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Russell CL, Moore S, Hathaway D, Cheng AL, Chen G, Goggin K. MAGIC Study: Aims, Design and Methods using SystemCHANGE™ to Improve Immunosuppressive Medication Adherence in Adult Kidney Transplant Recipients. BMC Nephrol 2016; 17:84. [PMID: 27421884 PMCID: PMC4947243 DOI: 10.1186/s12882-016-0285-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 06/24/2016] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Among adult kidney transplant recipients, non-adherence to immunosuppressive medications is the leading predictor of poor outcomes, including rejection, kidney loss, and death. An alarming one-third of kidney transplant patients experience medication non-adherence even though the problem is preventable. Existing adherence interventions have proven marginally effective for those with acute and chronic illnesses and ineffective for adult kidney transplant recipients. Our purpose is to describe the design and methods of the MAGIC (Medication Adherence Given Individual SystemCHANGE™) trial METHODS/DESIGN We report the design of a randomized controlled trial with an attention-control group to test an innovative 6-month SystemCHANGE™ intervention designed to enhance immunosuppressive medication adherence in adult non-adherent kidney transplant recipients from two transplant centers. Grounded in the Socio-Ecological Model, SystemCHANGE™ seeks to systematically improve medication adherence behaviors by identifying and shaping routines, involving supportive others in routines, and using medication taking feedback through small patient-led experiments to change and maintain behavior. After a 3-month screening phase of 190 eligible adult kidney transplant recipients, those who are <85 % adherent as measured by electronic monitoring, will be randomized into a 6-month SystemCHANGE™ intervention or attention-control phase, followed by a 6-month maintenance phase without intervention or attention. Differences in adherence between the two groups will be assessed at baseline, 6 months (intervention phase) and 12 months (maintenance phase). Adherence mediators (social support, systems-thinking) and moderators (ethnicity, perceived health) are examined. Patient outcomes (creatinine/blood urea nitrogen, infection, acute/chronic rejection, graft loss, death) and cost effectiveness are to be examined. DISCUSSION Based on the large effect size of 1.4 found in our pilot study, intervention shows great promise for increasing adherence. Grounded in the socio-ecological model, SystemCHANGE™ seeks to systematically improve medication adherence behaviors by identifying and shaping routines, involving supportive others in routines, and using medication taking feedback through small patient-lead experiments to change and maintain behavior. Medication adherence will be measured by electronic monitoring. Medication adherence persistence will be examined by evaluating differences between the two groups at the end of the 6-and 12- month phases. Mediators and moderators of medication adherence will be examined. Patient outcomes will be compared and a cost-effectiveness analysis will be conducted. TRIAL REGISTRATION ClinicalTrials.gov Registry: NCT02416479 Registered April 3, 2015.
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Affiliation(s)
- Cynthia L. Russell
- />School of Nursing and Health Studies, University of Missouri-Kansas City, Health Sciences Building 2407, Kansas City, MO 64108 USA
| | - Shirley Moore
- />Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106 USA
| | - Donna Hathaway
- />Department of Advanced Practice and Doctoral Studies, 920 Madison, #924, Memphis, TN 38163 USA
| | - An-Lin Cheng
- />School of Nursing and Health Studies, University of Missouri-Kansas City, Health Sciences Building 2407, Kansas City, MO 64108 USA
| | - Guoqing Chen
- />Department of Internal Medicine, University of Kansas Medical Center, 4043 Wescoe, MS 1037 3901 Rainbow Blvd, Kansas City, KS 66160 USA
| | - Kathy Goggin
- />Health Services and Outcomes Research, Children’s Mercy Hospitals and Clinics, University of Missouri - Kansas City Schools of Medicine and Pharmacy, 2401 Gillham Road, Kansas City, MO 64108 USA
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Russell CL. Culturally Responsive Interventions to Enhance Immunosuppressive Medication Adherence in Older African American Kidney Transplant Recipients. Prog Transplant 2016; 16:187-95; quiz 196. [PMID: 17007152 DOI: 10.1177/152692480601600302] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Context Immunosuppressive medication nonadherence is variable among older kidney transplant recipients and is a problem in African American recipients despite the severe consequences of this behavior. Many factors place older African American recipients at risk for medication nonadherence. Objective To provide an overview of interventions to enhance immunosuppressive medication adherence in older African American kidney transplant recipients using a culturally responsive model. Culturally sensitive, innovative, and transformation interventions are discussed. Situations when each intervention would be most and least appropriate are described. Conclusion Moving culturally appropriate interventions forward into practice and testing their effectiveness in improving adherence outcomes in vulnerable, older African American kidney transplant recipients is a worthy practice and research goal for transplant nursing.
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Affiliation(s)
- Cynthia L Russell
- Sinclair School of Nursing, University of Missouri-Columbia, Columbia, MO, USA
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Denhaerynck K, Desmyttere A, Dobbels F, Moons P, Young J, Siegal B, Greenstein S, Steiger J, Vanrenterghem Y, Squifflet JP, van Hooff JP, De Geest S. Nonadherence with Immunosuppressive Drugs: Us Compared with European Kidney Transplant Recipients. Prog Transplant 2016; 16:206-14. [PMID: 17007154 DOI: 10.1177/152692480601600304] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background System factors increasingly are suggested as important yet understudied correlates of nonadherence. Objective To explore the relationship between healthcare system and prevalence of nonadherence with immunosuppressive regimen by studying variation in nonadherence between European and US kidney transplant recipients and as well as nonadherence in European countries. Methods We performed a secondary data analysis on data collected in 3 independent cross-sectional studies using comparable methodology including patients from the United States, the Netherlands, Belgium, and Switzerland. Nonadherence was measured using 1 item of the Siegal questionnaire. Patients were categorized as nonadherent if they reported missing a dose of immunosuppression in the last 4 weeks. Analyses were performed by multiple mixed logistic regression, with center as a random effect and clinical and demographical differences between groups as fixed effects. Results 1563 US and 614 European patients from 3 different countries (Belgium [n=187], the Netherlands [n=85], and Switzerland [n=342]) were included. Prevalence of nonadherence in the United States and Europe was 19.3% and 13.2.%, respectively. This higher nonadherence in US patients was confirmed in a multiple logistic regression analysis (OR=1.78; 95% CI, 1.10–2.89). Nonadherence differed between Belgium (16%) and the Netherlands (14.1%) (OR=0.27; 95% CI, 0.09–0.80) and between Belgium and Switzerland (11.4%; OR=0.17; 95% CI, 0.0–0.42). Conclusion This is the first study showing differences in prevalence of nonadherence between European and US patients and among European patients. Further research should aim at unraveling the dynamics explaining these differences.
