Measuring transplant patients' compliance with immunosuppressive therapy

Follow-Up Factors Contribute to Immunosuppressant Adherence in Kidney Transplant Recipients

PURPOSE

Follow-up and immunosuppressive medication (ISM) adherence are both important for kidney transplant recipients postoperatively and whether follow-up factors affect the ISM adherence remains unclear. The aim of this study was to examine the relationship between follow-up factors and ISM adherence, and the factors associated with ISM adherence.

PATIENTS AND METHODS

An internet-based cross-sectional survey was conducted in a single kidney transplant center in China. The participants completed the internet-based questionnaire and the Basel Assessment of Adherence to Immunosuppressive Medication Scale (BAASIS©) from January 12 to January 26, 2021.

RESULTS

Finally, 288 (66.7%) participants responded to this survey. The percentage of full adherence to immunosuppressant was 51.7% (149/288), with 33.3% of the participants reporting a problem in timing dimension. We found that follow-up with a fixed doctor was significantly positive to good adherence (OR=2.124, 95% CI=1.111-4.062, P=0.023) after analyzing the survey data. Time since kidney transplantation and number of non-immunosuppressants were both associated with immunosuppressant adherence. No significant difference was found regarding the effect of the follow-up adherence on ISM adherence.

CONCLUSION

Our study demonstrated an insufficient prevalence of adherence to immunosuppressant in Chinese renal transplant recipients and revealed that follow-up with a fixed doctor may be a way to improve the patients' ISM adherence. This anonymous internet-based survey provides valuable insight into the actual adherence rate, factors associated with non-adherence, and situations that may improve medication-taking.

Medication nonadherence after kidney transplantation: an internet-based survey in Japan

Nonadherence to immunosuppressive medications after kidney transplantation is a major risk factor for allograft rejection and graft loss. Transplant recipients tend to conceal nonadherence in clinical settings. We conducted an internet-based cross-sectional survey aimed to clarify the prevalence and risk factors of patient nonadherence after kidney transplantation in Japan. The Basel Assessment of Adherence to Immunosuppressive Medication Scale (BAASIS©) was used to detect nonadherence. In this survey, patients were asked about their relationship with medical staff and their self-efficacy for taking medication, along with other questions. A total of 219 kidney transplant recipients were included in the analysis. Ninety-four demonstrated nonadherence (42.7%). The following factors were associated with nonadherence: short dialysis period prior to transplantation; undergoing transplantation at least twice; male sex; lack of satisfaction with the explanation of immunosuppressive medication; and absence of medical staff to consult upon forgetting to take drugs. The nonadherence group reported low self-efficacy for medication in many settings. This anonymous survey provides valuable insight into the actual nonadherence rate, factors associated with nonadherence, and life situations that may complicate medication-taking.

Medication adherence in renal transplant recipients: A latent variable model of psychosocial and neurocognitive predictors

Objective

Estimates indicate that 20–70% of renal transplant recipients are medication non-adherent, significantly increasing the risk of organ rejection. Medication adherence is negatively impacted by lower everyday problem solving ability, and associations between depressive symptoms, self-efficacy, and adherence are reported in renal transplant recipients. Nonetheless, to date, these associations have not been examined concurrently. Given the relationship between non-adherence and organ rejection, it is critical to gain a better understanding of the predictors of adherence in renal transplant recipients. To this end, we modeled relationships among cognitive abilities, depressive symptoms, self-efficacy, and adherence in this group.

Methods

Participants (N = 211) underwent renal transplant at least one year prior to participation. Adherence was measured via self-report, medication possession ratio, and immunosuppressant blood-level. Traditionally-measured neurocognitive and everyday problem-solving abilities were assessed. Depressive symptoms were measured via self-report, as were general and medication adherence related self-efficacy. Structural equation modeling was used to assess the fit of the model to available data.

Results

Everyday problem solving and self-efficacy had direct positive associations with adherence. Depressive symptoms were negatively associated with self-efficacy, but not adherence. Traditionally-measured neurocognitive abilities were positively associated with self-efficacy, and negatively associated with depressive symptoms.

Conclusions

We present a comprehensive investigation of relationships between cognitive and psychosocial factors and adherence in medically stable renal transplant recipients. Findings confirm the importance of everyday problem solving and self-efficacy in predicting adherence and suggest that influences of depressive symptoms and neurocognitive abilities are indirect. Findings have important implications for future development of interventions to improve medication adherence in renal transplant recipients.

Practice patterns to improve pre and post-transplant medication adherence in heart transplant centres: a secondary data analysis of the international BRIGHT study

BACKGROUND

As medication non-adherence is a major risk factor for poor post-transplant outcomes, we explored how adherence is assessed, enhanced and integrated across the transplant continuum.

AIM

The aim of this study was to study practice patterns regarding pre- and post-transplant medication adherence assessment and interventions in international heart transplant centres.

METHODS

We used data from the Building Research Initiative Group: chronic illness management and adherence in heart transplantation (BRIGHT) study, a cross-sectional study conducted in 36 heart transplant centres in 11 countries. On a 27-item questionnaire, 100 clinicians (range one to five per centre) reported their practice patterns regarding adherence assessment and intervention strategies pre-transplant, immediately post-transplant, less than one year, and one or more year post-transplant. Educational/cognitive, counselling/behavioural and psychosocial/affective strategies were assessed. Clinicians' responses (intervention present vs. absent; or incongruence in reporting intervention) were aggregated at the centre level.

