| | | |
Collapse
|
42
|
Hoegy D, Bleyzac N, Robinson P, Bertrand Y, Dussart C, Janoly-Dumenil A. Medication adherence in pediatric transplantation and assessment methods: a systematic review. Patient Prefer Adherence 2019; 13:705-719. [PMID: 31123396 PMCID: PMC6511245 DOI: 10.2147/ppa.s200209] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 03/01/2019] [Indexed: 12/16/2022] Open
Abstract
Background: Medication adherence is a major concern in public health. It is fully established that immunosuppressive therapy (IT) and concomitant medications affect transplant outcomes in the pediatric population, showing interest in adherence to this therapy. The aim of the present review was to report on medication adherence in pediatric population post-transplantation. This will enable us to know the situation in this particular population. Methods: A literature search was performed using the MEDLINE database. Studies that were published from January 1999 to January 2016 in English language and which investigated medication adherence in pediatric transplantation were included. The type of organ and the methods used to assess medication adherence were studied. Results: A total of 281 records were identified, from which 34 studies were selected: 38% (n=13) on kidney transplantation, 32% (n=11) on liver transplantation, and 23% (n=10) on the transplantation of other organs. Medication adherence was found to be lower than 80% in two-thirds of the studies (64%), and varied from 22% to 97%. This wide range was explained in part by the important heterogeneity of assessment methods among studies. The methods used were objective, non-objective, or combined both types. Most studies did not fully describe the data collected: the time since transplantation, the period over which adherence was assessed, the population, the medications, and the threshold discriminating adherence and non-adherence. Conclusion: The present study found poor medication adherence in the pediatric population post-transplantation. There was a wide range of medication adherence, explained largely by the heterogeneity of assessment methods. Future studies must consider the characteristics of each methodology, but also the threshold defining adherence should be chosen on the basis of clinical outcomes, and describe all data collected to gain precision. To improve adherence in this population, it is essential to identify factors influencing medication (IT and concomitant medications) adherence.
Collapse
Affiliation(s)
- Delphine Hoegy
- EA 4129 P2S Parcours Santé Systémique – Univ Claude Bernard Lyon 1, Univ Lyon 1, Lyon, France
- Pharmacy, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
- Correspondence: Delphine HoegyP2S, EA 4129, universités Lyon I & III, 5 place d’Arsonval, 69003, Lyon, FranceEmail
| | - Nathalie Bleyzac
- Institut d’Hématologie et d’Oncologie Pédiatrique, Hospices Civils de Lyon, Lyon, France
- EMR 3738, PK/PD Modeling in Oncology, université Lyon-Sud, Lyon, France
| | - Philip Robinson
- Direction de la Recherche Clinique et de l’Innovation, Hospices Civils de Lyon, Lyon, France
| | - Yves Bertrand
- Institut d’Hématologie et d’Oncologie Pédiatrique, Hospices Civils de Lyon, Lyon, France
- U1111-CNRS UMR 5308, University of Lyon I, ENS Lyon, Lyon, France
| | - Claude Dussart
- EA 4129 P2S Parcours Santé Systémique – Univ Claude Bernard Lyon 1, Univ Lyon 1, Lyon, France
- Central Pharmacy, Hospices Civils de Lyon, Lyon, France
| | - Audrey Janoly-Dumenil
- EA 4129 P2S Parcours Santé Systémique – Univ Claude Bernard Lyon 1, Univ Lyon 1, Lyon, France
- Pharmacy, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| |
Collapse
|
43
|
Long-term Immunosuppression Adherence After Kidney Transplant and Relationship to Allograft Histology. Transplant Direct 2018; 4:e392. [PMID: 30498769 PMCID: PMC6233670 DOI: 10.1097/txd.0000000000000824] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 07/10/2018] [Indexed: 01/27/2023] Open
Abstract
Background Nonadherence to immunosuppression after kidney transplant is an important contributor to graft failure. Little is known about how nonadherence changes 3 years posttransplant when Medicare coverage of immunosuppression ends and how that nonadherence impacts allograft histology. The goal of this study was to compare rates of nonadherence during posttransplant years 1 to 3 to years 3 to 5 and examine the relationship between nonadherence during years 3 to 5 and 5-year allograft histology. Methods We retrospectively analyzed 552 conventional kidney allografts in patients transplanted at our center between January 1, 1999, and June 1, 2010, who used the Mayo Clinic Specialty Pharmacy for the first 5 years posttransplant. Nonadherence was defined as less than 80% proportion of days covered. Overall adherence to immunosuppression appeared to be higher during years 3 and 5 compared to between years 1 and 3 (89.4% vs 82.9%, respectively; P < 0.0001 [paired t test]). Results Overall nonadherence during posttransplant years 3 to 5 appeared to be associated with fibrosis and inflammation on 5-year allograft biopsy but not with transplant glomerulopathy (16.9% vs 5.9%, P = 0.004; 10.4% vs 8.5%, P = 0.61, respectively). After adjusting for nonadherence to calcineurin inhibitor and prednisone therapy, only nonadherence to antimetabolite therapy remained significantly associated with 5-year fibrosis and inflammation (odds ratio, 10.6; 95% confidence interval, 1.5-76.1; P = 0.02). Conclusions Efforts to improve long-term adherence, possibly through the use of specialty pharmacies and increased adherence to antimetabolite therapy, may improve long-term allograft histology and survival, although further studies are needed to confirm these findings.