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Page TF, Woodward RS. Cost–effectiveness of Medicare’s coverage of immunosuppression medications for kidney transplant recipients. Expert Rev Pharmacoecon Outcomes Res 2014; 9:435-44. [DOI: 10.1586/erp.09.52] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Sandhu GS, Khattak M, Pavlakis M, Woodward R, Hanto DW, Wasilewski MA, Dimitri N, Goldfarb-Rumyantzev A. Recipient's unemployment restricts access to renal transplantation. Clin Transplant 2013; 27:598-606. [PMID: 23808849 DOI: 10.1111/ctr.12177] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2013] [Indexed: 01/06/2023]
Abstract
Equitable distribution of a scarce resource such as kidneys for transplantation can be a challenging task for transplant centers. In this study, we evaluated the association between recipient's employment status and access to renal transplantation in patients with end-stage renal disease (ESRD). We used data from the United States Renal Data System (USRDS). The primary variable of interest was employment status at ESRD onset. Two outcomes were analyzed in Cox model: (i) being placed on the waiting list for renal transplantation or being transplanted (whichever occurred first); and (ii) first transplant in patients who were placed on the waiting list. We analyzed 429 409 patients (age of ESRD onset 64.2 ± 15.2 yr, 55.0% males, 65.1% White). Compared with patients who were unemployed, patients working full time were more likely to be placed on the waiting list/transplanted (HR 2.24, p < 0.001) and to receive a transplant once on the waiting list (HR 1.65, p < 0.001). Results indicate that recipient's employment status is strongly associated with access to renal transplantation, with unemployed and partially employed patients at a disadvantage. Adding insurance status to the model reduces the effect size, but the association still remains significant, indicating additional contribution from other factors.
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Affiliation(s)
- Gurprataap S Sandhu
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
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Sarem S, Li J, Nekka F. Compliance descriptors: analysis and evaluation in terms of therapeutic effect. Biopharm Drug Dispos 2011; 32:76-88. [PMID: 21341277 DOI: 10.1002/bdd.739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2010] [Revised: 11/05/2010] [Accepted: 11/10/2010] [Indexed: 12/17/2022]
Abstract
The aim of this work was to evaluate the performance of various compliance parameters in order to identify those which best assess the impact of compliance on therapeutic issues. We will discuss the particularities and restrictions of these parameters by considering two criteria, namely sensitivity index and reliability, which respectively describe strength and robustness of the relationship between these parameters and compliance. Using real and virtual data, performance analysis of compliance parameters was carried out for drugs whose pharmacokinetic properties govern the time course of their actions. Within this context, it was found that the percentage of taken doses (PTD), the most widely used parameter, poorly performed in the evaluation of the therapeutic impact of compliance. On the other hand, the adjusted percentage of correct doses (PCD*) which we propose here, showed the best reliability, making it the most appropriate parameter for the comparison of different compliance patterns. The percentage of correct doses (PCD) has, in its turn, the highest sensitivity index and thus should be preferred for the assessment of changes in compliance. Hence, a perfect parameter for the evaluation of compliance impact cannot be universally identified since each parameter can have its own characteristic advantages and limitations. The methodology proposed here is general enough to be adapted for similar drug classes to evaluate their compliance descriptors.
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Affiliation(s)
- Sarem Sarem
- Faculté de Pharmacie, Université de Montréal, C.P. 6128, Succ. Centre-ville, Montréal, Québec, H3C 3J7 Canada
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Russell CL, Cetingok M, Hamburger KQ, Owens S, Thompson D, Hathaway D, Winsett RP, Conn VS, Madsen R, Sitler L, Wakefield MR. Medication adherence in older renal transplant recipients. Clin Nurs Res 2010; 19:95-112. [PMID: 20185804 DOI: 10.1177/1054773810362039] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
This project examined patterns, predictors, and outcomes of medication adherence in a convenience sample of 37 renal transplant recipients aged 55 years or older in a Mid-Southern U.S. facility using an exploratory, descriptive, longitudinal design. Electronic monitoring was conducted for 12 months using the Medication Event Monitoring System. An alarming 86% of the participants were nonadherent with medications. Four clusters of medication taking and timing patterns were identified with evening doses presenting particular challenges. Depression, self-efficacy, social support, and medication side effects did not predict medication adherence. There was no significant difference in medication adherence scores between those with and without infections. Medication adherence pattern data from electronic monitoring provides an opportunity for health care professionals to move away from blaming the patient by attempting to identify predictors for medication nonadherence. Medication dose taking and timing patterns could be explored with patients so that medication adherence interventions could target specific patient patterns.
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Affiliation(s)
- Cynthia L Russell
- Sinclair School of Nursing, University of Missouri, Columbia, MO 65203, USA.