RESULTS

The adherence assessment method most commonly used along the transplant continuum was questioning patients (range 75-88.9%). Pre-transplant, all three categories of intervention strategy were applied. Providing reading materials (82.9%) or instructions (68.6%), involving family or support persons in education (91.4%), and establishing partnership (91.4%) were used most frequently. Post-transplant, strategies closely resembled those employed pre-transplant. Training patients (during recovery) and cueing were more often applied during hospitalisation (74.3%). After the first year post-transplant, except for motivational interviewing (25.7-28.6%), the number of strategies decreased.

CONCLUSIONS

Across the transplant continuum, diverse adherence interventions are implemented; however, post-transplant, the frequency of adherence interventions decreases. Therefore, increased investment is necessary in long-term adherence interventions.

Evaluation of an Immunosuppressant Side Effect Instrument

Background

Clinicians continue to be compelled to evaluate the impact of immunosuppressive medication side effects on the quality of life of transplant recipients. We were asked to develop an instrument to measure side effects in immunosuppressed transplant recipients.

Objective

To construct an instrument that measures the impact and severity of side effects of immunosuppressive medications used in transplantation and to assess the reliability and validity of the newly developed instrument called the Memphis Survey.

Design

The instrument was constructed by a panel of physicians, nurses, and pharmacists with experience in treating transplant recipients. A small group of kidney transplant recipients (n=13) provided pilot data for refining and testing the instrument. A national sample of kidney, liver, and heart transplant recipients (n=505) provided data that were used to further develop the instrument.

Analysis

Factor analysis was used to determine the psychological dimensions underlying the instrument and to guide the construction of scales from the survey items. The instrument scales were then computed from the dataset of 505 transplant recipients to quantify the impact of immunosuppressant side effects on the quality of life of transplant recipients.

Results and Conclusion

Analyses showed the final instrument scales to be valid and reliable. Exploratory analysis suggests the need for further testing of the instrument to determine gender differences.

Psychosocial Assessments and Outcomes in Organ Transplantation

A qualitative review was conducted to define the term psychosocial as applied to transplant patients and to summarize evidence regarding the role and impact of psychosocial assessments and outcomes across the transplant process. English-language case series and empirical studies from January 1970 through April 1990 that were abstracted in Medline and Psychological Abstracts or listed in publications' bibliographies were used as data sources. A qualitative analysis was performed to determine the depth of the case reports and whether the empirical reports obtained statistically reliable, clinically significant findings. The authors conclude that psychosocial assessments differ in content and application to candidate selection depending on the transplant program. Psychosocial status before transplant does not consistently affect medical outcomes after transplant. Psychosocial status generally improves with transplant, although difficulties are prevalent in psychological adjustment and in compliance with medical regimens. Psychiatric history can predict psychological outcomes after transplant but does not consistently predict compliance. Social supports and coping strategies strengthen psychosocial outcomes. Posttransplant psychosocial outcomes may predict physical morbidity and mortality.

Compliance and Noncompliance in Kidney Transplant Patients: Cues for Transplant Coordinators

Maximizing kidney transplant patients' long-term compliance with immunosuppressants is a major challenge to transplant coordinators. Although previous research has found substantial proportions of recipients to be noncompliant, predictors of noncompliance and characteristics of noncompliers remain unclear. In this study of more than 1400 kidney transplant patients, we found noncompliance to be associated with patient and transplant characteristics and with patient beliefs concerning the efficacy of immunosuppressants. Three distinct profiles of noncompliers were identified: accidental noncompliers, invulnerables, and decisive noncompliers. This information can be used by transplant coordinators to recognize cues that predict noncompliance and to work with at-risk patients to forestall or remedy noncompliant behavior.

Negotiating Compliance in Heart Failure: Remaining Issues and Questions

Living with heart failure (HF) means living with a chronic illness characterized by periods of acute decompensation alternating with periods of relative stability. Improved medical care for patients with cardiovascular diseases, coupled with the aging of the populations in the developed world, has resulted in a steadily increasing prevalence of HF. Rehospitalization rates are high for this patient population. In 20–64% of the cases, poor compliance by patients with the prescribed HF treatment is a contributing factor to hospitalization. This article uses a review of the literature on HF non-compliance, including the prevalence, barriers, consequences, and the long-term outcomes of non-compliance with HF therapy, to illustrate remaining issues and questions. Original studies published in English or German between 1966 and June 2004 identified by combining patient compliance, non-compliance, adherence, self-care, rehospitalization, patient education, and management programs, with heart failure in the search strategy are included. Creative approaches to achieving a true partnership between providers and patients are needed if clinical outcomes are to improve.

Nonadherence with Immunosuppressive Drugs: Us Compared with European Kidney Transplant Recipients

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.

