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Bonn J, Ambrosino T, Rich K, Taylor A, Wadhwani SI. Implementation of a multicomponent medication adherence promotion system is associated with a decrease in late T-cell-mediated rejection. Liver Transpl 2024:01445473-990000000-00396. [PMID: 38814162 DOI: 10.1097/lvt.0000000000000413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 05/17/2024] [Indexed: 05/31/2024]
Abstract
Poor immunosuppression adherence in pediatric recipients of liver transplant (LT) contributes to late T-cell-mediated rejection (TCMR) in ~90% of cases and increases the risk of mortality. A medication adherence promotion system (MAPS) was found to reduce late rejection in pediatric recipients of kidney transplants. Using quality improvement methodology, we adapted and implemented the MAPS in our LT clinic. Our primary outcome was population-level rates of late TCMR, measured as a monthly incident rate. Three-hundred fourteen patients undergoing LT are currently cared for at our institution. One-hundred sixty-two (52%) are females with a median age of 16 years and a median age at LT of 2 years. Preimplementation, monthly rejection rates were 0.84 rejections per 100 patient-months. After iterative implementation of MAPS over 2.3 years, monthly rejection rates decreased to 0.46 rejections per 100 patient-months, a 45% decrease in late TCMR. Implementation of MAPS was associated with a sustained 45% decrease in TCMR at a single center, suggesting that quality improvement tools may help improve clinical outcomes. MAPS may be an important tool to ensure long-term allograft health. Future studies should rigorously test MAPS across a multicenter sample.
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Affiliation(s)
- Julie Bonn
- Division of Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Teresa Ambrosino
- Department of Surgery, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kristin Rich
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Amy Taylor
- Division of Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Sharad I Wadhwani
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
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2
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Leino AD, Kaiser TE, Khalil K, Mansell H, Taber DJ. Electronic health record-enabled routine assessment of medication adherence after solid organ transplantation: the time is now. Am J Transplant 2024; 24:711-715. [PMID: 38266711 DOI: 10.1016/j.ajt.2024.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 01/02/2024] [Accepted: 01/12/2024] [Indexed: 01/26/2024]
Abstract
Medication nonadherence after solid organ transplantation is recognized as an important impediment to long-term graft survival. Yet, assessment of adherence is often not part of routine care. In this Personal Viewpoint, we call for the transplant community to consider implementing a systematic process to screen and assess medication adherence. We believe acceptable tools are available to support integrating adherence assessments into the electronic health record. Creating a standard assessment can be done efficiently and cost-effectively if we come together as a community. More importantly, such monitoring can improve outcomes and strengthen provider-patient relationships. We further discuss the practical challenges and potential rebuttals to our position.
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Affiliation(s)
- Abbie D Leino
- College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA.
| | - Tiffany E Kaiser
- Department of Medicine, Division of Digestive Diseases, University of Cincinnati, Cincinnati, Ohio, USA
| | - Karen Khalil
- Transplant Institute, New York University Langone Health, New York, New York, USA
| | - Holly Mansell
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - David J Taber
- Department of Surgery, Division of Transplant Surgery, Medical University of South Carolina, Charleston, South Carolina
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3
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Killian MO, Little CW, Howry SK, Watkivs M, Triplett KN, Desai DM. Demographic Factors, Medication Adherence, and Post-transplant Health Outcomes: A Longitudinal Multilevel Modeling Approach. J Clin Psychol Med Settings 2024; 31:163-173. [PMID: 37589865 DOI: 10.1007/s10880-023-09970-4] [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] [Accepted: 07/26/2023] [Indexed: 08/18/2023]
Abstract
Few studies in pediatric solid organ transplantation have examined non-adherence to immunosuppressive medication over time and its associations with demographic factors and post-transplant outcomes including late acute rejection and hospitalizations. We examined longitudinal variation in patient Medication Level Variability Index (MLVI) adherence data from pediatric kidney, liver, and heart transplant recipients. Patient and administrative data from the United Network for Organ Sharing were linked with electronic health records and MLVI values for 332 patients. Multilevel mediation modeling indicated comparatively more variation in MLVI values between patients than within patients, longitudinally, over 10 years post transplant. MLVI values significantly predicted late acute rejection and hospitalization. MLVI partially mediated patient factors and post-transplant outcomes for patient age indicating adolescents may benefit most from intervention efforts. Results demonstrate the importance of longitudinal assessment of adherence and differences among patients. Efforts to promote medication adherence should be adapted to high-risk patients to increase likelihood of adherence.
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Affiliation(s)
- Michael O Killian
- College of Social Work, University Center, Florida State University, 296 Champions Way, Building C - Suite 2500, Tallahassee, FL, USA.
- College of Medicine, Florida State University, Tallahassee, FL, USA.
| | - Callie W Little
- College of Social Work, University Center, Florida State University, 296 Champions Way, Building C - Suite 2500, Tallahassee, FL, USA
| | - Savarra K Howry
- College of Social Work, University Center, Florida State University, 296 Champions Way, Building C - Suite 2500, Tallahassee, FL, USA
| | - Madison Watkivs
- College of Medicine, Florida State University, Tallahassee, FL, USA
| | - Kelli N Triplett
- Children's Health, Children's Medical Center of Dallas, Dallas, TX, USA
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Dev M Desai
- Children's Health, Children's Medical Center of Dallas, Dallas, TX, USA
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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4
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Kindem IA, Åsberg A, Midtvedt K, Bjerre A. Optimizing medication adherence with home-monitoring - A feasibility study using capillary microsampling and mHealth in solid organ-transplanted adolescents. Pediatr Transplant 2023; 27:e14590. [PMID: 37543722 DOI: 10.1111/petr.14590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/08/2023] [Accepted: 07/25/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND Reliable methods to detect and reduce medication nonadherence in solid organ-transplanted (SOT) adolescents are warranted. We aimed to evaluate the feasibility of combining a medication-manager application (TusenTac®-app) with home-sampling of tacrolimus (Tac) in young SOT recipients. METHODS Kidney and combined SOT recipients between 14 and 25 years were included. During an 8-week intervention period, the participants were instructed to use the transplant-specific, age-adapted TusenTac®-app daily and to perform weekly at-home Tac trough finger-prick microsampling. Microsample Tac concentrations were controlled against timed venous samples twice. Medication implementation and persistence adherence were measured with BAASIS© questionnaires, TusenTac®-registrations, Tac trough concentration coefficient of variation (CV%) and self-reporting by interview. For comparison, venous Tac trough CV% were obtained from the year before and after the short-term intervention. RESULTS Twenty-two recipients were included, two withdrawals, leaving 20; median age 17.9 (14.5-24.8) years, 12 females (60%). The participants registered their dosage intake 88% (1502/1703) of the expected times, and 90% (106/118) of the microsamples were obtained correctly. At inclusion, 11 recipients (55%) were nonadherent assessed with BAASIS© questionnaire, four of these (36%) turned adherent during the intervention period. At the end, 70% reported improved timing-adherence at the interview. There was no significant change in TacCV% from the year before to the year after the short-term intervention. Home-sampling was reliable and measured Tac concentrations accurately. CONCLUSIONS Home-monitoring, combining Tac finger-prick microsampling and a medication-manager app, is feasible in adolescent SOT recipients with 70% perceived improvement in medication timing-adherence. There were no significant long-term changes in TacCV% confirming the need for continuous use and individualized interventions.
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Affiliation(s)
- Ingvild Andrea Kindem
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
- Department of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Anders Åsberg
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
- Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Karsten Midtvedt
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Anna Bjerre
- Department of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Shemesh E, Duncan-Park S, Mazariegos G, Annunziato R, Anand R, Reyes-Mugica M, Mitchell J, Shneider BL. The improving Medication Adherence in Adolescents and young adults following Liver Transplantation (iMALT) multisite trial: Design and trial implementation considerations. Clin Trials 2023; 20:528-535. [PMID: 37269062 PMCID: PMC10524899 DOI: 10.1177/17407745231176834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND/AIMS Medication non-adherence is a leading cause of transplant rejection, organ loss, and death; yet no rigorous controlled study to date has shown compelling clinical benefits from an adherence-improving intervention. Non-adherent patients are less likely to participate in trials, and therefore, most studies enroll a majority of adherent patients who do not stand to benefit from the intervention, as they do not have the condition (non-adherence) under investigation. The improving Medication Adherence in adolescent Liver Transplant recipients trial specifically targets non-adherent patients to investigate whether a remote intervention to improve adherence results in reduced incidence of biopsy-confirmed rejection. METHODS Improving Medication Adherence in adolescent Liver Transplant is a randomized single-blind controlled multisite, multinational National Institutes of Health-funded trial involving 13 pediatric transplant centers in the United States and Canada. An innovative, objective adherence biomarker-the Medication Level Variability Index, which is the standard deviation of a series of medication blood levels for each patient, is used to identify non-adherent patients at risk for rejection. The index is computed using electronic health record information for all potentially eligible patients based on repeated reviews of the entire clinic's roster. Identified patients, after consent, are randomized to intervention versus control (treatment as usual) arms. The remote intervention is delivered for 2 years by trained interventionists who reside in various locations in the United States. The primary outcome is the incidence of biopsy-confirmed acute cellular rejection, as confirmed by a majority vote of three pathologists who are masked to the study allocation and clinical information. DISCUSSION Improving Medication Adherence in adolescent Liver Transplant includes several innovative design elements. The use of a validated, objective adherence index to survey a large cohort of transplant recipients allows the teams to avoid bias inherent in both convenience sampling and referral-based recruitment and enroll only patients whose computed index indicates substantially increased risk of rejection. The remote intervention paradigm helps to engage patients who are by definition hard to engage. The use of an objective, masked medical (rather than behavioral) outcome measure reduces the likelihood of biases related to clinical information and ensures broad acceptance by the field. Finally, monitoring for potential adverse events related to increased medication exposure due to the adherence intervention acknowledges that a successful intervention (increasing adherence) could have detrimental side effects via increased exposure to and potential toxicity of the medication. Such monitoring is almost never attempted in clinical trials evaluating adherence interventions.