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A clinical nurse specialist-led intervention to enhance medication adherence using the plan-do-check-act cycle for continuous self-improvement. CLIN NURSE SPEC 2010; 24:69-75. [PMID: 20168141 DOI: 10.1097/nur.0b013e3181cf554d] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
PURPOSE A clinical nurse specialist-led intervention to improve medication adherence in chronically ill adults using renal transplant recipients as an exemplar population is proposed. BACKGROUND/RATIONALE Meta-analyses and systematic reviews of chronically ill and transplant patients indicate that patient-specific characteristics not only are poor and inconsistent predictors for medication nonadherence but also are not amenable to intervention. Adherence has not meaningfully improved, despite meta-analyses and systematic narrative reviews of randomized controlled trials (RCTs) dealing with medication nonadherence in acutely and chronically ill persons and RCTs dealing with transplant patients. Interventions with a superior potential to enhance medication adherence must be developed. DESCRIPTION OF THE INTERVENTION Use of a clinical nurse specialist-led continuous self-improvement intervention with adult renal transplant recipients is proposed. Continuous self-improvement focuses on improving personal systems thinking and behavior using the plan-do-check-act process. Electronic medication monitoring reports, one of several objective measures of medication adherence, are used by the clinician to provide patient feedback during the check process on medication-taking patterns. CONCLUSION Continuous self-improvement as an intervention holds promise in supporting patient self-management and diminishing the blame that clinicians place on patients for medication nonadherence. Using an objective measure of medication adherence such as an electronic monitoring report fosters collaborative patient-clinician discussions of daily medication-taking patterns. Through collaboration, ideas for improving medication taking can be explored. Changes can be followed and evaluated for effectiveness through the continuous self-improvement process. IMPLICATIONS Future studies should include RCTs comparing educational and/or behavioral interventions to improve medication adherence.
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Willoughby LM, Fukami S, Bunnapradist S, Gavard JA, Lentine KL, Hardinger KL, Burroughs TE, Takemoto SK, Schnitzler MA. Health insurance considerations for adolescent transplant recipients as they transition to adulthood. Pediatr Transplant 2007; 11:127-31. [PMID: 17300489 DOI: 10.1111/j.1399-3046.2006.00639.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The advent of improved immunosuppression and enhanced allograft outcomes has resulted in a growing number of patients taking expensive immunosuppression medications for the rest of their lives. Healthcare costs for the majority of transplantation procedures in the USA currently are covered by Medicare, but coverage ends for outpatient immunosuppression medications 36-44 months after transplantation. Two or three immunosuppressive agents typically are included in post-transplant regimens with a total annual cost that can exceed 13,000 dollars. This represents a significant financial burden for families no matter if they have adequate health insurance coverage because of co-payment obligations. Evidence suggests that some patients have reduced immunosuppression doses because of an inability to afford their medication, increasing the risk of graft failure. The purpose of this article was to review these and other issues pertaining to medical insurance coverage and transplantation, particularly for adolescent recipients as they transition to adulthood.
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Affiliation(s)
- Lisa M Willoughby
- Department of Internal Medicine, Center for Outcomes Research, Saint Louis University, St Louis, MO 63104, USA
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Russell CL, Conn VS, Ashbaugh C, Madsen R, Hayes K, Ross G. Medication adherence patterns in adult renal transplant recipients. Res Nurs Health 2007; 29:521-32. [PMID: 17131276 PMCID: PMC8462975 DOI: 10.1002/nur.20149] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Patient adherence to immunosuppressive medications adherence is crucial to survival of the patient and a transplanted kidney, yet adherence is variable. Using a prospective, descriptive design, immunosuppressive medication adherence of 44 renal transplant recipients was followed for 6 months at a Midwestern transplant center using electronic monitoring. Four medication adherence patterns emerged from a hierarchical cluster analysis: those who took medications on time, those who took medications on time with late/missed doses, those who rarely took medications on time and who were late with morning and/or evening doses, and those who missed doses. This study is a step toward developing and implementing interventions targeted to specific patterns of poor adherence.
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Affiliation(s)
- Cynthia L Russell
- The John A. Hartford Foundation and Atlantic Philanthropies, Building Academic Geriatric Nursing Capacity, Fellow University of Missouri-Columbia, Sinclair School of Nursing S423, Columbia, Missouri 65211, USA
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Denhaerynck K, Desmyttere A, Dobbels F, Moons P, Young J, Siegal B, Greenstein S, Steiger J, Vanrenterghem Y, Squifflet JP, van Hooff J, De Geest S. Nonadherence with immunosuppressive drugs: US compared with European kidney transplant recipients. Prog Transplant 2006. [DOI: 10.7182/prtr.16.3.42x638u8610630k0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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12
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Russell C. Culturally responsive interventions to enhance immunosuppressive medication adherence in older African American kidney transplant recipients. Prog Transplant 2006. [DOI: 10.7182/prtr.16.3.b3170416r0q030ht] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Denhaerynck K, Dobbels F, Cleemput I, Desmyttere A, Schäfer-Keller P, Schaub S, De Geest S. Prevalence, consequences, and determinants of nonadherence in adult renal transplant patients: a literature review. Transpl Int 2005; 18:1121-33. [PMID: 16162098 DOI: 10.1111/j.1432-2277.2005.00176.x] [Citation(s) in RCA: 310] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
This literature review summarizes the evidence on the prevalence, determinants, clinical and economic consequences of nonadherence with immunosuppressive drugs in renal transplant patients. A literature search yielded 38 articles measuring nonadherence by self-report, collateral report, assay, refill prescriptions or electronic monitoring. The weighted mean prevalence of self-reported nonadherence was 28%. Nonadherence is associated with poor clinical outcomes, contributing to 20% of late acute rejection episodes and 16% of the graft losses (weighted means). In addition, nonadherence results in lower lifetime costs because of shorter survival, yet also in a lower number of quality adjusted life years. Consistent determinants of nonadherence were younger age, social isolation, and cognitions (e.g. low self-efficacy, certain health beliefs). Determinants concerning the health care system/team seem to be under-investigated. Because the evidence summarized in this review is based on older immunosuppressive regimens, further research should focus on prevalence, determinants and consequences of nonadherence with newer immunosuppressive regimens.