Collapse
|
44
|
Pediatric Outcomes in Transplant: PersOnaliSing Immunosuppression To ImproVe Efficacy (POSITIVE Study): The Collaboration and Design of a National Transplant Precision Medicine Program. Transplant Direct 2018; 4:e410. [PMID: 30584591 PMCID: PMC6283088 DOI: 10.1097/txd.0000000000000842] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 09/15/2018] [Indexed: 11/26/2022] Open
Abstract
Background Despite age-related differences in biology, physiology, and behavior, transplant immunosuppression is not tailored by age. This likely contributes to high graft failure and posttransplant complications. We present the aims, design, and methods of the Pediatric Outcomes in Transplant: PersOnaliSing Immunosuppression To ImproVe Efficacy Study aimed at personalizing posttransplant immunosuppression in children and young adults. Methods In this prospective observational cohort study, we recruited pediatric and young adult solid organ transplant, pediatric allogeneic hematopoietic stem cell transplant recipients, and matched living and deceased organ donors from 14 transplant centers across Canada. Clinical data, questionnaires, biospecimens, and pharmacy records were collected at serial time points: (1) to identify genetic and host immune factors that influence immunosuppression dose requirements across different ages and transplant types, (2) to identify viral-host interactions that increase susceptibility to Epstein-Barr virus infection, and (3) to define care processes and structures associated with medication adherence in adolescents and young adults. Results From 2015 to 2018, 1662 new and prevalent transplant recipients were screened, 1166 were recruited for the various aims, including 370 liver, 445 kidney, 277 heart, 19 lung, 19 multiple, and 36 hematopoietic stem cell transplant transplants. Twelve percent were younger than 2 years, 30% were 2 to 10 years, 42% were 10 to 18 years, and 16% were 18 to 24 years at enrollment. Nine hundred thirty-one consented to participation in aims 1 and 2 (90% consent rate), 287 to aim 3 (82% consent rate). Biospecimens collected included 898 for DNA, 276 for immunoassays, and 717 for biomarker studies. Seventy percent participants have completed follow-up; 30% are pending study completion. Conclusions The design of this national multicenter cross-organ network helped maximize recruitment of a large patient cohort for studying age and organ-related differences in immunosuppression needs that would not otherwise be feasible. Leveraging the unique clinical, biological, environmental, and behavioral characteristics of this cohort will help develop precision medicine strategies for individualizing posttransplant immunosuppression.