Medication level variability index predicts rejection, possibly due to nonadherence, in adult liver transplant recipients

Nonadherence to immunosuppressants may play a role in late rejection in liver transplant recipients. In children, emerging data suggest that adherence can be measured through the computation of the standard deviation (SD) of consecutive blood levels of tacrolimus, which results in a number that reflects the degree of variability between individual measures: the medication level variability index (MLVI). A higher MLVI value means erratic immunosuppression, likely due to less adherence. Data on this method are limited for adults. We obtained data from the medical charts of 150 randomly selected adult recipients. The MLVI was significantly higher for patients who had biopsy-confirmed rejection (mean MLVI = 3.8, SD = 3.2) versus the rest of the cohort (mean MLVI = 2.3, SD = 1.5, P = 0.003), and it was significantly higher for patients who suffered rejection versus patients whose biopsy sample was not read as rejection (mean MLVI = 2.6, SD = 1.6, P = 0.008). The MLVI was associated with rejection and predicted its occurrence. A threshold MLVI of 2.0 resulted in 77% sensitivity and 60% specificity in predicting rejection; a threshold of 1.8 resulted in a sensitivity of 92% and a specificity of 48%. The area under the curve in a receiver operating characteristic curve analysis was 0.71 (95% CI = 0.61-0.81). In conclusion, the MLVI is associated with and can predict rejection, possibly related to nonadherence, in adult liver transplant recipients.

A trial of family partnership and education interventions in heart failure

BACKGROUND

Lowering dietary sodium and adhering to medication regimens are difficult for persons with heart failure (HF). Because these behaviors often occur within the family context, this study evaluated the effects of family education and partnership interventions on dietary sodium (Na) intake and medication adherence (MA).

METHODS AND RESULTS

HF patient and family member (FM) dyads (n = 117) were randomized to: usual care (UC), patient-FM education (PFE), or family partnership intervention (FPI). Dietary Na (3-day food record), urinary Na (24-hour urine), and MA (Medication Events Monitoring System) were measured at baseline (BL) before randomization, and at 4 and 8 months. FPI and PFE reduced urinary Na at 4 months, and FPI differed from UC at 8 months (P = .016). Dietary Na decreased from BL to 4 months, with both PFE (P = .04) and FPI (P = .018) lower than UC. The proportion of subjects adherent to Na intake (≤2,500 mg/d) was higher at 8 months in PFE and FPI than in UC (χ(2)(2) = 7.076; P = .029). MA did not differ among groups across time. Both FPI and PFE groups increased HF knowledge immediately after intervention.

CONCLUSIONS

Dietary Na intake, but not MA, was improved by PFE and FPI compared with UC. The UC group was less likely to be adherent with dietary Na. Greater efforts to study and incorporate family-focused education and support interventions into HF care are warranted.

Increased adherence eight months after switch from twice daily calcineurin inhibitor based treatment to once daily modified released tacrolimus in heart transplantation

Background

Modified-release tacrolimus (TAC) is a new, once-daily oral formulation of the established immunosuppressive agent TAC. This study evaluated long-term patient adherence, as well as safety and efficacy, in stable patients after heart transplantation (HTx) who switched from a conventional twice daily calcineurin inhibitor-based regimen (TAC or cyclosporine A [CsA]) to a once-daily modified-release TAC regimen.

Methods

Stable patients were switched from conventional TAC or CsA (twice-daily dosing) to modified-release TAC (once-daily dosing) according to manufacturer’s recommendations using a pre-experimental design. Self-reported adherence was assessed at baseline and 8 months after the switch with the Basel Assessment of Adherence with Immunosuppressive Medication Scale (BAASIS). Additionally, routine laboratory values were analyzed 8 months after switch.

Results

Of 76 patients (58 male, 18 female) initially included, 72 were available for statistical analysis, as modified-release TAC was discontinued due to diarrhea in one patient and gastrointestinal discomfort in three patients. Overall nonadherence at baseline for any of the four BAASIS items was 75.0% versus 40.3% after 8 months (P<0.0001). After 8 months, adherence was improved in 41 patients (56.9%), unchanged in 27 (37.5%), and reduced in four patients (5.6%). The BAASIS visual analog scale score improved significantly from 87.0% ± 13.5% to 97.5% ± 5.7% (P<0.0001). No significant changes were observed for hematological, renal, or liver function parameters after 8 months (all P=not significant).

Conclusion

To our knowledge, this is the first study in stable patients after HTx to demonstrate a significant improvement in long-term (ie, 8-month) patient adherence after the switch to modified-release TAC. Modified-release TAC was generally well tolerated. Further studies are currently underway to investigate long-term safety after HTx of various calcineurin inhibitors for prevention of rejection and occurrence of side effects.

Increased adherence after switch from twice daily calcineurin inhibitor based treatment to once daily modified released tacrolimus in heart transplantation: a pre-experimental study

BACKGROUND

Modified release tacrolimus (TAC) is a new, once-daily oral formulation of the established immunosuppressive agent TAC. Simplification of regimen has been associated with better adherence. This study evaluated patient adherence, as well as safety and efficacy among chronic stable heart transplantation (HT) patients switched from a conventional twice daily calcineurin inhibitor-based regimen (TAC or cyclosporine A [CsA]) to (once daily) modified release TAC.

METHODS

We switched 54 chronic stable patients (41 males and 13 females) from twice daily dosing with conventional TAC or CsA to once daily dosing with modified release TAC. Self-reported adherence was assessed at baseline and at 4 months after the switch using the Basel Assessment of Adherence with Immunosuppressive Medication Scale [BAASIS]), a 4-item validated questionnaire including also a Visual Analogue Scale (VAS). Nonadherence was defined as any self-reported nonadherence on any item.

RESULTS

Modified release TAC was discontinued in 4 patients because of diarrhea (n = 1) or gastrointestinal discomfort (n = 3) leaving 50 evaluable patients. Overall nonadherence at baseline for any of the 4 items was 74% versus 38% after 4 months (P = .0001). Thereafter, adherence improved in 28 patients (56.0%), was unchanged in 18 (36.0%), and decreased in 4 subjects (8.0%). The VAS score improved from 82.3% ± 2.6% to 97.5% ± 4.8% (P < .0001). No significant changes were observed after 4 months regarding hematologic, renal, or liver function parameters (all P = NS).