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Affiliation(s)
- Eyal Shemesh
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Rachel Annunziato
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Fordham University, Bronx, NY, USA
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6
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Killian MO, Schelbe L, Lustria MLA, Watkivs M, Gupta D. Engaging Adolescent Heart Transplant Recipients Through In-App Messaging During Mobile Health Intervention. Prog Transplant 2023; 33:229-235. [PMID: 37491864 DOI: 10.1177/15269248231189862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
Introduction: Adolescents heart transplant recipients experience difficulty with adherence to immunosuppressive medication leading to increased risk of organ rejection, hospitalization, and mortality. Few interventions have been successful to promote medication adherence in adolescent heart transplant patients as most fail to engage the patient in the behavioral change process and support patient-provider communication. The purpose of this study was to explore the nature and degree of in-app communication between adolescent heart transplant recipients and nursing staff during an asynchronous mobile video directly observed therapy intervention. Methods: A content analysis of 894 in-app messages exchanged between 10 adolescent patients and nurses during a 12-week mobile-based intervention was conducted. Two authors used an inductive, iterative process to guide a thematic analysis of the asynchronous in-app messages with high interrater reliability ranging from 81.5% to 100%. Findings: In-app messages fell under 3 broad content categories: (1) interpersonal support and rapport-building, (2) medically related questions and information, or (3) functional information about the intervention and the mHealth app. Results demonstrated the degree to which interpersonal engagement occurred during the intervention, the nature of these exchanges, and their relationship to medication adherence. Conclusions: The study provided insights into the feasibility and benefits of 2-way communication features of the directly observed therapy intervention in promoting engagement and in improving medication adherence among adolescent heart transplant patients. Continued research and clinical focus on patient engagement and impactful aspects of interpersonal communication could aid in the translation of this intervention into standard clinical care at pediatric transplant centers.
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Affiliation(s)
- Michael O Killian
- College of Social Work, Florida State University, Tallahassee, FL, USA
- College of Medicine, Florida State University, Tallahassee, FL, USA
| | - Lisa Schelbe
- College of Social Work, Florida State University, Tallahassee, FL, USA
| | - Mia Liza A Lustria
- College of Medicine, Florida State University, Tallahassee, FL, USA
- School of Information, College of Communication and Information, Florida State University, Tallahassee, FL, USA
- College of Social Sciences and Public Policy, Florida State University, Tallahassee, FL, USA
| | - Madison Watkivs
- Interdisciplinary Medical Sciences, College of Medicine, Florida State University, Tallahassee, FL, USA
| | - Dipankar Gupta
- UF Shands Children's Hospital, UF Health Congenital Heart Center, University of Florida, Gainesville, FL, USA
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Impact of CYP3A5 genotype on de-novo LCP tacrolimus dosing and monitoring in kidney transplantation. Pharmacogenet Genomics 2023; 33:59-65. [PMID: 36877088 DOI: 10.1097/fpc.0000000000000494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
OBJECTIVES LCP tac has a recommended starting dose of 0.14 mg/kg/day in kidney transplant. The goal of this study was to assess the influence of CYP3A5 on perioperative LCP tac dosing and monitoring. METHODS This was a prospective observational cohort study of adult kidney recipients receiving de-novo LCP tac. CYP3A5 genotype was measured and 90-day pharmacokinetic and clinical were assessed. Patients were classified as CYP3A5 expressors (*1 homozygous or heterozygous) or nonexpressors (LOF *3/*6/*7 allele). RESULTS In this study, 120 were screened, 90 were contacted and 52 provided consent; 50 had genotype results, and 22 patients expressed CYP3A5*1. African Americans (AA) comprised 37.5% of nonexpressors versus 81.8% of expressors (P = 0.001). Initial LCP tac dose was similar between CYP3A5 groups (0.145 vs. 0.137 mg/kg/day; P = 0.161), whereas steady state dose was higher in expressors (0.150 vs. 0.117 mg/kg/day; P = 0.026). CYP3A5*1 expressors had significantly more tac trough concentrations of less than 6 ng/ml and significantly fewer tac trough concentrations of more than 14 ng/ml. Providers were significantly more likely to under-adjust LCP tac by 10 and 20% in CYP3A5 expressors versus nonexpressors (P < 0.03). In sequential modeling, CYP3A5 genotype status explained the LCP tac dosing requirements significantly more than AA race. CONCLUSION CYP3A5*1 expressors require higher doses of LCP tac to achieve therapeutic concentrations and are at higher risk of subtherapeutic trough concentrations, persisting for 30-day posttransplant. LCP tac dose changes in CYP3A5 expressors are more likely to be under-adjusted by providers.
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Wagner-Skacel J, Fink N, Kahn J, Dalkner N, Jauk E, Bengesser S, Mairinger M, Schüssler G, Pieh C, Stadlbauer V, Kirsch AH, Zitta S, Rosenkranz AR, Fickert P, Schemmer P. Improving adherence to immunosuppression after liver or kidney transplantation in individuals with impairments in personality functioning – A randomized controlled single center feasibility study. Front Psychol 2023; 14:1150548. [PMID: 36968754 PMCID: PMC10033957 DOI: 10.3389/fpsyg.2023.1150548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 02/20/2023] [Indexed: 03/11/2023] Open
Abstract
IntroductionAlthough adherence to immunosuppressive medication is the key factor for long-term graft survival today, 20–70% of transplant recipients are non-adherent to their immunosuppressive medication.ObjectiveA prospective, randomized, controlled single-center feasibility study was designed to evaluate the impact of a step guided multicomponent interprofessional intervention program for patients after kidney or liver transplantation on adherence to their immunosuppressive medication in daily clinical practice.Materials and methodsThe intervention consisted of group therapy and daily training as well as individual sessions in a step guided approach. The primary endpoint of the study was adherence to immunosuppression as assessed with the “Basel Assessment of Adherence to Immunosuppressive Medications Scale” (BAASIS). The coefficient of variation (CV%) of Tacrolimus (TAC) through levels and the level of personality functioning was a secondary endpoint. We conducted six monthly follow-up visits.ResultsForty-one age- and sex-matched patients [19 females, 58.5 (SD = 10.56) years old, 22 kidney- and 19 liver transplantation] were randomized to the intervention- (N = 21) or control-group (N = 20). No differences between intervention- and control groups were found in the primary endpoint adherence and CV% of TAC. However, in further exploratory analyses, we observed that individuals with higher impairments in personality functioning showed higher CV% of TAC in the controls. The intervention might compensate personality-related susceptibility to poor adherence as evident in CV% of TAC.DiscussionThe results of the feasibility study showed that this intervention program was highly accepted in the clinical setting. The Intervention group could compensate higher CV% of TAC after liver or kidney transplantation in individuals with lower levels of personality functioning and non-adherence.Clinical trial registrationClinicalTrials.gov, identifier NCT04207125.