Collapse
|
45
|
Paraskeva MA, Levin KC, Westall GP, Snell GI. Lung transplantation in Australia, 1986–2018: more than 30 years in the making. Med J Aust 2018; 208:445-450. [DOI: 10.5694/mja17.00909] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 12/05/2017] [Indexed: 11/17/2022]
Affiliation(s)
| | | | - Glen P Westall
- Alfred Hospital, Melbourne, VIC
- Monash University, Melbourne, VIC
| | - Gregory I Snell
- Alfred Hospital, Melbourne, VIC
- Monash University, Melbourne, VIC
| |
Collapse
|
46
|
Potter LM, Maldonado AQ, Lentine KL, Schnitzler MA, Zhang Z, Hess GP, Garrity E, Kasiske BL, Axelrod DA. Transplant recipients are vulnerable to coverage denial under Medicare Part D. Am J Transplant 2018; 18:1502-1509. [PMID: 29446874 DOI: 10.1111/ajt.14703] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 02/05/2018] [Accepted: 02/07/2018] [Indexed: 01/25/2023]
Abstract
Transplant immunosuppressants are often used off-label because of insufficient randomized prospective trial data to achieve organ-specific US Food and Drug Administration (FDA) approval. Transplant recipients who rely on Medicare Part D for immunosuppressant drug coverage are vulnerable to coverage denial for off-label prescriptions, unless use is supported by Centers for Medicare & Medicaid Services (CMS)-approved compendia. An integrated dataset including national transplant registry data and 3 years of dispensed pharmacy records was used to identify the prevalence of immunosuppression use that is both off-label and not supported by CMS-approved compendia. Numbers of potentially vulnerable transplant recipients were identified. Off-label and off-compendia immunosuppression regimens are frequently prescribed (3-year mean: lung 66.5%, intestine 34.2%, pancreas 33.4%, heart 21.8%, liver 16.5%, kidney 0%). The annual retail cost of these at-risk medications exceeds $30 million. This population-based study of transplant immunosuppressants vulnerable to claim denials under Medicare Part D coverage demonstrates a substantial gap between clinical practice, current FDA approval processes, and policy mandates for pharmaceutical coverage. This coverage barrier reduces access to life-saving medications for patients without alternative resources and may increase the risk of graft loss and death from medication nonadherence.
Collapse
Affiliation(s)
- Lisa M Potter
- Department of Pharmacy, University of Chicago Medicine, Chicago, IL, USA
| | | | - Krista L Lentine
- Saint Louis University Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Mark A Schnitzler
- Saint Louis University Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Zidong Zhang
- Saint Louis University Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Gregory P Hess
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,Scientific Studies & Projects, Symphony Health, Conshohocken, PA, USA
| | - Edward Garrity
- Division of Lung Transplantation, University of Chicago Medicine, Chicago, IL, USA
| | - Bertram L Kasiske
- Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN, USA.,Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN, USA
| | - David A Axelrod
- Transplant and Hepatobiliary Surgery, Lahey Clinic, Burlington, MA, USA
| |
Collapse
|
47
|
McGillicuddy JW, Taber DJ, Mueller M, Patel S, Baliga PK, Chavin KD, Sox L, Favela AP, Brunner-Jackson BM, Treiber FA. Sustainability of improvements in medication adherence through a mobile health intervention. Prog Transplant 2018; 25:217-23. [PMID: 26308780 DOI: 10.7182/pit2015975] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Context-Very few patient-centered, theory-guided programs for medication adherence and blood pressure control have been conducted in kidney transplant recipients. Objective-To evaluate preliminary indications of sustainability of improved blood pressure in kidney transplant recipients 12 months after completion of a 3-month randomized controlled trial of a mobile health pilot program to improve blood pressure and medication adherence. Participants and Design-A total of 18 of the 19 trial participants were contacted and all consented to inclusion in the retrospective analysis of their medical records showing their clinic-recorded systolic blood pressures at 3, 6, and 12 months following participation in the 3-month trial of a medical regimen self-management intervention. Results-A significant group difference in systolic blood pressure was observed longitudinally, indicating that the intervention group, as compared with the standard-care group, exhibited lower clinic-measured systolic blood pressures at the 12-month posttrial follow-up visit (P= .01). At 12-month follow-up, success in establishing and sustaining control of systolic blood pressure (<131 mm Hg) was greater in the intervention group (50%) than in the control group (11%). Conclusion-Patients in the intervention group continued to exhibit lower systolic blood pressure than did patients in the control group 12 months after the trial ended, suggesting that the intervention may have a durable impact on blood pressure control that most likely reflects sustained medication adherence. These findings will aid in the development of an adequately powered randomized controlled trial to address the sustainable impact of the intervention program on medication adherence and blood pressure control.