CONCLUSIONS

Therapeutic regimens for transplant recipients are often complex, contributing to a high incidence of medication nonadherence. This study in chronic, stable, heart transplantation patients demonstrated a significant improvement in patient adherence after a switch to modified release TAC, which was generally well tolerated.

Efficacy, safety, and immunosuppressant adherence in stable liver transplant patients converted from a twice-daily tacrolimus-based regimen to once-daily tacrolimus extended-release formulation

The aim of this study was to determine the efficacy, safety, and immunosuppressant adherence in 125 stable liver transplant (LT) patients converted from twice-daily tacrolimus (TAC BID) to once-daily TAC (TAC OD). Tacrolimus trough levels, laboratory parameters, metabolic disorders, selected patient reported outcomes, and adverse events were assessed. Mean TAC trough level concentration was 6.1 ± 2.3 ng/ml at study entry, decreased to 5.5 ± 2.1 ng/ml (P = 0.016) and 5.5 ± 2.2 ng/ml (P = 0.019) after 1 and 2 weeks, respectively, and tended to equal the baseline value during further follow-up. At week 1, TAC concentrations were lower in 62.4% of patients and higher in 36.0% when compared with baseline. Renal and cardiovascular risk factors remained stable and no rejection episodes occurred over 12 months. Adverse events were consistent with the safety profile known from previous studies with TAC BID. Nonadherence measured by the "Basel Assessment of Adherence Scale to Immunosuppressives" was evident in 66.4% at study entry and decreased to 30.9% postconversion (P < 0.0001). Prevalence of nonadherence at baseline was significantly higher in patients converted >2 years after LT and in those ≤60 years of age. Conversion to TAC OD is safe, enhances immunosuppressant adherence and should be accompanied by a close TAC level monitoring during the initial period.

Electronically measured adherence to immunosuppressive medications and kidney function after deceased donor kidney transplantation

BACKGROUND

Non-adherence with immunosuppressive medications can result in allograft rejection and eventually allograft loss.

METHODS

In a racially diverse population, we utilized microelectronic cap monitors to determine the association of adherence with a single immunosuppressive medication and kidney allograft outcomes post-transplantation. This prospective cohort study enrolled 243 patients from eight transplant centers to provide adherence and kidney allograft outcomes data. To determine the association of adherence with change in estimated glomerular filtration rate (eGFR), we fit mixed effects models with the outcome being change in eGFR over time. We also fit Cox proportional hazards models to determine the association of adherence with time to persistent 25% and 50% decline in eGFR.

RESULTS

The distribution of adherence post-transplant was as follows: 164 (68%), 49 (20%), and 30 (12%) had >85-100%, 50-85%, and <50% adherence, respectively. Seventy-nine (33%) and 36 (15%) of the subjects experienced a persistent 25% decline in eGFR or allograft loss and 50% decline in eGFR or allograft loss during follow-up. Adherence was not associated with acute rejection or 25% decline or 50% decline in eGFR. In the adjusted and unadjusted model, adherence and black race were not associated with change in eGFR over time.

CONCLUSIONS

Non-adherence with a single immunosuppressive medication was not associated with kidney allograft outcomes.

Pretransplant predictors of posttransplant adherence and clinical outcome: an evidence base for pretransplant psychosocial screening

INTRODUCTION

There is growing awareness, yet scant prospective evidence that pretransplant (TX) psychosocial factors may predict post-TX outcome. We examined which pre-TX psychosocial factors predict post-TX nonadherence with immunosuppression (NA) and clinical outcomes in heart, liver, and lung TX.

METHODOLOGY

We prospectively followed 141 patients (28 heart, 61 liver, and 52 lung) from pre-TX until 1 year post-TX. Multivariable analyses determined which pre-TX factors (i.e., anxiety, depression, personality traits, social support, adherence with medication, and smoking status) predict poor post-TX outcome (i.e., NA, late acute rejection, graft loss, and resource utilization), controlling for medical predictors of poor outcome.

RESULTS

Pre-TX self-reported medication nonadherence (odds ratio [OR]=7.9), lower received social support (OR=0.9), a higher education (OR=2.7), and lower "conscientiousness" (OR=0.8) were independent predictors of post-TX NA. Not living in a stable relationship predicted graft loss (OR=4.9). Pre-TX medication NA was the only predictor for presence of late acute rejection (OR=4.4). No other pre-TX predictors for poor outcome could be found.

CONCLUSION

This is the first prospective study demonstrating that selected pre-TX psychosocial factors predict post-TX NA and poor clinical outcome, implying that pre-TX screening should include this set of factors in addition to traditional medical criteria.

Impact of a pharmaceutical care program on liver transplant patients' compliance with immunosuppressive medication: a prospective, randomized, controlled trial using electronic monitoring

INTRODUCTION

Compliance with immunosuppressive therapy plays a major role in the long-term success of organ transplantation. Thus, strategies to promote compliance in posttransplant care are of particular interest. At the pharmacy department of the University Hospital Mainz, a program for pharmaceutical care of organ transplant patients has been developed for the first time ever. The main objective of the presented study was to examine the influence of this program on liver transplant patients' compliance with immunosuppressive therapy.