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Affiliation(s)
- Kris Denhaerynck
- Institute of Nursing Science, University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland
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Kenna LA, Labbé L, Barrett JS, Pfister M. Modeling and simulation of adherence: approaches and applications in therapeutics. AAPS JOURNAL 2005; 7:E390-407. [PMID: 16353919 PMCID: PMC2750977 DOI: 10.1208/aapsj070240] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Partial adherence with a prescribed or randomly assigned dose gives rise to unintended variability in actual drug exposure in clinical practice and during clinical trials. There are tremendous costs associated with incomplete and/or improper drug intake-to both individual patients and society as a whole. Methodology for quantifying the relation between adherence, exposure and drug response is an area of active research. Modeling and statistical approaches have been useful in evaluating the impact of adherence on therapeutics and in addressing the challenges of confounding and measurement error which arise in this context. This paper reviews quantitative approaches to using adherence information in improving therapeutics. It draws heavily on applications in the area of HIV pharmacology.
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Feinstein S, Keich R, Becker-Cohen R, Rinat C, Schwartz SB, Frishberg Y. Is noncompliance among adolescent renal transplant recipients inevitable? Pediatrics 2005; 115:969-73. [PMID: 15805372 DOI: 10.1542/peds.2004-0211] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To evaluate the prevalence of noncompliance and factors that influence poor adherence to immunosuppressive drug regimens among kidney transplant recipients. METHODS We reviewed immunosuppressive drug compliance in 79 posttransplant patients. Patient self-report and low plasma calcineurin inhibitor levels served as indicators of noncompliance. RESULTS The prevalence of noncompliance was found to be highest in adolescents who were responsible for their own medications and who underwent cadaveric kidney transplantation (CTx; 45.5%) and lower after living related transplantation (28.6%). There were no documented cases of noncompliance among any recipient of living unrelated (commercial) transplantation. Among 13 noncompliant patients, the first indication of "drug holiday" was low plasma calcineurin inhibitor levels in 11 children. Two additional children presented with acute rejection. In 7 patients, repeated episodes of "drug holidays" led to acute rejection later: 21.4 +/- 13.2 months after the first decrease in plasma calcineurin inhibitor level had been recorded. All 9 patients who experienced acute rejection subsequently developed chronic rejection. In 4 patients, noncompliance did not influence graft function. Psychosocial factors that were associated with noncompliance included insufficient family support, low self-awareness caused by poor cognitive abilities, and denial. CONCLUSIONS The absence of cases of noncompliance in adolescents who underwent commercial living unrelated kidney transplantation suggests that although noncompliance is prevalent, it is not inevitable. Strategies to decrease noncompliance in young patients with chronic illnesses can be learned from the experience with transplant recipients. The general pediatrician has a central role in identifying and addressing the problem of noncompliance in adolescents with chronic disease.
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Affiliation(s)
- Sofia Feinstein
- Division of Pediatric Nephrology, Shaare Zedek Medical Center and Hebrew University-Hadassah School of Medicine, Jerusalem, Israel
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Abstract
Three decades ago renal transplantation had become the accepted therapy for end-stage renal disease in children. Cyclosporine (CsA) was introduced into the majority of clinical immunosuppressive protocols in the 1980s and attained a vital place in the armamentarium of antirejection drugs for children. However, CsA therapy is not without adverse effects, notably posttransplant hypertension, hyperlipidemia, and nephrotoxicity. The cosmetic side effects of CsA, principally hirsutism and gum hyperplasia, are significant and very important to children particularly when drug compliance issues are vital to achieve success. The central role CsA has played to date in the development of successful treatment protocols for children undergoing renal transplantation is explored, including the importance of therapeutic drug level monitoring to optimize clinical outcomes.
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Affiliation(s)
- I E Willetts
- Nephrourology Unit, Great Ormond Street Hospital for Children NHS Trust, London, UK
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Yen EF, Hardinger K, Brennan DC, Woodward RS, Desai NM, Crippin JS, Gage BF, Schnitzler MA. Cost-effectiveness of extending Medicare coverage of immunosuppressive medications to the life of a kidney transplant. Am J Transplant 2004; 4:1703-8. [PMID: 15367228 DOI: 10.1111/j.1600-6143.2004.00565.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Unless they maintain Medicare status through disability or age, kidney transplant recipients lose their Medicare coverage of immunosuppression 3 years after transplantation. A significant transplant survival advantage has previously been demonstrated by the extension of Medicare immunosuppressive medication coverage from 1 year to 3 years, which occurred between 1993 and 1995. The United States Renal Data System (USRDS) was analyzed for recipients of kidney transplants from 1995 to 1999. Using a Markov model, we estimated survival and costs of the current system of 3-year coverage compared with lifetime immunosuppression coverage. Results were calculated from the perspectives of society and Medicare. Extension of immunosuppression coverage produced an expected improvement from 38.6% to 47.6% in graft survival and from 55.4% to 61.8% in patient survival. The annualized expected savings to society from lifetime coverage was $136 million assuming current rates of transplantation. Medicare would break-even compared with current coverage if the fraction of patients using extended coverage was <32%. The extension would be cost-effective to Medicare if this fraction was <91%. Extended Medicare immunosuppression coverage to the life of a kidney transplant should result in better transplant and economic outcomes, and should be considered by policy makers.