Collapse
Affiliation(s)
- John W McGillicuddy
- Medical University of South Carolina (JWM, DT, MM, SP, PKB, KDC, LS, AF, BB-J, FAT), College of Charleston (LS, AF), Charleston, South Carolina
| | - David J Taber
- Medical University of South Carolina (JWM, DT, MM, SP, PKB, KDC, LS, AF, BB-J, FAT), College of Charleston (LS, AF), Charleston, South Carolina
| | - Martina Mueller
- Medical University of South Carolina (JWM, DT, MM, SP, PKB, KDC, LS, AF, BB-J, FAT), College of Charleston (LS, AF), Charleston, South Carolina
| | - Sachin Patel
- Medical University of South Carolina (JWM, DT, MM, SP, PKB, KDC, LS, AF, BB-J, FAT), College of Charleston (LS, AF), Charleston, South Carolina
| | - Prabhakar K Baliga
- Medical University of South Carolina (JWM, DT, MM, SP, PKB, KDC, LS, AF, BB-J, FAT), College of Charleston (LS, AF), Charleston, South Carolina
| | - Kenneth D Chavin
- Medical University of South Carolina (JWM, DT, MM, SP, PKB, KDC, LS, AF, BB-J, FAT), College of Charleston (LS, AF), Charleston, South Carolina
| | - Luke Sox
- Medical University of South Carolina (JWM, DT, MM, SP, PKB, KDC, LS, AF, BB-J, FAT), College of Charleston (LS, AF), Charleston, South Carolina
| | - April P Favela
- Medical University of South Carolina (JWM, DT, MM, SP, PKB, KDC, LS, AF, BB-J, FAT), College of Charleston (LS, AF), Charleston, South Carolina
| | - Brenda M Brunner-Jackson
- Medical University of South Carolina (JWM, DT, MM, SP, PKB, KDC, LS, AF, BB-J, FAT), College of Charleston (LS, AF), Charleston, South Carolina
| | - Frank A Treiber
- Medical University of South Carolina (JWM, DT, MM, SP, PKB, KDC, LS, AF, BB-J, FAT), College of Charleston (LS, AF), Charleston, South Carolina
| |
Collapse
|
48
|
Dew MA, Posluszny DM, DiMartini AF, Myaskovsky L, Steel JL, DeVito Dabbs AJ. Posttransplant Medical Adherence: What Have We Learned and Can We Do Better? CURRENT TRANSPLANTATION REPORTS 2018; 5:174-188. [PMID: 30416933 DOI: 10.1007/s40472-018-0195-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Purpose of review Non-adherence to the medical regimen after kidney transplantation can contribute to poor clinical outcomes, and strategies to maximize adherence are sought by care providers and patients alike. We assessed recent evidence on prevalence, risk factors, and clinical outcomes associated with non-adherence to the medical regimen after kidney transplantation. We summarized recent clinical trials testing interventions to improve adherence and generated recommendations for future research and clinical practice. Recent findings A large evidence base documents rates of non-adherence to each of the multiple components of the regimen, including medication-taking, lifestyle activities, clinical care requirements, and substance use restrictions. Some risk factors for non-adherence are well known but the full range of risk factors remains unclear. Non-adherence to immunosuppressants and to other components of the regimen increases morbidity and mortality risks. Recent interventions, including education and counseling; electronic health strategies; and medication dose modifications, show promise for reducing immunosuppressant non-adherence. However, most of these interventions would be difficult to deploy in everyday clinical practice. Systematic dissemination of efficacious interventions into clinical practice has not been undertaken. Summary Rates and risk factors for non-adherence to the medical regimen have been examined and there is evidence that non-adherence may be ameliorated by a range of interventions. Although gaps in the evidence base remain, it would be timely to devote greater efforts to dissemination of findings. Thus, efforts are needed to assist transplant programs in using existing evidence to better identify patients who are non-adherent and to design and implement strategies to reduce or prevent non-adherence.