METHODS

To measure compliance, medication event monitoring systems were used. Dosing compliance (DC) was calculated for each patient and the mean DC was compared between the two groups. Further direct and indirect methods of measuring compliance served to confirm the electronic compliance data.

RESULTS

Pharmaceutical care of liver transplant patients led to a significant increase in compliance with the immunosuppressive therapy. The mean DC of the intervention group was 90%+/-6% compared with 81%+/-12% in the control group (P=0.015). Only two patients (10%) in the intervention group and nine patients (43%) in the control group showed a DC less than 80% (P=0.032). Furthermore, patients in the intervention group were more likely to achieve target blood levels.

CONCLUSION

Patients who received pharmaceutical care with traditional patient care showed significantly better compliance with their immunosuppressive medication than patients who received only traditional patient care. Pharmaceutical care proved to be an effective intervention that should be implemented in posttransplant care.

Acute rejection in non-compliant renal allograft recipients: a distinct morphology

Non-compliance for immunosuppressive medication is frequent in renal transplant recipients, and associated with late acute rejection and graft loss. Although numerous studies were published on risk factors and outcome, no data are available on the histopathology of the 'non-compliant' allograft. As non-compliant patients swing between subtherapeutic and toxic doses of immunosuppression, trough levels show large variation. We questioned whether the histology of acute rejection in non-compliers (i) differs from the 'classical' acute rejection; (ii) shows more concomitant calcineurin-inhibitor toxicity; (iii) is associated with C4d and plasma cell (PC)-rich infiltrates. Based on validated interview methods/self reporting, 145 adult renal allograft recipients, transplanted for greater than one yr, on cyclosporine A and corticosteroids, were categorized as either compliant or non-compliant. Non-compliance was defined in 32 patients (22.1%). All late (greater than one yr) allograft biopsies were reviewed (Banff) and immuno-stained for C4d. Computerized morphometry was performed on late biopsies with features of acute cellular rejection. Sixty-two patients had > or =1 late biopsy [41 (36.2%) compliant/21 (65.6%) non-compliant; p = 0.0043], comprising a pool of 90 biopsies (61 compliant/29 non-compliant; p = 0.0303). 'Non-compliant' biopsies had higher scores of C4d (p = 0.0092), acute tubular damage (p = 0.0058), and peritubular capillaritis (p = 0.0070). 'Non-compliant' biopsies with acute cellular rejection showed less interstitial edema (p = 0.0165), more interstitial infiltrate (p = 0.0100), more interstitial fibrosis (p = 0.0277), and more tubular atrophy (p = 0.0197). PC-rich infiltrates correlated with C4d (p = 0.0080). Detection of non-compliance is mandatory as it represents an important cause of graft loss. This study describes histologic features of renal allograft biopsies in non-compliant patients that could help identifying this patient profile.

Prevalence and Consequences of Nonadherence to Hemodialysis Regimens

Adherence to fluid restrictions and dietary and medication guidelines as well as attendance at prescribed hemodialysis sessions of a hemodialysis regimen are essential for adequate management of end-stage renal disease. A literature review was conducted to determine the prevalence and consequences of nonadherence to the different aspects of a hemodialysis regimen and the methodological obstacles in research on nonadherence. Nonadherence to the prescribed regimen is a common problem in hemodialysis and is associated with increased morbidity and mortality. Research on nonadherence is associated with 2 major obstacles: inconsistencies in definitions and invalid measurement methods. Further research is needed to validate measurement methods and to establish clinically relevant operational definitions of nonadherence.

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

BACKGROUND

Despite the impact of medical regimen nonadherence on health outcomes after organ transplantation, there is mixed and conflicting evidence regarding the prevalence and predictors of posttransplant nonadherence. Clinicians require precise information on nonadherence rates in order to evaluate patients' risks for this problem.

METHODS

A total of 147 studies of kidney, heart, liver, pancreas/kidney-pancreas, or lung/heart-lung recipients published between 1981 and 2005 were included in a meta-analysis. Average nonadherence rates were calculated for 10 areas of the medical regimen. Correlations between nonadherence and patient psychosocial risk factors were examined.

RESULTS

Across all types of transplantation, average nonadherence rates ranged from 1 to 4 cases per 100 patients per year (PPY) for substance use (tobacco, alcohol, illicit drugs), to 19 to 25 cases per 100 PPY for nonadherence to immunosuppressants, diet, exercise, and other healthcare requirements. Rates varied significantly by transplant type in two areas: immunosuppressant nonadherence was highest in kidney recipients (36 cases per 100 PPY vs. 7 to 15 cases in other recipients). Failure to exercise was highest in heart recipients (34 cases per 100 PPY vs. 9 to 22 cases in other recipients). Demographics, social support, and perceived health showed little correlation with nonadherence. Pretransplant substance use predicted posttransplant use.

CONCLUSIONS

The estimated nonadherence rates, overall and by transplant type, allow clinicians to gauge patient risk and target resources accordingly. Nonadherence rates in some areas--including immunosuppressant use--appear unacceptably high. Weak correlations of most patient psychosocial factors with nonadherence suggest that attention should focus on other classes of variables (e.g., provider-related and systems-level factors), which may be more influential.

Prevalence, consequences, and determinants of nonadherence in adult renal transplant patients: a literature review

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.