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Affiliation(s)
- Jolana Wagner-Skacel
- Department of Medical Psychology, Psychosomatics, and Psychotherapy, Medical University of Graz, Graz, Austria
- University Transplant Center Graz, Medical University of Graz, Graz, Austria
| | - Nadja Fink
- University Transplant Center Graz, Medical University of Graz, Graz, Austria
- Division of Abdominal, Visceral, and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Judith Kahn
- University Transplant Center Graz, Medical University of Graz, Graz, Austria
- Division of Abdominal, Visceral, and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Nina Dalkner
- Department of Psychiatry and Psychotherapeutic Medicine, Medical University of Graz, Graz, Austria
| | - Emanuel Jauk
- Department of Medical Psychology, Psychosomatics, and Psychotherapy, Medical University of Graz, Graz, Austria
| | - Susanne Bengesser
- Department of Psychiatry and Psychotherapeutic Medicine, Medical University of Graz, Graz, Austria
| | - Marco Mairinger
- Department of Psychiatry and Psychotherapeutic Medicine, Medical University of Graz, Graz, Austria
| | - Gerhard Schüssler
- Department of Medical Psychology, Psychosomatics, and Psychotherapy, Medical University of Graz, Graz, Austria
| | - Christoph Pieh
- Department of Psychosomatic Medicine, University for Continuing Education Krems, Krems an der Donau, Austria
| | - Vanessa Stadlbauer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Alexander H. Kirsch
- University Transplant Center Graz, Medical University of Graz, Graz, Austria
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- *Correspondence: Alexander H. Kirsch,
| | - Sabine Zitta
- University Transplant Center Graz, Medical University of Graz, Graz, Austria
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Alexander R. Rosenkranz
- University Transplant Center Graz, Medical University of Graz, Graz, Austria
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Peter Fickert
- University Transplant Center Graz, Medical University of Graz, Graz, Austria
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Peter Schemmer
- University Transplant Center Graz, Medical University of Graz, Graz, Austria
- Division of Abdominal, Visceral, and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
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9
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Morizawa Y, Satoh H, Arai M, Iwasa S, Sato A, Fujimoto K. Association Between Nonadherence and Transient Hyperuricemia in Pediatric Kidney Transplantation. Transplant Proc 2023; 55:129-133. [PMID: 36581508 DOI: 10.1016/j.transproceed.2022.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 08/29/2022] [Accepted: 09/20/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Nonadherence among pediatric transplant recipients is a significant problem that reduces graft survival and leads to poor kidney graft outcomes. It is, however, extremely difficult to detect during a regular follow-up. This study, therefore, aimed to investigate the risk factors involved in nonadherence, focusing on unexplained transient hyperuricemia in pediatric kidney transplant (KTx) recipients at a single pediatric center. METHODS This retrospective study included 167 patients who underwent KTx at our pediatric center. A Cox proportional hazards analysis was performed to evaluate the risk of nonadherence using the following factors: age, sex, body mass index SD score, transient hyperuricemia, hypertension, and follow-up period. RESULTS Nonadherence was identified in 19 patients (11%), with the average (SD) age and post-KTx duration at diagnosis being 17.21 (4.73) years and 79.21 (38.77) months, respectively. Thirty-four patients (20%) were diagnosed with transient hyperuricemia at a median of 14 months after KTx. On multivariate Cox regression analysis, transient hyperuricemia was the only independent risk factor for nonadherence after KTx. CONCLUSIONS Transient hyperuricemia was identified as one of the risk factors for nonadherence after KTx; therefore, careful monitoring for transient hyperuricemia may allow early detection of nonadherence.
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Affiliation(s)
- Y Morizawa
- Department of Urology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan; Department of Urology, Nara Medical University, Kashihara, Nara, Japan.
| | - H Satoh
- Department of Urology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - M Arai
- Department of Urology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - S Iwasa
- Department of Urology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - A Sato
- Department of Urology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - K Fujimoto
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
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Localization of drug biodistribution in a 3D-bioengineered subcutaneous neovascularized microenvironment. Mater Today Bio 2022; 16:100390. [PMID: 36033374 PMCID: PMC9403502 DOI: 10.1016/j.mtbio.2022.100390] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/29/2022] [Accepted: 07/30/2022] [Indexed: 01/13/2023] Open
Abstract
Local immunomodulation has shown the potential to control the immune response in a site-specific manner for wound healing, cancer, allergy, and cell transplantation, thus abrogating adverse effects associated with systemic administration of immunotherapeutics. Localized immunomodulation requires confining the biodistribution of immunotherapeutics on-site for maximal immune control and minimal systemic drug exposure. To this end, we developed a 3D-printed subcutaneous implant termed 'NICHE', consisting of a bioengineered vascularized microenvironment enabled by sustained drug delivery on-site. The NICHE was designed as a platform technology for investigating local immunomodulation in the context of cell therapeutics and cancer vaccines. Here we studied the ability of the NICHE to localize the PK and biodistribution of different model immunomodulatory agents in vivo. For this, we first performed a mechanistic evaluation of the microenvironment generated within and surrounding the NICHE, with emphasis on the parameters related to molecular transport. Second, we longitudinally studied the biodistribution of ovalbumin, cytotoxic T lymphocyte-associated antigen-4-Ig (CTLA4Ig), and IgG delivered locally via NICHE over 30 days. Third, we used our findings to develop a physiologically-based pharmacokinetic (PBPK) model. Despite dense and mature vascularization within and surrounding the NICHE, we showed sustained orders of magnitude higher molecular drug concentrations within its microenvironment as compared to systemic circulation and major organs. Further, the PBPK model was able to recapitulate the biodistribution of the 3 molecules with high accuracy (r > 0.98). Overall, the NICHE and the PBPK model represent an adaptable platform for the investigation of local immunomodulation strategies for a wide range of biomedical applications.
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11
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Killian MO, Clifford S, Lustria MLA, Skivington GL, Gupta D. Directly observed therapy to promote medication adherence in adolescent heart transplant recipients. Pediatr Transplant 2022; 26:e14288. [PMID: 35436376 DOI: 10.1111/petr.14288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 03/28/2022] [Accepted: 04/01/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE HT recipients experience high levels of medication non-adherence during adolescence. This pilot study examined the acceptability and feasibility of an asynchronous DOT mHealth application among adolescent HT recipients. The app facilitates tracking of patients' dose-by-dose adherence and enables transplant team members to engage patients. The DOT application allows patients to self-record videos while taking their medication and submit for review. Transplant staff review the videos and communicate with patients to engage and encourage medication adherence. METHODS Ten adolescent HT recipients with poor adherence were enrolled into a single-group, 12-week pilot study examining the impact of DOT on adherence. Secondary outcomes included self-report measures from patients and parents concerning HRQOL and adherence barriers. Long-term health outcomes assessed included AR and hospitalization 6 months following DOT. FINDINGS Among 14 adolescent HT patients approached, 10 initiated the DOT intervention. Of these, 8 completed the 12-week intervention. Patients and caregivers reported high perceptions of acceptability and accessibility. Patients submitted 90.1% of possible videos demonstrating medication doses taken. MLVI values for the 10 patients initiating DOT decreased from 6 months prior to the intervention (2.86 ± 1.83) to 6 months following their involvement (2.08 ± 0.87) representing a 21.7% decrease in non-adherence, though not statistically significant given the small sample size. CONCLUSIONS Result of this pilot study provides promising insights regarding the feasibility, acceptability, and potential impact of DOT for adolescent HT recipients. Further randomized studies are required to confirm these observations.
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Affiliation(s)
- Michael O Killian
- College of Social Work, Florida State University, Tallahassee, Florida, USA.,College of Medicine, Florida State University, Tallahassee, Florida, USA
| | - Stephanie Clifford
- Congenital Heart Center, UF Health Shands Children's Hospital, University of Florida, Gainesville, Florida, USA.,College of Nursing, University of Florida, Gainesville, Florida, USA
| | - Mia Liza A Lustria
- College of Medicine, Florida State University, Tallahassee, Florida, USA.,School of Information, College of Communication and Information, Florida State University, Tallahassee, Florida, USA
| | - Gage L Skivington
- College of Social Work, Florida State University, Tallahassee, Florida, USA
| | - Dipankar Gupta
- Congenital Heart Center, UF Health Shands Children's Hospital, University of Florida, Gainesville, Florida, USA.,Department of Pediatrics, College of Medicine, University of Florida, Gainesville, Florida, USA
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12
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Abstract
Liver transplantation (LT) for children results in excellent short- and long-term patient and graft survival. LT is a lifesaving procedure in children with acute or chronic liver disease, hepatic tumors, and select genetic metabolic diseases in which it can significantly improve quality of life. In this article, the authors discuss the unique aspects of pediatric LT, including the indications, appropriate patient selection and evaluation, allocation of organs, transplant surgery including the use of variant grafts, posttransplant care including immunosuppression management, prognosis, and transition of care.
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Affiliation(s)
- Sara Kathryn Smith
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Johns Hopkins School of Medicine, 600 N Wolfe Street, Baltimore, MD 21287, USA.