Collapse
Affiliation(s)
- Mary Amanda Dew
- Department of Psychiatry, University of Pittsburgh School of Medicine and Medical Center, 3811 O'Hara Street, Pittsburgh, PA 15213, USA.,Departments of Psychiatry, Psychology, Epidemiology, Biostatistics, and the Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Donna M Posluszny
- Department of Medicine and University of Pittsburgh Medical Center Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Andrea F DiMartini
- Departments of Psychiatry and Surgery and the Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Larissa Myaskovsky
- Department of Internal Medicine, Nephrology Division, and the Center for Healthcare Equity in Kidney Disease, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Jennifer L Steel
- Departments of Surgery, Psychiatry, and Psychology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Annette J DeVito Dabbs
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
49
|
Cytolytic Induction Therapy Improves Clinical Outcomes in African-American Kidney Transplant Recipients. Ann Surg 2017; 266:450-456. [PMID: 28654544 DOI: 10.1097/sla.0000000000002366] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Determine the impact of cytolytic versus IL-2 receptor antibody (IL-2RA) induction on acute rejection, graft loss and death in African-American (AA) kidney transplant (KTX) recipients. BACKGROUND AAs are underrepresented in clinical trials in transplantation; thus, there is controversy regarding the optimal choice of perioperative antibody induction in KTX to improve outcomes. METHODS National cohort study using US transplant registry data from January 1, 2000 to December 31, 2009 in adult solitary AA KTX recipients, with at least 5 years of follow-up. Multivariable logistic and Cox regression were utilized to assess the outcomes of acute rejection, graft loss, and mortality, with interaction terms to assess effect modification. RESULTS Twenty-five thousand eighty-four adult AAs receiving solitary KTX were included, 16,927 (67.5%) received cytolytic induction and 8157 (32.5%) received IL-2RA induction. After adjustment for recipient sociodemographics, donor, and transplant characteristics, the use of cytolytic induction therapy reduced the risk of acute rejection by 32% (OR 0.68, 0.62-0.75), graft loss by 9% (HR 0.91, 0.86-0.97), and death by 12% (HR 0.88, 0.83-0.94). There were a number of significant effect modifiers, including public insurance, panel reactive antibody, delayed graft function, and steroid withdrawal; in these groups, cytolytic induction substantially improved clinical outcomes. CONCLUSIONS These data demonstrate that cytolytic induction therapy, as compared with IL-2RA, reduces the risk of rejection, graft loss, and death in adult AA KTX recipients, particularly in those who are sensitized, receive public insurance, develop delayed graft function, or undergo steroid withdrawal.
Collapse
|
50
|
Massart A, Ghisdal L, Abramowicz M, Abramowicz D. Operational tolerance in kidney transplantation and associated biomarkers. Clin Exp Immunol 2017; 189:138-157. [PMID: 28449211 DOI: 10.1111/cei.12981] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2017] [Indexed: 12/30/2022] Open
Abstract
In the 1960s, our predecessors won a historical battle against acute rejection and ensured that transplantation became a common life-saving treatment. In parallel with this success, or perhaps because of it, we lost the battle for long-lived transplants, being overwhelmed with chronic immune insults and the toxicities of immunosuppression. It is likely that current powerful treatments block acute rejection, but at the same time condemn the few circulating donor cells that would have been able to elicit immunoregulatory host responses towards the allograft. Under these conditions, spontaneously tolerant kidney recipients - i.e. patients who maintain allograft function in the absence of immunosuppression - are merely accidents; they are scarce, mysterious and precious. Several teams pursue the goal of finding a biomarker that would guide us towards the 'just right' level of immunosuppression that avoids rejection while leaving some space for donor immune cells. Some cellular assays are attractive because they are antigen-specific, and provide a comprehensive view of immune responses toward the graft. These seem to closely follow patient regulatory capacities. However, these tests are cumbersome, and require abundant cellular material from both donor and recipient. The latest newcomers, non-antigen-specific recipient blood transcriptomic biomarkers, offer the promise that a practicable and simple signature may be found that overcomes the complexity of a system in which an infinite number of individual cell combinations can lead possibly to graft acceptance. Biomarker studies are as much an objective - identifying tolerant patients, enabling tolerance trials - as a means to deciphering the underlying mechanisms of one of the most important current issues in transplantation.
Collapse
Affiliation(s)
- A Massart
- Department of Nephrology, Dialysis, and Transplantation, CUB Hôpital Erasme and Institute of Interdisciplinary Research in Molecular and Human Biology (IRIBHM), Université Libre de Bruxelles, Brussels, Belgium
| | - L Ghisdal
- Department of Nephrology, Centre Hospitalier EpiCURA, Baudour, Belgium
| | - M Abramowicz
- Department of Human Genetics, CUB Hôpital Erasme and Institute of Interdisciplinary Research in Molecular and Human Biology (IRIBHM), Université Libre de Bruxelles, Brussels, Belgium
| | - D Abramowicz
- Department of Nephrology, Universitair Ziekenhuis Antwerpen and Antwerp University, Antwerp, Belgium
| |
Collapse
|