Prevalence of prednisolone (non)compliance in adult liver transplant recipients

Limited evidence is available concerning (non)compliance with the immunosuppressive regimen in adult liver transplant recipients. In our study we prospectively assessed prednisolone (non)compliance in 108 adult liver transplant recipients using electronic event monitoring (EEM) in an outpatient setting. The EEM is a pill bottle fitted with a cap containing a microelectronic circuit that registers date and time of bottle openings and closings. Median taking compliance was 100% (range 60-105%), median dosing compliance was 99% (range 58-100%); median timing compliance (TIC) was 94% (42-100%). A drug holiday (DH) of > or =48 h was found in 39% of the patients of > or =72 h in 16% of the patients. Using EEM in liver transplant recipients, we found an overall high level of compliance for prednisolone, except that TIC was low in about one third of the patients. Age below 40 years was found a significant risk factor for decreased TIC and for DHs of > or =48 h.

Adherence to the Therapeutic Regimen in Heart, Lung, and Heart-Lung Transplant Recipients

Optimal outcome after heart, lung, and heart-lung transplantation can only be obtained if patients are supported in adhering to a lifelong therapeutic regimen. The transplant patient's therapeutic regimen consists of a lifelong medication regimen, including immunosuppressive drugs; monitoring for signs and symptoms related to complications; avoidance of risk factors for cardiovascular disease and cancer (ie, diet and exercise prescriptions, nonsmoking); avoidance of abuse/dependence of alcohol or illegal drugs, as well as attending regular clinical checkups. Nonadherence to all aspects of this regimen is substantial. Nonadherence has been related to negative clinical outcome in view of acute rejections, graft vasculopathy, higher costs, and mortality. This review focuses on the prevalence, correlates, and consequences of nonadherence to the therapeutic regimen in heart, lung, and heart-lung transplantation. The current state of the-art on adherence-enhancing interventions is reported. Priorities for future research are outlined.

Prevalence and correlates of self-reported pretransplant nonadherence with medication in heart, liver, and lung transplant candidates

BACKGROUND

Evidence on prevalence and correlates of pretransplant medication nonadherence (MNA) is limited. The present study explored self-reported prevalence and correlates of MNA before heart, liver, and lung transplantation.

METHODS

This cross-sectional descriptive study included 174 patients: 69 lung, 33 heart, and 72 liver transplant candidates. MNA was assessed by self-report using the following question: "During the past 14 days, how often did you not take your medication?" Patients scoring once or higher on a five-point rating scale were considered to be nonadherent. Correlates of MNA explored were demographics, anxiety and depression (Hospital Anxiety and Depression Inventory), personality traits (NEO Personality Inventory-Revised), perceived health status (Euro-QOL), and social support (Social Support Questionnaire).

RESULTS

Prevalence of pretransplant MNA was 16.7% and was comparable among the three groups. After correction for multiple comparisons (i.e., P=0.01), higher educational level (P=0.006) was related to MNA. Less severe depression (P=0.069), lower scores on the personality trait conscientiousness (P=0.021), and less received social support (P=0.062) tended to be related to MNA. Multiple logistic regression revealed that higher educational level (P=0.008), lower received social support (P=0.013), and lower conscientiousness (P=0.023) were independent predictors of pretransplant MNA.

CONCLUSIONS

Several correlates of MNA allow identification of patients at risk for pretransplant MNA.

Tobacco and alcohol use in lung transplant candidates and recipients

Tobacco and alcohol use among lung transplant candidates and recipients is unknown. Our first goal was to describe tobacco and alcohol use before and after lung transplant in patients with cystic fibrosis (CF) and other pulmonary diseases (non-CF). Our second goal was to determine whether demographic variables, depression, anxiety and social support predicted tobacco and alcohol use. Self-report data from transplant candidates and recipients, and transplant nurse coordinator ratings of post-transplant smoking and drinking were utilized. Data from two samples were analyzed. Sample 1 comprised 219 patients being evaluated for lung transplant, and sample 2 comprised 45 transplant recipients who were 1-7 yrs post-transplant. The results from analyzing sample 1 indicated that 72% of non-CF patients and 16% of CF patients had a history of smoking cigarettes, and the majority of patients in both groups had consumed alcohol in the past. For CF patients, past smoking was related to higher depression scores, and past drinking was related to higher education and lower social support. For non-CF patients, a history of smoking was associated with being Caucasian and older. For CF patients, a history of drinking was associated with being older and less depressed, and for non-CF patients a history of drinking was associated with higher education and lower social support. Post-transplant 100% of recipients reported abstinence from tobacco, and over 60% reported abstinence from alcohol. Transplant coordinator ratings corroborated that no transplant recipients were using tobacco products or consuming alcohol in an excessive or problematic manner. For both groups, consuming alcohol after transplant was related to lower levels of social support. In conclusion, lung recipients remain abstinent from tobacco, and although over 30% of patients consume alcohol after transplant, it is not at problematic levels. Smoking and drinking behaviors were related to demographic variables, depression, and low social support.