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Affiliation(s)
- Eugene F Yen
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
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Butler JA, Roderick P, Mullee M, Mason JC, Peveler RC. Frequency and impact of nonadherence to immunosuppressants after renal transplantation: a systematic review. Transplantation 2004; 77:769-76. [PMID: 15021846 DOI: 10.1097/01.tp.0000110408.83054.88] [Citation(s) in RCA: 394] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Nonadherence to immunosuppressants is recognized to occur after renal transplantation, but the size of its impact on transplant survival is not known. A systematic literature search identified 325 studies (in 324 articles) published from 1980 to 2001 reporting the frequency and impact of nonadherence in adult renal transplant recipients. Thirty-six studies meeting the inclusion criteria for further review were grouped into cross-sectional and cohort studies and case series. Meta-analysis was used to estimate the size of the impact of nonadherence on graft failure. Only two studies measured adherence using electronic monitoring, which is currently thought to be the most accurate measure. Cross-sectional studies (n=15) tended to rely on self-report questionnaires, but these were poorly described; a median (interquartile range) of 22% (18%-26%) of recipients were nonadherent. Cohort studies (n=10) indicated that nonadherence contributes substantially to graft loss; a median (interquartile range) of 36% (14%-65%) of graft losses were associated with prior nonadherence. Meta-analysis of these studies showed that the odds of graft failure increased sevenfold (95% confidence interval, 4%-12%) in nonadherent subjects compared with adherent subjects. Standardized methods of assessing adherence in clinical populations need to be developed, and future studies should attempt to identify the level of adherence that increases the risk of graft failure. However, this review shows nonadherence to be common and to have a large impact on transplant survival. Therefore, significant improvements in graft survival could be expected from effective interventions to improve adherence.
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Affiliation(s)
- Janet A Butler
- University Mental Health Group, Royal South Hants Hospital, Southampton, United Kingdom.
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Chaverri C. Impact of cyclosporine in the development of immunosuppressive therapy. Transplant Proc 2004; 36:80S-82S. [PMID: 15041312 DOI: 10.1016/j.transproceed.2004.01.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cyclosporine has been of great interest to the transplant community during the last 20 years. It has permitted an evolution of knowledge through the changes in its original galenic formulation of Sandimmune to Neoral, and now through the recent application of the knowledge of pharmacodynamics and pharmacokinetics to tailor drug doses to each individual. The achievements of cyclosporine are still valid and possibly will be for the next years.
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Affiliation(s)
- C Chaverri
- Nephrology Service at The Mexico Hospital, Social Security, San Jose, Costa Rica.
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Walters SJ, Whitfield M, Akehurst RL, Chilcott JB. Economic implications of the use of basiliximab in addition to triple immunosuppressive therapy in renal allograft recipients: a UK perspective. PHARMACOECONOMICS 2003; 21:129-138. [PMID: 12515574 DOI: 10.2165/00019053-200321020-00005] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVE To compare resource use and costs in renal transplant recipients treated with basiliximab or placebo plus triple immunosuppressive therapy. DESIGN International randomised, double-blind, placebo-controlled trial; economic evaluation undertaken alongside the efficacy trial. The economic evaluation was performed from a UK National Health Service hospital perspective. SETTING 31 centres in 12 countries. PARTICIPANTS 345 renal transplant recipients were enrolled; 340 were randomised (basiliximab 168; placebo 172) and included in the intention-to-treat analysis. INTERVENTION Treatment with placebo or basiliximab (20mg intravenous bolus) on day 0 and day 4 after transplantation. MAIN OUTCOME MEASURES Resource utilisation in multiple categories and treatment costs for basiliximab and placebo-treated patients during the 6-month post-transplantation period. RESULTS No statistically significant differences were found in any of the economically important categories of resource use or in the mean cost of treatment per person across the whole trial. The mean cost of treatment, including the cost of basiliximab, was pound 16 095 for basiliximab recipients and pound 15 864 (1997/1998 costs) for placebo recipients, a mean difference of pound 231 (95% CI: - pound 1983 to pound 2446), which was not significant. Basiliximab treatment led to a significant reduction in acute rejection episodes (basiliximab 20.8%; placebo 34.9%; p = 0.005). CONCLUSIONS Basiliximab therapy confers a significant clinical benefit to renal transplant recipients without increasing overall treatment costs.
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Affiliation(s)
- Stephen J Walters
- School of Health and Related Research, University of Sheffield, Sheffield, UK.