| | - Tamir Miloh
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Miami, Highland Professional Building, 1801 Northwest 9th Avenue, Miami, FL 33136, USA
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13
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Skeens M, Sezgin E, Stevens J, Landier W, Pai A, Gerhardt C. An mHealth App to Promote Adherence to Immunosuppressant Medication and Track Symptoms in Children After Hematopoietic Stem Cell Transplant: Protocol for a Mixed Methods Usability Study. JMIR Res Protoc 2022; 11:e39098. [PMID: 35862184 PMCID: PMC9353681 DOI: 10.2196/39098] [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: 04/28/2022] [Revised: 05/11/2022] [Accepted: 05/13/2022] [Indexed: 11/23/2022] Open
Abstract
Background In the United States, poor adherence accounts for up to 70% of all medication-related hospital admissions, resulting in $100 billion in health care costs annually. In pediatrics, adherence is largely dependent on caregivers. In a high-risk hematopoietic stem cell transplant (HSCT) population, caregivers are isolated with their child due to infection risk and must manage challenging treatment regimens at home, often with limited time and support. Complex behavioral interventions, typically employed to address adherence, are difficult to deliver and manage in the context of these daily tasks. The most successful adherence interventions, and thus improved clinical outcomes, have included mobile health (mHealth) reminder approaches and a direct measure of adherence. Objective This is a 3-phase project, with this protocol describing phase 2, to determine the usability and feasibility of an mHealth app (BMT4me) designed to promote adherence to immunosuppressant medication and to track symptoms among children who received HSCT. Methods This study uses an iterative convergent mixed methods design to develop and assess the usability and feasibility of an adherence digital health intervention. We will recruit 15 caregivers of pediatric patients receiving HSCT to complete user testing. Qualitative and quantitative data will be integrated to enhance and expand upon study findings. Results Enrollment began in September 2021 and is ongoing. A total of 7 caregivers have enrolled. We anticipate completion by fall 2022. We anticipate high usability scores and a better understanding of unique features within the app that are needed for HSCT families post transplant. To date, usability scores among enrolled participants are greater than 70%. Feedback from qualitative interviews is being used to further adapt the app by adding specific weekly logs, call provider options, and voice to text. Conclusions This protocol describes a mixed methods usability and feasibility study to develop and implement a smartphone app for caregivers of children receiving HSCT. The app was designed to improve immunosuppressant adherence and to track symptoms in the acute phase post discharge. Study findings will inform further refinement of the app and the feasibility of a pilot randomized controlled trial examining efficacy on clinical outcomes. Trial Registration ClinicalTrials.gov NCT04976933; https://clinicaltrials.gov/ct2/show/NCT04976933 International Registered Report Identifier (IRRID) DERR1-10.2196/39098
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Affiliation(s)
- Micah Skeens
- Center for Biobehavioral Health, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, United States
| | - Emre Sezgin
- Nationwide Children's Hospital, Columbus, OH, United States
| | - Jack Stevens
- Center for Biobehavioral Health, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, United States
| | - Wendy Landier
- Division of Pediatric Hematology Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Ahna Pai
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Cynthia Gerhardt
- Center for Biobehavioral Health, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, United States
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14
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Oomen L, Bootsma-Robroeks C, Cornelissen E, de Wall L, Feitz W. Pearls and Pitfalls in Pediatric Kidney Transplantation After 5 Decades. Front Pediatr 2022; 10:856630. [PMID: 35463874 PMCID: PMC9024248 DOI: 10.3389/fped.2022.856630] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 02/15/2022] [Indexed: 11/13/2022] Open
Abstract
Worldwide, over 1,300 pediatric kidney transplantations are performed every year. Since the first transplantation in 1959, healthcare has evolved dramatically. Pre-emptive transplantations with grafts from living donors have become more common. Despite a subsequent improvement in graft survival, there are still challenges to face. This study attempts to summarize how our understanding of pediatric kidney transplantation has developed and improved since its beginnings, whilst also highlighting those areas where future research should concentrate in order to help resolve as yet unanswered questions. Existing literature was compared to our own data of 411 single-center pediatric kidney transplantations between 1968 and 2020, in order to find discrepancies and allow identification of future challenges. Important issues for future care are innovations in immunosuppressive medication, improving medication adherence, careful donor selection with regard to characteristics of both donor and recipient, improvement of surgical techniques and increased attention for lower urinary tract dysfunction and voiding behavior in all patients.
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Affiliation(s)
- Loes Oomen
- Division of Pediatric Urology, Department of Urology, Radboudumc Amalia Children's Hospital, Nijmegen, Netherlands
| | - Charlotte Bootsma-Robroeks
- Department of Pediatric Nephrology, Radboudumc Amalia Children's Hospital, Nijmegen, Netherlands
- Department of Pediatrics, Pediatric Nephrology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Elisabeth Cornelissen
- Department of Pediatric Nephrology, Radboudumc Amalia Children's Hospital, Nijmegen, Netherlands
| | - Liesbeth de Wall
- Division of Pediatric Urology, Department of Urology, Radboudumc Amalia Children's Hospital, Nijmegen, Netherlands
| | - Wout Feitz
- Division of Pediatric Urology, Department of Urology, Radboudumc Amalia Children's Hospital, Nijmegen, Netherlands
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15
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Duncan-Park S, Danziger-Isakov L, Armstrong B, Williams N, Odim J, Shemesh E, Sweet S, Annunziato R. Posttraumatic stress and medication adherence in pediatric transplant recipients. Am J Transplant 2022; 22:937-946. [PMID: 34837457 PMCID: PMC8897237 DOI: 10.1111/ajt.16896] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 11/02/2021] [Accepted: 11/04/2021] [Indexed: 01/25/2023]
Abstract
Adolescent transplant recipients may encounter a range of potentially traumatic events (PTEs) pre- and posttransplant, yet little is known about the relationship between posttraumatic stress symptoms (PTSS) and medication adherence in this population. In the present study, adolescent recipients and caregivers completed psychosocial questionnaires at enrollment. Outpatient tacrolimus trough level data were collected over 1 year to calculate the Medication Level Variability Index (MLVI), a measure of medication adherence. Nonadherence (MLVI ≥2) was identified in 34.8% of patients, and most (80.7%) reported ≥1 PTE exposure. Levels of PTSS indicating likely posttraumatic stress disorder (PTSD) were endorsed by 9.2% of patients and 43.7% of caregivers. PTSS and MLVI were significantly correlated in the liver subgroup (r = .30, p = .04). Hierarchical multivariable linear regression analyses revealed overall patient PTSS were significantly associated with QoL (p < .001). PTEs are common in adolescent recipients; a minority may meet criteria for PTSD. PTSS screening to identify nonadherence risk requires further investigation and addressing PTSS may improve QoL. Caregivers appear at greater risk for PTSD and may require their own supports. The study was approved by each participating center's Institutional Review Board.
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Affiliation(s)
- Sarah Duncan-Park
- Icahn School of Medicine at Mount Sinai, NY, NY
- Fordham University, Bronx, NY
| | | | | | | | | | | | | | - Rachel Annunziato
- Icahn School of Medicine at Mount Sinai, NY, NY
- Fordham University, Bronx, NY
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16
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Campagna BR, Tutino R, Stevanovic K, Flood J, Halevi G, Shemesh E, Annunziato RA. Acceleration of mobile health for monitoring post-transplant in the COVID-19 era: Applications for pediatric settings. Pediatr Transplant 2022; 26:e14152. [PMID: 34661316 PMCID: PMC8646582 DOI: 10.1111/petr.14152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 08/13/2021] [Accepted: 08/17/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Since the start of the COVID-19 pandemic and consequent lockdowns, the use of telehealth interventions has rapidly increased both in the general population and among transplant recipients. Among pediatric transplant recipients, this most frequently takes the form of interventions on mobile devices, or mHealth, such as remote visits via video chat or phone, phone-based monitoring, and mobile apps. Telehealth interventions may offer the opportunity to provide care that minimizes many of the barriers of in-person care. METHODS The present review followed the PRISMA guidelines. Sources up until October 2020 were initially identified through searches of PsycInfo® and PubMed® . RESULTS We identified ten papers that reported findings from adult interventions and five studies based in pediatrics. Eight of the adult publications stemmed from the same two trials; within the pediatric subset, this was the case for two papers. Studies that have looked at mHealth interventions have found high acceptability rates over the short run, but there is a general lack of data on long-term use. CONCLUSIONS The literature surrounding pediatric trials specifically is sparse with all findings referencing interventions that are in early stages of development, ranging from field tests to small feasibility trials. The lack of research highlights the need for a multi-center RCT that utilizes robust measures of medication adherence and other outcome variables, with longer-term follow-up before telehealth interventions should be fully embraced.
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Affiliation(s)
- Bianca R. Campagna
- Department of PsychologyFordham UniversityBronxNew YorkUSA,Department of PediatricsKravis Children’s HospitalIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Rebecca Tutino
- Department of PsychologyFordham UniversityBronxNew YorkUSA,Department of PediatricsKravis Children’s HospitalIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | | | - Julia Flood
- Department of PsychologyFordham UniversityBronxNew YorkUSA
| | - Gali Halevi
- Department of MedicineIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA,Department of Medical EducationIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Eyal Shemesh
- Department of PediatricsKravis Children’s HospitalIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Rachel A. Annunziato
- Department of PsychologyFordham UniversityBronxNew YorkUSA,Department of PediatricsKravis Children’s HospitalIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
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17
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Gandolfini I, Palmisano A, Fiaccadori E, Cravedi P, Maggiore U. Detecting, preventing, and treating non-adherence to immunosuppression after kidney transplantation. Clin Kidney J 2022; 15:1253-1274. [PMID: 35756738 PMCID: PMC9217626 DOI: 10.1093/ckj/sfac017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Indexed: 11/12/2022] Open
Abstract
Medication non-adherence (MNA) is a major issue in kidney transplantation and it is associated with increased risk of rejection, allograft loss, patients’ death and higher healthcare costs. Despite its crucial importance, it is still unclear what are the best strategies to diagnose, prevent and treat MNA. MNA can be intentional (deliberate refusal to take the medication as prescribed) or unintentional (non-deliberate missing the prescribed medication). Its diagnosis may rely on direct methods, aiming at measuring drug ingestions, or indirect methods that analyse the habits of patients to adhere to correct drug dose (taking adherence) and interval (time adherence). Identifying individual risk factors for MNA may provide the basis for a personalized approach to the treatment of MNA. Randomized control trials performed so far have tested a combination of strategies, such as enhancing medication adherence through the commitment of healthcare personnel involved in drug distribution, the use of electronic reminders, therapy simplification or various multidisciplinary approaches to maximize the correction of individual risk factors. Although most of these approaches reduced MNA in the short-term, the long-term effects on MNA and, more importantly, on clinical outcomes remain unclear. In this review, we provide a critical appraisal of traditional and newer methods for detecting, preventing and treating non-adherence to immunosuppression after kidney transplantation from the perspective of the practising physician.