Race and electronically measured adherence to immunosuppressive medications after deceased donor renal transplantation

Nonadherence to immunosuppressive medications may partly explain the worse allograft outcomes among black recipients of renal transplants. In a prospective cohort study of recipients of deceased donor renal transplants, microelectronic cap monitors were placed on bottles of one immunosuppressive medication to (1) measure average daily percentage adherence during the first posttransplantation year and (2) determine the factors associated with adherence. A total of 278 transplant recipients who provided sufficient microelectronic adherence data were grouped into four categories of average daily percentage adherence: 95 to 100% adherence (41.0% of patients), 80 to 95% adherence (32.4%), 50 to 80% adherence (12.9%), and 0 to 50% adherence (13.7%). In the unadjusted ordinal logistic regression model, black race was associated with decreased adherence (odds ratio [OR], 0.43; 95% confidence interval [CI], 0.26 to 0.72; P = 0.001). Cause of renal disease, Powerful Others health locus of control, transplant center, and dosing frequency were also associated with adherence. After adjustment for transplant center and dosing frequency, the association between black race and decreased adherence was substantially attenuated (OR, 0.65; 95% CI, 0.38 to 1.14, P = 0.13). Transplant center (P = 0.003) and increased dosing frequency (OR, 0.43; 95% CI, 0.22 to 0.86, for three or four times per day dosing; OR, 2.35; 95% CI, 1.01 to 5.45, for daily dosing; versus two times per day dosing; P = 0.003) remained independently associated with adherence. Other baseline demographic, socioeconomic, medical, surgical, and psychosocial characteristics were not associated with adherence. The transplant center and dosing frequencies of immunosuppressive medications are associated with adherence and explain a substantial proportion of the race-adherence relationship.

Factors modifying stress from adverse effects of immunosuppressive medication in kidney transplant recipients

INTRODUCTION

The adverse effects of immunosuppression appear in the majority of patients with a negative impact on morbidity, mortality and quality of life. The group of adverse symptoms manifested as changes in appearance, mood and energy are often more stressful than serious metabolic changes because of their direct negative influence on patients' well-being. The aim of this study is to explore the adverse symptoms of immunosuppressive medication which are the most stressful for transplanted patients, and which are the modifying factors.

PATIENTS AND METHODS

A total of 157 adult kidney transplant recipients from two transplant centres in Slovakia with a functioning graft transplanted <7 yr ago were examined. Patients participated in an interview focusing on stress from adverse effects, and their education and social support. Medical records were searched for information about immunosuppression protocols, dialysis treatment before transplantation, type of received organ and period after transplantation. The effect of the selected variables on the total score for stress from adverse effects was tested using ANOVA. The effect of the selected factors on stress from each single adverse effect was explored using t-test and ANOVA.

RESULTS

The most stressful symptoms were pain, weakness, weight gain, facial changes, depression and anxiety. The mean value of the total score for stress from adverse effects was 8.03 +/- 6.53 (minimum 0, maximum 30, range: 0-64), indicating low stress. Women and patients with lower education significantly more often felt the adverse effects of immunosuppression as stressful (p < 0.001 and p < 0.05, respectively). Age, social support, dialysis modality before transplantation, time from transplantation and type of immunosuppressive treatment did not affect the total score for stress from adverse effects. However, variables that were not significant in the overall score reached significance in some symptoms.

CONCLUSIONS

Women and patients with lower education significantly more often felt the adverse effects of immunosuppression as stressful; in a more detailed analysis the use of new drugs was connected with less stress in some symptoms. The use of these drugs can improve life quality for transplant recipients, decrease non-compliance, and thus prevent graft loss.

Prevalence and correlates of nonadherence to antiretroviral therapy in a population of HIV patients using Medication Event Monitoring System

Nonadherence to antiretroviral therapy (ART) jeopardizes good clinical outcome in people living with HIV. In a single-center prospective study, prevalence and correlates of nonadherence were investigated in 43 patients on ART. Nonadherence was assessed using Medication Event Monitoring System (MEMS), self-report and collateral report of treating physicians. Based on MEMS data, median taking adherence, dosing adherence, and timing adherence was 98% (interquartile range [IQR] = 5.3), 91.5% (IQR = 18), and 86% (IQR = 31.5), respectively. The median number of drug holidays per 100 days was 0.8 (IQR = 4.8). The prevalence of nonadherence measured by MEMS was 40%. Self-reported nonadherence and collateral report of nonadherence by physicians varied from 5% to 41% and 24% to 28%, respectively. Patients were categorized as adherent or nonadherent based on a clinically validated algorithm derived from MEMS parameters. Nonadherent patients used significantly more escaping coping strategies (p = 0.003) and planned problem solving strategies (p = 0.049), were prescribed significantly more antiretroviral medications (p = 0.02) and were significantly longer on ART (p = 0.04) than adherent patients. Identified correlates of nonadherence may help clinicians in detecting patients with HIV at risk for nonadherence and can support the development of adherence enhancing interventions.

Prospective study on late consequences of subclinical non-compliance with immunosuppressive therapy in renal transplant patients

In this prospective study we compared the incidence of late acute rejections (LAR) and changes in serum-creatinine over time between compliers and noncompliers with immunosuppressive therapy more than 1 year post transplantation and explored the relative contribution of non-compliance and other risk factors in the occurrence of LAR. One hundred and forty-six adult renal transplant recipients were followed during a 5-year period. Patients were interviewed at the beginning of the study and categorized as non-compliers if they admitted to have skipped immunosuppressive medication on a regular basis during the previous 12 months. The occurrence of LAR during the follow-up period was recorded. We identified 22.6% non-compliers of which 21.2% experienced a late acute rejection compared with 8% in the group of compliers at 5 years postinclusion (p < 0.05). Kaplan-Meier survival analysis showed a decreased rejection free time in non-compliers compared with compliers (p = 0.03). Non-compliant patients had a 3.2 higher risk of LAR (Cox regression analysis, p = 0.005). Non-compliers experienced a higher increase in serum-creatinine over time (Linear Mixed Models, p < 0.001). Non-compliance in renal transplant patients more than 1-year post transplantation is associated with an increased risk for LAR and a higher increase in serum-creatinine during the following 5 years.