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21
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Walters SJ, Whitfield M, Akehurst RL, Chilcott JB. Pharmacoeconomic evaluation of Simulect prophylaxis in renal transplant recipients. Transplant Proc 2001; 33:3187-91. [PMID: 11750367 DOI: 10.1016/s0041-1345(01)02356-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- S J Walters
- Sheffield Health Economics Group, University of Sheffield, Sheffield, England
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22
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Gerstenkorn C, Robertson H, Bell A, Shenton B, Talbot D. CMV infection as a contributory factor for renal allograft injury and loss. Transplant Proc 2001; 33:2461-2. [PMID: 11406211 DOI: 10.1016/s0041-1345(01)02047-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- C Gerstenkorn
- Department of Renal Medicine and Renal Transplantation, St George's Hospital, London, United Kingdom
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23
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Mahalati K, Belitsky P, West K, Kiberd B, Fraser A, Sketris I, Macdonald AS, McAlister V, Lawen J. Approaching the therapeutic window for cyclosporine in kidney transplantation: a prospective study. J Am Soc Nephrol 2001; 12:828-833. [PMID: 11274245 DOI: 10.1681/asn.v124828] [Citation(s) in RCA: 140] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Neoral dosing is traditionally based on cyclosporine (CyA) trough levels (C(0)). Four-h area under the curve (AUC(0-4)) for Neoral in the early posttransplantation period was shown previously to have a better correlation to acute rejection (AR) and CyA nephrotoxicity (CyANT), compared with C(0). An AUC(0-4) range of 4400 to 5500 microg/h per L during the first week was associated with the lowest AR and CyANT. This article describes a prospective study to assess the feasibility, safety, and efficacy of dosing Neoral solely by AUC(0-4) monitoring, regardless of C(0), in the first 3 mo after kidney transplantation. Fifty-nine kidney transplant recipients received Neoral-based triple immunosuppression. AUC(0-4) was measured on days 3, 5, 7, 10, and 14 and weeks 3, 4, 6, and 8, then monthly. Target AUC(0-4) was 4400 to 5500 microg/h per L. Dose was adjusted by percentage difference from target AUC(0-4). Ninety-four percent of AUC were performed on the scheduled day or close to it. No patients had CyANT while AUC(0-4) was in target range. Four patients had reversible CyANT with AUC(0-4) > 5500. Only 1 of 33 patients (3%) who achieved and maintained AUC(0-4) > 4400 by day 3 posttransplantation had AR, whereas 10 of 22 (45%) of those with day 3 to 5 AUC(0-4) < 4400 had AR (P: = 0.0002). In logistic regression analysis, higher early AUC(0-4) was the only significant variable associated with lower serum creatinine at 3 mo. Neoral dose monitoring by AUC(0-4) is a potentially valuable tool for optimizing Neoral immunosuppression. Attainment of a target range of 4400 to 5500 microg/h per L for AUC(0-4) early after transplantation has been demonstrated to reduce significantly the risk of AR and CyANT.
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Affiliation(s)
- Kamran Mahalati
- Kidney Transplant Program and the Department of Urology, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Philip Belitsky
- Kidney Transplant Program and the Department of Urology, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Kenneth West
- Kidney Transplant Program and the Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Bryce Kiberd
- Kidney Transplant Program and the Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Albert Fraser
- Kidney Transplant Program and the Department of Pathology, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Ingrid Sketris
- Kidney Transplant Program and the Department of Pharmacy, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Alan S Macdonald
- Kidney Transplant Program and the Department of Surgery, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Vivian McAlister
- Kidney Transplant Program and the Department of Surgery, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Joseph Lawen
- Kidney Transplant Program and the Department of Urology, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
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24
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Abstract
The consequences of failing to comply to doctor's instructions can be damaging and devastating for the individual patient and their family. Noncompliance also leads to waste, as it reduces the potential benefits of therapy, and to the extra cost of treating avoidable consequent morbidity. Life-long immunosuppression is a prerequisite for good graft function, and noncompliance is often associated with late acute rejection episodes, graft loss, and death. It might be assumed that transplant patients constitute a highly motivated group, and that compliance would be high. Unfortunately, this is not the case: overall noncompliance rates vary from 20 to 50%. This overview includes literature on heart, liver, and kidney transplants in adult and pediatric transplant patients. Compliance behavior after transplantation, noncompliance and its relationship to organ loss and death, retransplantation outcome after graft loss due to noncompliance, and reasons for postoperative noncompliance will be addressed.
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Affiliation(s)
- K Laederach-Hofmann
- Internal Medicine and Cardiology FMH, Unit for Psychosomatic and Psychosocial Medicine, Inselspital, University of Berne, Berne, Switzerland
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25
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Mahalati K, Belitsky P, Sketris I, West K, Panek R. Neoral monitoring by simplified sparse sampling area under the concentration-time curve: its relationship to acute rejection and cyclosporine nephrotoxicity early after kidney transplantation. Transplantation 1999; 68:55-62. [PMID: 10428267 DOI: 10.1097/00007890-199907150-00011] [Citation(s) in RCA: 336] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cyclosporine (CsA) dosing is traditionally based on trough blood levels (C0) rather than area under the concentration-time curve (AUC), although AUC correlates better with posttransplantation clinical events. For Neoral, AUC based on limited sampling correlates closely with full 12-hr AUC. The purpose of our study was to correlate C0 with AUC based on CsA levels at 0, 1, 2, 3, and 4 hr after dose (PK0-4) and to compare this AUC with C0 in predicting acute rejection (AR) and acute cyclosporine nephrotoxicity (CsANT) in de novo first kidney transplant patients. METHODS PK0-4 was done 2-4 days after starting Neoral for 156 patients. All received CsA-based triple-drug immunosuppression without antibody induction. AUC was calculated as projected 12-hr (AUC0-12) and actual 4-hr (AUC0-4) from the PK0-4 using the parallel trapezoid rule. Neoral dosing was based on C0 not AUC. AUC was retrospectively compared with C0 as a predictor of AR and CsANT during the first 90 days. RESULTS C0 correlated poorly with AUC0-12 and AUC0-4 (r=0.61 and r=0.42). C0 (mean+/-SEM) levels were not significantly different in 34 patients with and 109 without AR (293+/-21 vs. 294+/-11 microg/L, P=0.95). AUC0-12 and AUC0-4 were significantly lower in patients with than without AR (AUC0-12 9090+/-598 vs. 10608+/-336 microg x h/L, P=0.01; AUC0-4 3934+/-306 vs. 4802+/-166 microg.h/L, P=0.006). In stepwise regression analysis only AUC0-12 or AUC0-4 (P=0.03/P=0.02) and delayed graft function (P=0.007) predicted AR. AUC0-12, AUC0-4, and C0 were all significantly higher in patients with CsANT than without CsANT (AUC0-12 11746+/-650 vs. 10023+/-301 microg x h/L, P=0.01; AUC0-4 5270+/-358 vs. 4474+/-150 microg x h/L, P=0.01; C0 343+/-18 vs. 287+/-10 microg/L, P=0.01), but in stepwise regression analysis C0 was not an independent predictor of CsANT. Patients with AUC0-12 in the range of 9500 to 11500 microg x h/L or AUC0-4 between 4400 and 5500 microg x h/L had the lowest incidence of AR (13% and 7%, respectively) without significantly higher risk for CsANT. CONCLUSION C0 correlates poorly with AUC based on PK0-4. Early AUC based on PK0-4 is more closely associated with AR and CsANT than is C0. Our data suggest that a target AUC0-12 of 9500-11500 or AUC0-4 of 4400-5500 microg x h/L may provide optimal Neoral immunosuppression.