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Affiliation(s)
- Ilaria Gandolfini
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Nephrology Unit, University Hospital of Parma, Parma, Italy
| | | | - Enrico Fiaccadori
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Nephrology Unit, University Hospital of Parma, Parma, Italy
| | - Paolo Cravedi
- Department of Medicine, Division of Nephrology and Translational Transplant Research Center, Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Umberto Maggiore
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Nephrology Unit, University Hospital of Parma, Parma, Italy
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18
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Integration of addiction treatment and behavioral therapies in comprehensive liver transplantation care to augment adherence and reduce alcohol relapse. JOURNAL OF LIVER TRANSPLANTATION 2022. [DOI: 10.1016/j.liver.2021.100061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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19
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Abstract
Medication non-adherence causes poor outcomes in paediatric organ transplantation. COVID-19 pandemic has led to an exponential use of mobile health approaches for patient care. Herein, we describe a pilot intervention study using mobile video directly observed therapy building on emerging trends in research and clinical practice pertaining to medication adherence in paediatric organ transplantation.
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20
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Bailey P, Vergis N, Allison M, Riddell A, Massey E. Psychosocial Evaluation of Candidates for Solid Organ Transplantation. Transplantation 2021; 105:e292-e302. [PMID: 33675318 DOI: 10.1097/tp.0000000000003732] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Transplant candidates should undergo an assessment of their mental health, social support, lifestyle, and behaviors. The primary aims of this "psychosocial evaluation" are to ensure that transplantation is of benefit to life expectancy and quality of life, and to allow optimization of the candidate and transplant outcomes. The content of psychosocial evaluations is informed by evidence regarding pretransplant psychosocial predictors of transplant outcomes. This review summarizes the current literature on pretransplant psychosocial predictors of transplant outcomes across differing solid organ transplants and discusses the limitations of existing research. Pretransplant depression, substance misuse, and nonadherence are associated with poorer posttransplant outcomes. Depression, smoking, and high levels of prescription opioid use are associated with reduced posttransplant survival. Pretransplant nonadherence is associated with posttransplant rejection, and nonadherence may mediate the effects of other psychosocial variables such as substance misuse. There is evidence to suggest that social support is associated with likelihood of substance misuse relapse after transplantation, but there is a lack of consistent evidence for an association between social support and posttransplant adherence, rejection, or survival across all organ transplant types. Psychosocial evaluations should be undertaken by a trained individual and should comprise multiple consultations with the transplant candidate, family members, and healthcare professionals. Tools exist that can be useful for guiding and standardizing assessment, but research is needed to determine how well scores predict posttransplant outcomes. Few studies have evaluated interventions designed to improve psychosocial functioning specifically pretransplant. We highlight the challenges of carrying out such research and make recommendations regarding future work.
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Affiliation(s)
- Pippa Bailey
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Renal and Transplant Service, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Nikhil Vergis
- Liver Services Department, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
- Department of Metabolism Digestion and Reproduction, Imperial College London, UK
| | - Michael Allison
- Cambridge Liver Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Amy Riddell
- Renal and Transplant Service, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
- University of Exeter Medical School, Exeter, UK
| | - Emma Massey
- Department of Internal Medicine, Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
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21
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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.
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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.
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22
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Bülbüloğlu S, Demir B. The effect of perceived social support on psychological resilience in liver transplant patients receiving immunosuppression therapy. Transpl Immunol 2021; 69:101475. [PMID: 34600070 DOI: 10.1016/j.trim.2021.101475] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 09/24/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVE This study was conducted to investigate the effect of social support on psychological resilience in liver transplant patients receiving immunosuppression therapy. METHOD This study was carried out as a descriptive and cross-sectional study with the participation of 290 liver transplant patients hospitalized in the liver transplant center of a research and application hospital. Personal Information Form, Multidimensional Scale of Perceived Social Support (MSPSS) and Brief Resilience Scale (BRS) were used in data collection. The data analysis was performed with IBM Statistical Package for the Social Sciences Statistics 25. RESULTS According to the data obtained, it was determined that 30.4% of the patients were 58 years old and over, 81% of them were male and 92.8% of them were married. It was found that all of the patients used antimetabolites and corticosteroids, and 82.8% of them used calcineurin inhibitors. It was determined that 32.8% of the patients experienced infection, neuropsychiatric problems and nephrotoxicity at the same time. The psychological resilience of the patients was found to be moderate, and their perceived social support was found to be low. CONCLUSION It is not always possible for liver transplant patients to deal with their situation effectively. The psychological resilience and social support levels of patients who have undergone liver transplantation should be noticed, and social, economic and psychological support should be provided.
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Affiliation(s)
- Semra Bülbüloğlu
- Division of Surgical Nursing, Nursing Department, Erbaa Health Sciences Faculty, Gaziosmanpasa University, Erbaa, Tokat, Turkey.
| | - Bilsev Demir
- Division of Surgical Nursing, Nursing Department, Health Sciences Faculty, Turgut Özal University, Malatya, Turkey
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23
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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: 3] [Impact Index Per Article: 1.0] [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.
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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
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24
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Shemesh E, LaPointe Rudow D. Perspectives of solid organ transplant recipients on taking medications: Valuable research, just the beginning. Am J Transplant 2021; 21:3221-3222. [PMID: 33891800 DOI: 10.1111/ajt.16620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 04/14/2021] [Accepted: 04/15/2021] [Indexed: 01/25/2023]
Affiliation(s)
- Eyal Shemesh
- Division of Behavioral and Developmental Health, The Department of Pediatrics and Kravis Children's Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Dianne LaPointe Rudow
- Department of Population Health Science and Policy, Recanati Miller Transplantation Institute, Mount Sinai Hospital, New York, New York, USA
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25
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Hussain T, Nassetta K, O'Dwyer LC, Wilcox JE, Badawy SM. Adherence to immunosuppression in adult heart transplant recipients: A systematic review. Transplant Rev (Orlando) 2021; 35:100651. [PMID: 34592641 DOI: 10.1016/j.trre.2021.100651] [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: 06/21/2021] [Revised: 08/24/2021] [Accepted: 09/13/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Successful maintenance of a heart transplant (HTx) graft requires adherence to a triple-drug regimen of immunosuppression. However, achieving adequate adherence can be difficult secondary to complicated dosing regimens, side effects, and mental/emotional barriers. A detailed review of current patterns of adherence to immunosuppression in adult HTx recipients is lacking. OBJECTIVE This systematic review aims to detail the current landscape of adherence to immunosuppression in adult heart transplant patients, including the measurement of adherence, correlates to adherence, health outcomes associated with nonadherence, as well as strategies to improve adherence in HTx patients. METHODS We conducted searches in PubMed MEDLINE, Embase, CENTRAL register of Controlled Trials (Wiley), and Scopus, from inception to March 2020. Studies were eligible if they outlined an aspect of adherence (as noted above in the objective) to immunosuppression in adult HTx patients. The HTx cohort had to contain at least 10 patients and measurement of adherence had to be done with an objective or otherwise validated measure of adherence (e.g. drug levels, automated pill bottles or adherence questionnaires). Two authors independently screened the articles for inclusion, then subsequently reviewed the full texts of the included articles. Data was extracted into standardized forms and bias evaluations were done using the Newcastle-Ottawa or modified Newcastle-Ottawa tools, depending on the study type. The authors followed all guidelines for the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. RESULTS The titles/abstracts of 880 articles were reviewed. Ultimately, 23 articles were included in the final review. The median number of participants was 101, with a range of 19 to 1397. Studies provided information on baseline levels of adherence (17 studies), correlates to adherence (14 studies), health outcomes related to nonadherence (3 studies) and interventions to improve adherence (3 studies). Baseline adherence estimates varied greatly depending on the adherence measure. Multiple significant correlates to nonadherence exist and appear to affect patients with certain sociodemographic backgrounds, those with psychological/psychiatric comorbidities and those with poor support structures. Nonadherence is associated with transplant coronary artery disease and acute late rejection; it may also be associated with long-term mortality. Finally, a simplified dosing regimen with once-a-day tacrolimus as well as use of a mobile phone-based intervention were associated with improved adherence. Bias scores were most deficient due to self-reported outcomes in 18 studies, and lack of controls/adjustments for confounders, in 7 studies. CONCLUSIONS Adherence to immunosuppression in transplant patients varies, but is associated with observable and modifiable factors which are worth addressing. Further high-quality studies regarding strategies to improve adherence are needed in the literature.