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Affiliation(s)
- K Mahalati
- Department of Urology, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
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26
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Robbins ML. Medication adherence and the transplant recipient: helping patients at each stage of change. Transplant Proc 1999; 31:29S-30S. [PMID: 10372040 DOI: 10.1016/s0041-1345(99)00120-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- M L Robbins
- Cancer Prevention Research Center, University of Rhode Island, Kingston 02881, USA
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27
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Wainwright SP, Fallon M, Gould D. Psychosocial recovery from adult kidney transplantation: a literature review. J Clin Nurs 1999; 8:233-45. [PMID: 10578745 DOI: 10.1046/j.1365-2702.1999.00220.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Kidney transplantation is the preferred treatment for patients with end-stage chronic renal disease. There appears to be no recent and extensive review of the literature on psychosocial recovery from adult kidney transplantation. This comprehensive review considers literature on six aspects of patient recovery and rehabilitation: psychiatric sequelae, functional recovery, stress and coping, the psychological impact of failed kidney transplants, quality of life (QOL), and adherence with medications. We conclude that although studies have become both more ambitious and rigorous, there is a pressing need to move away from descriptive research toward carefully designed multidisciplinary psychological intervention studies with kidney transplant patients.
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Affiliation(s)
- S P Wainwright
- Department of Nursing Studies, King's College London, UK
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28
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Savoldi S, Scolari F, Sandrini S, Tardanico R, Morassi L, Zubani R, Bossini N, Viola BF, Maiorca R. Early histopathologic changes predicting long-term kidney transplant survival. Transplant Proc 1998; 30:1726-8. [PMID: 9723257 DOI: 10.1016/s0041-1345(98)00406-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- S Savoldi
- Division of Nephrology, Spedall Civili Hospital, Brescia, Italy
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29
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Savoldi S, Maiorca R, Chiappini R, Scolari F, Sandrini S. Trough cyclosporine concentration variability. Transplant Proc 1998; 30:1642-4. [PMID: 9723225 DOI: 10.1016/s0041-1345(98)00374-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- S Savoldi
- Divisione di Nefrologia e Dialisi, Spedali Civili, Brescia, Italy
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30
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Islam MS, Francos GC, Dunn SR, Burke JF. Mycophenolate mofetil and reduction in cyclosporine dosage for chronic renal allograft dysfunction. Transplant Proc 1998; 30:2230-1. [PMID: 9723452 DOI: 10.1016/s0041-1345(98)00601-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- M S Islam
- Division of Nephrology, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA
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31
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Tanabe K, Ishikawa N, Tokumoto T, Takahashi K, Oshima T, Fuchinoue S, Toma H. Factors affecting long-term renal allograft survival in cyclosporine-treated kidney transplants. Transplant Proc 1998; 30:1805-9. [PMID: 9723291 DOI: 10.1016/s0041-1345(98)00440-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- K Tanabe
- Department of Urology, Tokyo Women's Medical College, Japan
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32
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Abstract
The problems of non-adherence with treatment in health care in general, and with medication adherence in particular, is an area with a voluminous and burgeoning literature. However, there appears to be no review of the literature on non-adherence with medications in organ transplant patients. This comprehensive review therefore considers literature on adherence in adult kidney, heart and liver transplantation. The particular problem of adherence in paediatric transplant patients is also addressed. This transplant research literature is then evaluated within the broader context of social science research on medication adherence. From the review it is apparent that there is an urgent need for research which examines the patient's beliefs about their illness and medicines. Such research is a precursor for rigorous nursing intervention studies which aim to promote adherence by being tailored to the patient's perceptions.
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33
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Savoldi S, Maiorca R, Maderna M, Chiappini R, Corbetta G. Low intrapatient variability of blood cyclosporine levels is correlated with excellent graft survival. Transplant Proc 1997; 29:288-9. [PMID: 9122999 DOI: 10.1016/s0041-1345(96)00110-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- S Savoldi
- Divisione di Nefrologia e Dialisi, Spedali Civili and University, Brescia, Italy
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34
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Feucht HE, Opelz G. The humoral immune response towards HLA class II determinants in renal transplantation. Kidney Int 1996; 50:1464-75. [PMID: 8914011 DOI: 10.1038/ki.1996.460] [Citation(s) in RCA: 107] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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35
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De Geest S, Abraham I, Dunbar-Jacob J. Measuring transplant patients' compliance with immunosuppressive therapy. West J Nurs Res 1996; 18:595-605. [PMID: 8918210 DOI: 10.1177/019394599601800509] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- S De Geest
- Department of Nursing, School of Public Health, Catholic University of Leuven, Belgium
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36
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Tanabe K, Takahashi K, Toma H. Causes of long-term graft failure in renal transplantation. World J Urol 1996; 14:230-5. [PMID: 8873436 DOI: 10.1007/bf00182072] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
A single-center experience of 980 consecutive renal transplant recipients treated with cyclosporine (CyA) was reviewed to analyze the causes of renal allograft loss and the factors affecting long-term renal survival in CyA-treated kidney transplants. In all, 217 grafts were lost during the observation period, with the most common causes of graft loss being chronic rejection (96 cases, 44%), death with a functioning graft (52 cases, 24%), glomerulonephritis (28 cases, 13%), and acute rejection (20 cases, 8%). The actuarial 10-year survival of patients with living and cadaveric grafts was 93% and 91%, respectively. The actuarial 10-year survival of living and cadaveric grafts was 70% and 63%, respectively. Patients were divided into two groups, namely a graft-survival group (n = 763) and a graft-loss group (n = 217). There was no significant difference between the two groups in terms of sex, donor source, donor age, recipient age, duration of hemodialysis, retransplants, transfusions, presensitization, of HLA match. There was no difference between the graft-survival group and the graft-loss group in the mean CyA dose given or the mean CyA trough level measured at any time following transplantation. Acute rejection episodes occurred in patients from the graft-survival group (55%) as compared with those from the graft-loss group (83%; P < 0.00001). These data suggest that long-term graft survival in CyA-treated kidney transplant patients is primarily influenced by the occurrence of rejection episodes rather than by the drug dose or the duration of CyA administration. CyA nephrotoxicity was not the major risk factor for long-term graft survival in CyA-treated renal transplants.