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Affiliation(s)
- Tasmeen Hussain
- Department of Internal Medicine, Northwestern University McGaw Medical Center, 251 E. Huron St., Ste. 16-738, Chicago, IL 60611, USA.
| | - Keira Nassetta
- Department of Pediatrics, Lurie Children's Hospital, 225 E. Chicago Ave., Chicago, IL 60611, USA.
| | - Linda C O'Dwyer
- Galter Health Sciences Library & Learning Center, Northwestern University Feinberg School of Medicine, 320 E. Superior Street, Chicago, IL 60611, USA.
| | - Jane E Wilcox
- Department of Cardiology, Northwestern Memorial Hospital, NMH/Arkes Family Pavilion, Ste. 600; 676 N. St. Clair Ave., Chicago, IL 60611, USA.
| | - Sherif M Badawy
- Division of Hematology, Oncology, and Stem Cell Transplant, Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA; Department of Pediatrics, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Chicago, IL 60611, USA.
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Bulbuloglu S, Kapikiran G. The effect of immunosuppressive therapy after liver transplantation on activities of daily living and fear of death during the COVID-19 pandemic. Transpl Immunol 2021; 69:101470. [PMID: 34555504 PMCID: PMC8452371 DOI: 10.1016/j.trim.2021.101470] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 09/14/2021] [Accepted: 09/14/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND In our study, we aimed to investigate the effect of immunosuppressive therapy after liver transplantation on activities of daily living and fear of death during the COVID-19 pandemic. METHODS This study was conducted as a cross-sectional study with the participation of 213 liver transplant patients hospitalized in the liver transplant center of a university hospital. The data analysis was performed with IBM SPSS (Statistical Package for the Social Sciences) Statistics 25. RESULTS Katz's Activities of Daily Living (ADL) were semi-independent and the total score was 11.07 ± 1.59, and the Death Attitude Profile-Revised (DAP-R) total score was 152.23 ± 5.34. It was determined that the DAP-R score was around 150 points in the minimum and maximum score ranges of Katz ADL after liver transplantation. CONCLUSIONS High fear of death threatens resilience and can make patients feel lonely, helpless, sad, abandoned and stressed. Clinicians should spend more time with their patients.
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Affiliation(s)
- Semra Bulbuloglu
- Nursing Department, Erbaa Health Sciences Faculty, Gaziosmanpasa University, Tokat, Turkey
| | - Gurkan Kapikiran
- Nursing Department, Health Sciences Faculty, Bingol University, Bingol, Turkey..
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Demir B, Bulbuloglu S. The effect of immunosuppression therapy on activities of daily living and comfort level after liver transplantation. Transpl Immunol 2021; 69:101468. [PMID: 34536554 DOI: 10.1016/j.trim.2021.101468] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 09/12/2021] [Accepted: 09/13/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVES This study was carried out to investigate the effect of immunosuppression therapy on activities of daily living and comfort level after liver transplantation. MATERIALS AND METHODS This study was conducted in a descriptive and correlational type with the participation of 148 liver transplant patients hospitalized in the liver transplant center of a university hospital. Personal Information Form, Katz Activities of Daily Living Scale and General Comfort Questionnaire were used in data collection. The data analysis was performed with IBM SPSS (Statistical Package for the Social Sciences) Statistics 25. RESULTS According to the results obtained from the study, it was determined that 31.1% of the patients were 58 years old and over, 20.9% of them were between 48- and 57 years old, and 81.8% of them were male. It was found that 61.5% of the patients were between the 11th and 21st days after transplantation and 26.4% of them were given oxygen with a non-invasive catheter. It was determined that the patients were semi-independent in activities of daily living and had a moderate comfort level. CONCLUSIONS It is not always possible for liver transplant patients to effectively deal with their condition. The low comfort level and quality of life of patients who have undergone liver transplantation should be noticed, and social, economic and psychological support should be provided.
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Affiliation(s)
- Bilsev Demir
- Division of Surgical Nursing, Nursing Department, Health Sciences Faculty, Turgut Ozal University, Malatya, Turkey.
| | - Semra Bulbuloglu
- Division of Surgical Nursing, Nursing Department, Erbaa Health Sciences Faculty, Gaziosmanpasa University, Tokat, Turkey.
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Designing and Psychometric Properties of Appraisal Adherence to Care and Treatment Scale in Liver Transplantation Recipients. HEPATITIS MONTHLY 2021. [DOI: 10.5812/hepatmon.113911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Background: Care and treatment adherence are important factors for given good liver transplantation outcomes. Objectives: Design and validate an instrument to appraise adherence to care and treatment in liver transplantation recipients. Methods: A mixed-methods sequential exploratory study was conducted in two phases from 2017 to 2019, in the Liver Transplantation Clinic Tehran, Iran. In the qualitative phase, the concept of care and treatment adherence in liver transplantation recipients extracted by a conventional content analysis was performed on semi-structural interviews that were conducted on 18 liver transplantation recipients that were recruited through purposive sampling technique. Also, two physicians, one nurse coordinator of the liver transplantation team, and two family members were interviewed. The scale was developed based on operational definitions extracted from the qualitative phase. The validity was assessed by face, content, construct validity, and confirmatory factor analysis. The reliability was also evaluated by calculating test-retest intraclass correlation coefficient and Cronbach's alpha. The exploratory factor analysis was carried out with 286 filled the questionnaire. Results: Four factors were extracted in factor analysis. These factors explained 45.622% of the variance. The final version of the scale consisted of 20 items. The Cronbach's alpha coefficient reported as 0.889 for the total scale and the intraclass correlation coefficient was reported as 0.912. The confirmatory factor analysis led to a fitting model. Chi-square indices were reported as CMIN/DF = 2.34, NFI = 0.94, CFI = 0.96, and RAMSEA = 0.067. Conclusions: With a four factors structure, validity and reliability of adherence to care and treatment scale are acceptable; therefore, it can be used for appraisal care and treatment adherence in liver transplant recipients.
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Taber DJ, Hirsch J, Keys A, Su Z, McGillicuddy JW. Etiologies and Outcomes Associated With Tacrolimus Levels Out of a Typical Range That Lead to High Variability in Kidney Transplant Recipients. Ther Drug Monit 2021; 43:401-407. [PMID: 33560095 PMCID: PMC8119313 DOI: 10.1097/ftd.0000000000000863] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/27/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND High tacrolimus intrapatient variability (tac IPV) is associated with poor outcomes in kidney transplantation, including rejection, donor-specific antibodies, and graft loss. A common cause of high tac IPV is related to patient nonadherence, but this is yet to be conclusively demonstrated. METHODS This was a longitudinal cohort study comprising adult kidney recipients, who received transplants between 2015 and 2017, with follow-ups through February 2020. The goal of this study was to identify the most common etiologies of tac levels outside the typical range, which lead to high tac IPV, and assess the etiology-specific associations between high tac IPV and graft outcomes. Multivariate Cox regression was used to assess time-to-event analyses. RESULTS In total, 537 adult kidney recipients were included; 145 (27%) were identified as having a high tac IPV (>40%) 3-102 months post-transplant. Common etiologies of tac levels significantly outside the standard goal range (6-12 ng/mL) leading to high tac IPV included patient nonadherence (20%), infections (19%), tac-related toxicities (17%), and undocumented issues (27%). In multivariable Cox modeling, those with high tac IPV because of nonadherence had a 3.5 times higher risk of late acute rejection (P = 0.019) and 2.2 times higher risk of late graft loss (P = 0.044). No other etiologies in the typical tac level range were significantly associated with either acute rejection or graft loss. CONCLUSIONS Although high tac IPV has many causes, only high tac IPV caused by nonadherence is consistently associated with poor allograft outcomes.
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Affiliation(s)
- David J Taber
- Department of Surgery, Division of Transplant Surgery, Medical University of South Carolina, Charleston SC
| | - Jason Hirsch
- Department of Surgery, Division of Transplant Surgery, Medical University of South Carolina, Charleston SC
| | - Alison Keys
- College of Pharmacy, Medical University of South Carolina, Charleston SC
| | - Zemin Su
- Department of Medicine, Medical University of South Carolina, Charleston SC
| | - John W McGillicuddy
- Department of Surgery, Division of Transplant Surgery, Medical University of South Carolina, Charleston SC
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Sandal S, Chen T, Cantarovich M. Evaluation of Transplant Candidates With a History of Nonadherence: An Opinion Piece. Can J Kidney Health Dis 2021; 8:2054358121990137. [PMID: 33598301 PMCID: PMC7863559 DOI: 10.1177/2054358121990137] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 01/03/2021] [Indexed: 12/18/2022] Open
Affiliation(s)
- Shaifali Sandal
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Tianyan Chen
- Division of Hepatology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Marcelo Cantarovich
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
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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.
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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
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Abstract
Medication nonadherence (MNA) after solid organ transplantation is highly prevalent and associated with (late) (sub)clinical acute rejection, graft dysfunction and graft loss, development of donor-specific anti-HLA antibodies, and antibody-mediated rejection. MNA is predominantly unintentional and originates from barriers to adherence that are often multifactorial and complex. Tools to establish an early diagnosis of MNA include incorporation of MNA as a vital sign in daily clinical practice, self-reporting using validated questionnaires, calculating intrapatient variability in drug exposure and applying electronic monitoring, and recent audio and video technologies such as in home telemonitoring. MNA is a modifiable risk factor after organ transplantation, and treatment is most effective if a multimodal approach is used. Management of MNA comprises education (cognitive) and counseling (behavioral) that require the involvement of a trained multidisciplinary team [ideally physician, nurse (specialist), social worker, transplant coordinator, psychologist, clinical pharmacist], electronic reminder and support systems (eg, Medication Event Monitoring System, smartphone), and different types of novel mobile health applications as well as simplification of the medication dosing regimen. Future studies that evaluate novel therapeutic approaches for MNA should assure the use of reliable MNA measures, focus on multimodal individualized therapy for enriched nonadherent target populations (eg, adolescents), and incorporate clinically relevant endpoints. Costs, time, and personnel investments should be taken into account when assessing scalability and cost-effectiveness of novel therapeutic strategies. This review provides suggestions how different types of transplant centers can set up a dedicated MNA program according to available resources to define and achieve realistic clinical goals in managing MNA.
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Kelly D, Wray J. Non-adherence and transition clinics. Best Pract Res Clin Gastroenterol 2020; 46-47:101687. [PMID: 33158474 DOI: 10.1016/j.bpg.2020.101687] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/18/2020] [Accepted: 09/18/2020] [Indexed: 02/07/2023]
Abstract
The majority of children who undergo liver transplantation now survive into adulthood and their requirement for life-long follow-up means that they will need to transition from paediatric to adult services. Poor transition is a risk factor for poor clinical and psychosocial outcomes and one of the barriers to effective transition is vulnerability to risk-taking behaviours, and specifically non-adherence. This chapter focuses on practical considerations for transitioning young people from paediatric to adult services, with a particular focus on the risk factors associated with non-adherence and examples of interventions for managing it.
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Affiliation(s)
- Deirdre Kelly
- Liver Unit, Birmingham Women's & Children's Hospital, University of Birmingham, UK.
| | - Jo Wray
- Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, UK.
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Beck DK, Tielen M, Rechards M, Timman R, Boonstra C, Versteegh J, van de Wetering J, Zietse R, van Gelder T, Weimar W, van Saase J, van Busschbach J, Massey EK. Comparison of a home-based (multi) systemic intervention to promoting Medication AdheRence and Self-management among kidney transplant recipients with care-as-usual: the MARS randomized controlled trial protocol. BMC Nephrol 2020; 21:374. [PMID: 32859157 PMCID: PMC7453377 DOI: 10.1186/s12882-020-02008-z] [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: 07/06/2020] [Accepted: 08/03/2020] [Indexed: 11/10/2022] Open
Abstract
Background After kidney transplantation non-adherence and inadequate self-management undermine clinical outcomes and quality of life. Both have been demonstrated to be substantial in all age groups. However, interventions promoting adherence and self-management among kidney transplant recipients that have proven to be effective are scarce. In this study we aim to develop and test an intervention to optimize adherence and self-management. In this article we describe the background and design of the trial entitled ‘promoting Medication AdheRence and Self-management among kidney transplant recipients’ (MARS-trial)’. Methods/design This is a single-center, parallel arm randomized controlled trial. Nonadherent kidney transplant recipients aged 12 years or older are eligible for inclusion. Patients will be randomly assigned to either the experimental or a control group. The control group will receive care-as-usual. The experimental group will receive care-as-usual plus the MARS-intervention. The MARS-intervention is an outreaching intervention, based on the principles of (multi) systemic therapy which means involving the social network. A standardized intervention protocol is used for consistency but we will tailor the behavior change techniques used to the specific needs and determinants of each patient. The primary outcome of medication adherence will be measured using electronic monitoring. Secondary outcome measures regarding medication adherence and self-management are also assessed. Data is collected at baseline (T0), after a run-in period (T1), at six months post-baseline/end of treatment (T2) and after a six month follow-up period (T3). Discussion We combined elements of (multi) systemic therapy and evidence-based behavior change techniques to create an outreaching and highly individualized intervention. In this trial we will investigate the impact on medication adherence and self-management after kidney transplantation. Trial registration Netherlands Trial Register,trial number NTR7462. Registered 7th September 2018, https://www.trialregister.nl/trial/7264
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Affiliation(s)
- Denise Karin Beck
- Department of Internal Medicine - Section Nephrology & Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015, Rotterdam, GD, Netherlands.
| | - Mirjam Tielen
- Department of Internal Medicine - Section Nephrology & Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015, Rotterdam, GD, Netherlands
| | - Marloes Rechards
- Department of Internal Medicine - Section Nephrology & Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015, Rotterdam, GD, Netherlands
| | - Reinier Timman
- Department of Medical Psychology and Psychotherapy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Charlotte Boonstra
- Department of Medical Psychology and Psychotherapy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Josette Versteegh
- Department of Pediatric Nephrology, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jacqueline van de Wetering
- Department of Internal Medicine - Section Nephrology & Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015, Rotterdam, GD, Netherlands
| | - Robert Zietse
- Department of Internal Medicine - Section Nephrology & Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015, Rotterdam, GD, Netherlands
| | - Teun van Gelder
- Department of Internal Medicine - Section Nephrology & Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015, Rotterdam, GD, Netherlands
| | - Willem Weimar
- Department of Internal Medicine - Section Nephrology & Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015, Rotterdam, GD, Netherlands
| | - Jan van Saase
- Department of Internal Medicine - Section Nephrology & Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015, Rotterdam, GD, Netherlands
| | - Jan van Busschbach
- Department of Medical Psychology and Psychotherapy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Emma Kay Massey
- Department of Internal Medicine - Section Nephrology & Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015, Rotterdam, GD, Netherlands
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Nguyen C, Dew MA, Irizarry T, McNulty M, Rennick J, Knäuper B, Descoteaux A, Grenier A, Jeannot L, Foster BJ, DeVito Dabbs AJ. Promoting medication adherence from the perspective of adolescent and young adult kidney transplant recipients, parents, and health care professionals: A TAKE-IT TOO study. Pediatr Transplant 2020; 24:e13709. [PMID: 32388916 PMCID: PMC7392786 DOI: 10.1111/petr.13709] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 02/10/2020] [Accepted: 03/03/2020] [Indexed: 12/30/2022]
Abstract
Medication non-adherence is an important factor limiting allograft survival after kidney transplantation in AYA. Some interventions, including the TAKE-IT, showed some success in promoting adherence but the potential for scalability and use in routine clinical practice is limited. We applied user-centered design to gather the perspectives of recipients, parents, and health professionals concerning their needs, challenges, and potential intervention strategies to design an optimal, multi-component medication adherence intervention. The qualitative study was conducted at four Canadian and three American kidney transplant programs. Separate focus groups for recipients, parents, and health professionals were convened to explore these stakeholders' perspectives. Directed content analysis was employed to identify themes that were shared vs distinct across stakeholders. All stakeholder groups reported challenges related to taking medications on time in the midst of their busy schedules and the demands of transitioning toward independence during adolescence. The stakeholders also made suggestions for the multi-component behavioral intervention, including an expanded electronic pillbox and companion website, education materials, and customized digitized features to support shared responsibility and communication among recipients, parents, and health professionals. Several suggestions regarding the functionality and features of the potential intervention reported in this early stage will be explored in more depth as the iterative process unfolds. Our approach to actively involve all stakeholders in the process increases the likelihood of designing an adherence intervention that is truly user-informed and fit for the clinical setting.
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Affiliation(s)
- Christina Nguyen
- UH Rainbow Babies and Children’s Hospital Division of Pediatrics, Division of Pediatric Nephrology, Cleveland, OH, USA
| | - Mary Amanda Dew
- University of Pittsburgh School of Medicine, Psychiatry Pittsburgh, PA, USA
| | - Taya Irizarry
- University of Pittsburgh School of Nursing, Acute and Tertiary Care Pittsburgh, PA, USA
| | - Mary McNulty
- University of Pittsburgh School of Medicine, Psychiatry Pittsburgh, PA, USA
| | - Janet Rennick
- Research Institute of the McGill University Health Centre Montreal, QC, CAN
| | | | - Annie Descoteaux
- Centre Hospitalier Universitaire Ste. Justine, Montreal, QC, CAN
| | | | - Lovemine Jeannot
- Research Institute of the McGill University Health Centre Montreal, QC, CAN
| | - Bethany J Foster
- Research Institute of the McGill University Health Centre Montreal, QC, CAN
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Tang J, James L, Howell M, Tong A, Wong G. eHealth Interventions for Solid Organ Transplant Recipients: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Transplantation 2020; 104:e224-e235. [PMID: 32732828 DOI: 10.1097/tp.0000000000003294] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Lack of support for self-management may contribute to adverse health outcomes. eHealth has the potential to support self-management, but evidence in solid organ transplantation remains unclear. This review aims to evaluate the benefits and harms of eHealth interventions to support self-management in solid organ transplant recipients. METHODS We searched Cochrane Central Register of Controlled Trials, MEDLINE, and Embase databases for randomized trials of eHealth interventions in solid organ transplant recipients. We calculated the risk ratios or standardized mean difference of outcomes, and summary estimates were determined using random-effects models. The Cochrane risk of bias tool and Grading of Recommendations, Assessment, Development, and Evaluations were used to assess trial quality. RESULTS Twenty-one trials from 6 countries involving 2114 participants were included. Compared with standard care, eHealth interventions improved medication adherence (risk ratio, 1.34; CI, 1.12-2.56; I = 75%) and self-monitoring behavior (risk ratio, 2.58; CI, 1.56-4.27; I = 0%) up to 12 mo posttransplant. The treatment effects were largely consistent across different subgroups except for intervention functionality and mode of delivery. The effects on other outcomes were uncertain. Nine trials reported harms. The overall risk of bias was considered high or unclear, and the quality of evidence was low to very low for all outcomes. CONCLUSIONS eHealth interventions may improve medication adherence and self-monitoring behavior in the short term, but high-quality intervention studies are needed to determine whether eHealth will improve long-term patient-relevant outcomes.