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Affiliation(s)
- K Tanabe
- Department of Urology, Tokyo Women's Medical College, Japan
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37
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Pirsch JD, Ploeg RJ, Gange S, D'Alessandro AM, Knechtle SJ, Sollinger HW, Kalayoglu M, Belzer FO. Determinants of graft survival after renal transplantation. Transplantation 1996; 61:1581-6. [PMID: 8669101 DOI: 10.1097/00007890-199606150-00006] [Citation(s) in RCA: 133] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
We studied multiple determinants of graft survival at a single center and the effects of nonimmunologic graft loss on transplant survival. This retrospective study examined the results of 589 cadaver donor transplants performed between 1986 and 1992. Graft survival rates were calculated using Kaplan-Meier estimates for both overall graft survival (all causes of graft loss) and immunologic graft survival (function lost due to acute or chronic rejection and noncompliance). Cadaver graft survival was significantly poorer with an increasing degree of DR mismatch (P=0.02). An analysis of pretransplant variables showed graft loss risk was highest with greater DR mismatches, two B-antigen mismatch, higher donor serum creatinine, and younger recipient age. After transplantation, acute rejection was the most significant factor associated with long-term graft survival. Our data demonstrate a significant advantage for zero DR and one DR mismatch cadaver donor transplants, with excellent immunologic graft survival. This study suggests that a combination of immediate graft function, prevention of acute rejection by appropriate early immunosuppressive therapy, and acceptable DR match enhances cadaveric graft survival.
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Affiliation(s)
- J D Pirsch
- Department of Medicine, University of Wisconsin Medical School, Madison, Wisconsin, USA
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38
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Borel JF, Baumann G, Chapman I, Donatsch P, Fahr A, Mueller EA, Vigouret JM. In vivo pharmacological effects of ciclosporin and some analogues. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 1996; 35:115-246. [PMID: 8920206 DOI: 10.1016/s1054-3589(08)60276-8] [Citation(s) in RCA: 99] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- J F Borel
- Sandoz Pharma AG, Preclinical Research Division, Basel Switzerland
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39
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Sketris I, Yatscoff R, Keown P, Canafax DM, First MR, Holt DW, Schroeder TJ, Wright M. Optimizing the use of cyclosporine in renal transplantation. Clin Biochem 1995; 28:195-211. [PMID: 7554239 DOI: 10.1016/0009-9120(95)91341-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To review the existing data on the use of cyclosporine (CsA) in kidney transplantation, particularly with respect to therapeutic drug monitoring. DATA SOURCES A literature search was conducted of applicable articles related to therapeutic drug monitoring of cyclosporine in renal transplantation. Previous consensus guidelines were examined. Discussions on issues related to this topic convened in Toronto, ON, on June 15-16, 1994. DATA SYNTHESIS The literature was analyzed to examine patient factors and drug interactions affecting CsA concentrations, the effect of CsA concentrations on patient outcome, current methods of analysis, pharmacodynamic monitoring, and new immunosuppressants. CONCLUSIONS CsA has improved the success of kidney transplantation, reducing the incidence and severity of acute rejection and improving short-term patient and graft survival. The rate of graft loss after the first year (primarily due to chronic rejection) has remained largely unchanged. Sandimmune Neoral offers promise due to its better bioavailability and limited dependence on bile flow for absorption. Long-term studies are underway to determine its effectiveness and safety. Indications for therapeutic drug monitoring for CsA are provided.
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Affiliation(s)
- I Sketris
- College of Pharmacy, Dalhousie University, Halifax, NS
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40
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Conlon PJ, Medwar W, Hanson S, Donohoe J, Carmody M, Walshe JJ. Long term outcome of renal transplantation in the pre cyclosporin era: one centre's experience. Ir J Med Sci 1995; 164:109-12. [PMID: 7607833 DOI: 10.1007/bf02973273] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The number of renal transplants has been increasing steadily over the last twenty years. This increase has been associated with a significant improvement in the one year graft and patient survival. However, as survival improves, long term complications are becoming more clinically important. We, therefore, retrospectively reviewed our experience of renal transplantation in 165 patients between January 1970 and December 1980, and describe in detail the complications experienced by those whose grafts functioned for 10 years or longer. The 10 year patient survival rate was 47% and graft survival rate was 30%. The graft survival rate for living related grafts was superior to that of cadaveric grafts. The major cause of mortality in the first year following renal transplantation was infection and in subsequent years, cardiovascular disease predominated. Patients whose grafts functioned for 10 years or more developed a variety of complications including infection, skin cancer and hepatic dysfunction. Clinicians involved in the long term care of the patients need to be aware of these problems and skilled in their management.
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Affiliation(s)
- P J Conlon
- Department of Renal Medicine and Transplantation, Beaumont Hospital, Dublin, Ireland
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