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Affiliation(s)
- James Tang
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Laura James
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Martin Howell
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- 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, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Germaine Wong
- Sydney School of Public Health, The University of Sydney, Sydney, 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
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Beyond Survival in Solid Organ Transplantation: A Summary of Expert Presentations from the Sandoz 6th Standalone Transplantation Meeting, 2018. Transplantation 2020; 103:S1-S13. [PMID: 31449167 DOI: 10.1097/tp.0000000000002846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Implementing a Process to Systematically Identify and Address Poor Medication Adherence in Pediatric Liver Transplant Recipients. Pediatr Qual Saf 2020; 5:e296. [PMID: 32656465 PMCID: PMC7297389 DOI: 10.1097/pq9.0000000000000296] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 04/01/2020] [Indexed: 12/25/2022] Open
Abstract
Objectives Poor adherence to medication following pediatric liver transplantation remains a major challenge, with some estimates suggesting that 50% of adolescent liver transplant recipients exhibit reduced medication adherence. To date, no gold standard has emerged to address this challenge; however, system interventions are most likely to be successful. We sought to implement a system to identify and address adherence barriers in a liver transplant clinic. Methods Using structured quality improvement methods, including multiple plan-do-study-act cycles, we developed a system to screen for patients at risk of poor adherence, identify patient- and/or parent-reported barriers to adherence, and partner with patients to overcome identified barriers. We developed a process to track key outcomes, including the variability in tacrolimus trough levels and episodes of late acute cellular rejection. Results The practice saw a total of 85 patients over 6 months, and about half were females. Over this period, the improvement team implemented this system-level process with high reliability (>90% of patients received the bundle of interventions). The most commonly identified adherence barrier by patients and caregivers was "forgetting." The second most commonly identified adherence barrier by patients was that the medication "gets in the way of their activities," whereas by caregivers, it was "difficulty swallowing pills." Discussion We identified challenges and opportunities to screen for poor adherence and identify patient- and/or caregiver-reported barriers to immunosuppression adherence. Identifying such barriers and partnering with patients to overcome those barriers using patient-centered, barrier-specific interventions could improve long-term graft survival through improved medication adherence.
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Shemesh E, Shneider BL, Mazariegos GV. Weekend versus weekday adherence: Do we, or do we not, thank God it's Friday? Am J Transplant 2020; 20:7-9. [PMID: 31597219 DOI: 10.1111/ajt.15640] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 09/06/2019] [Accepted: 09/22/2019] [Indexed: 01/25/2023]
Affiliation(s)
- Eyal Shemesh
- Icahn School of Medicine at Mount Sinai and Kravis Children's Hospital, New York, New York
| | | | - George V Mazariegos
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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Campagna BR, Weatherley K, Shemesh E, Annunziato RA. Adherence to Medication During Transition to Adult Services. Paediatr Drugs 2020; 22:501-509. [PMID: 32889685 PMCID: PMC7474320 DOI: 10.1007/s40272-020-00414-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The transition from childhood and adolescence to adulthood is often tumultuous. For individuals with a chronic medical condition, this progression also includes a gradual transition to independence in healthcare management as well as a transfer in care location at some set point. As adolescents navigate these sometimes challenging processes, there is a significant risk for a decline in adequate health behaviors, which can have dire consequences. One of the most vital components of the transfer to adult care is medication adherence. Poor medication adherence puts patients at risk for worse outcomes, with the most profound being increased mortality for many conditions. In recent years, acknowledgment of the need to create evidence-based methods to aid patients during the transition period has been growing. This paper seeks to provide an overview of current research and recommendations for interventions to increase adherence to medication regimens during this period.
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Affiliation(s)
- Bianca R. Campagna
- grid.256023.0000000008755302XDepartment of Psychology, Fordham University, 441 E. Fordham Road, Bronx, NY 10458 USA ,grid.59734.3c0000 0001 0670 2351Department of Pediatrics, Icahn School of Medicine at Mount Sinai, Kravis Children’s Hospital, New York, NY USA
| | - Kristen Weatherley
- grid.59734.3c0000 0001 0670 2351Department of Pediatrics, Icahn School of Medicine at Mount Sinai, Kravis Children’s Hospital, New York, NY USA
| | - Eyal Shemesh
- grid.59734.3c0000 0001 0670 2351Department of Pediatrics, Icahn School of Medicine at Mount Sinai, Kravis Children’s Hospital, New York, NY USA
| | - Rachel A. Annunziato
- grid.256023.0000000008755302XDepartment of Psychology, Fordham University, 441 E. Fordham Road, Bronx, NY 10458 USA ,grid.59734.3c0000 0001 0670 2351Department of Pediatrics, Icahn School of Medicine at Mount Sinai, Kravis Children’s Hospital, New York, NY USA
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Cajanding R. Immunosuppression following organ transplantation. Part 2: complications and their management. ACTA ACUST UNITED AC 2019; 27:1059-1065. [PMID: 30281349 DOI: 10.12968/bjon.2018.27.18.1059] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Advances in the care of patients who have had a solid organ transplant has led to a growing population of post-transplant patients, who are also living for longer. As a result of their longer life expectancy, transplant recipients often face a multitude of challenges, including optimising their immunosuppressive regimens and managing potential complications. Life-threatening infections, malignancies, and organ-specific toxicities are the complications post-transplant patients commonly encounter and these complications are often associated with increased morbidity and mortality, adverse graft functioning and survival, profound impairment in the patient's quality of life, and significant healthcare burden. This article, the second of two parts, gives an overview of the issues involved in the care of patients who are receiving immunosuppressants. The common complications encountered by post-transplant patients are discussed and their assessment, management, prevention and treatment explored.
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Affiliation(s)
- Ruff Cajanding
- Staff Nurse, Liver Intensive Therapy Unit, Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London
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Gokoel SRM, Gombert-Handoko KB, Zwart TC, van der Boog PJM, Moes DJAR, de Fijter JW. Medication non-adherence after kidney transplantation: A critical appraisal and systematic review. Transplant Rev (Orlando) 2019; 34:100511. [PMID: 31627978 DOI: 10.1016/j.trre.2019.100511] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 08/27/2019] [Accepted: 08/28/2019] [Indexed: 10/26/2022]
Abstract
Medication non-adherence is one of the most important causes for shortened graft survival subsequently leading to a reduction in kidney graft survival results. Our aim was to provide an overview of its prevalence, risk factors, diagnostic methods and interventions to improve adherence in kidney transplant recipients. Therefore, we systematically searched the databases PubMed, COCHRANE Library, Web of Science and EMBASE for studies addressing "medication adherence", "compliance", "adherence", "kidney transplantation" and "life style factors". We identified 96 studies that satisfied our inclusion criteria. A problematic lack of a uniformly accepted definition for non-adherence was found, consequently leading to a wide range in non-adherence prevalence (36-55%). Using one uniformly accepted non-adherence definition should therefore be encouraged. A wide range in diagnostic methods makes it difficult to accurately detect non-adherence. Heterogeneous results of intervention studies make it difficult to select the best adherence enhancing method, challenging the battle against medication non-adherence. Literature suggests a combination of personalized interventions, based on patient-specific non-adherent behavior, to be most successful in improvement of adherence. High quality diagnostic methods and multidisciplinary, personalized interventions with focus on relevant clinical outcome are essential in overcoming medication non-adherence in kidney transplant recipients.
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Affiliation(s)
- Sumit R M Gokoel
- Division of Nephrology, Department of Medicine, Leiden University Medical Center, Leiden, the Netherlands.
| | - Kim B Gombert-Handoko
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Tom C Zwart
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Paul J M van der Boog
- Division of Nephrology, Department of Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Dirk Jan A R Moes
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Johan W de Fijter
- Division of Nephrology, Department of Medicine, Leiden University Medical Center, Leiden, the Netherlands
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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
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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
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Abstract
Liver transplantation (LT) for children has excellent short- and long-term patient and graft survival. LT is a lifesaving procedure in children with acute or chronic liver disease, hepatic tumors, and a few genetic metabolic diseases in which it can significantly improve quality of life. In this article, the authors discuss the unique aspects of pediatric LT, including the indications, patient selection and evaluation, allocation, transplant surgery and organ selection, posttransplant care, prognosis, adherence, and transition of care.
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Affiliation(s)
- Yen H Pham
- Pediatric Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Texas Children's Hospital, 18200 Katy Freeway, Suite 250, Houston, TX 77094, USA
| | - Tamir Miloh
- Pediatric Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Houston, TX 77030, USA.
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