Medication adherence in pediatric and adolescent liver transplant recipients

OBJECTIVE

Nonadherence to medications is a leading cause of morbidity in children and adolescents who have had a transplant, yet there are no published data about the use of different methods for detecting whether these children are taking their medications. There are also no published data about the age of transition at which a child assumes responsibility over taking the medications. This information is important if interventions to improve adherence are contemplated.

METHODS

We present an analysis of data obtained in the first year of the implementation of an adherence assessment protocol at a pediatric liver transplant clinic in a tertiary medical care center. Data were obtained for children and adolescents who had a liver transplant at least 1 year before the assessments took place. We used 5 adherence detection methods. The 4 subjective methods were self-reported, scaled questionnaires answered by nurses, physicians, caregivers, and patients. For the objective method, a standard deviation (SD) was calculated for tacrolimus blood levels obtained from each patient over time. A higher SD suggests increased variation among patients' blood levels and hence more erratic medication taking. We also asked the patients and caregivers who is responsible for taking the medications and what are the reasons for not taking them. The medical outcome measures were biopsy-proven rejection episodes, number of biopsies regardless of the results, number of hospital admissions, and number of in-patient days.

RESULTS

An analysis of 81 cases (258 assessments) revealed that the only method that predicted the medical outcome variables (biopsy-proven rejection and number of biopsies) was the SD of medication blood levels. Patients', clinicians', and caregivers' reports were not predictive. Clinicians' ratings of adherence were not correlated with patients' or caregivers'. The transition of responsibility for medication taking occurred approximately at the age of 12 years. Forgetfulness was cited as the most common reason for nonadherence by patients and caregivers; medication side effects were not frequently cited.

CONCLUSIONS

Our results indicate that clinical impression is not sufficient to determine whether children and adolescents are taking their medications after they have had a liver transplant. An objective assessment method should be used. Interventions targeting adherence should address the child's increasing role beginning in early adolescence. A clinical protocol incorporating objective assessments of adherence could potentially be implemented in other settings. It could form the basis for the evaluation of efficacy of interventions seeking to improve adherence to medications.

The economic implications of non-adherence after renal transplantation

BACKGROUND

The economic impact of therapeutic non-adherence in chronic diseases has rarely been examined using qualitative standards for economic evaluation. This study illustrates the impact of non-adherence on the cost utility of renal transplantation versus haemodialysis from the societal perspective and examines the scope for adherence-enhancing interventions.

METHODS

Long-term costs and outcomes in adherent and non-adherent renal transplant patients were simulated in a Markov model. The cost (euros, year 2000 values) and outcome data that were imputed in the model were derived from a prospective study in renal transplantation candidates performed in 2002. Probabilities of adverse events, graft rejection, graft loss and death in adherent and non-adherent renal transplant patients were derived from literature.

RESULTS

Compared with dialysis, renal transplantation offers a better outcome in both adherent and non-adherent patients. Lifetime costs after transplantation in the adherent patient group are higher than lifetime dialysis costs and lifetime costs in the non-adherent patient group, mainly because adherent patients live longer after transplantation. Long-term outcomes after transplantation are better for adherent than for non-adherent patients. The mean cost per QALY gained in adherent patients relative to non-adherent patients was euro 35 021 per QALY (95% CI 26 959, 46 620).

CONCLUSION

Compared with established healthcare interventions, such as haemodialysis, renal transplantation can be considered a cost-effective therapy for patients with end-stage renal disease, even if patients are non-adherent after transplantation. The low incremental cost per QALY calculated in this model for adherent renal transplant patients, suggests there may be scope for adherence-enhancing interventions (provided that such interventions with a sufficiently high effectiveness exist or can be developed). As the findings are based on simulated long-term costs and outcomes, they should not be considered as precise estimates of the impact of non-adherence. This study is rather meant as an illustration of how non-adherence may impact on the results of cost-effectiveness analyses.

Validity Testing of the Long-Term Medication Behavior Self-Efficacy Scale

Self-efficacy is an important determinant of health behavior that can be targeted for intervention. Little effort has been given to the development of valid measures for self-efficacy with medication taking for adherence research. The purpose of this study was to determine the criterion validity of the Long-Term Medication Behavior Self-Efficacy Scale (LTMBSES). Individual patient data from 6 existing adherence studies in transplant, hyperlipidemia, and AIDS/HIV patients (n = 1021) were pooled. Validity was determined by assessing the relation between the LTMBSES score and medication adherence—both self-reported and electronically monitored. A weak relationship was found between the LTMBSES score and adherence, which can possibly be attributed to a ceiling effect, caused by a too homogeneous population and/or a failure of the scale to challenge patients. Generalized Estimating Equations revealed that the total average self-efficacy score predicted reported medication adherence (p < .0001). The Receiver Operating Characteristic curve revealed the area under the curve was 0.67, indicating a significant (p < .0001), but poor predictive capability. Evidence for criterion validity of the Long-Term Medication Behavior Self-Efficacy Scale is not yet convincing. Future research should focus on: (1) validation in a population with a more heterogenous level of adherence, and (2) making the scale more challenging by referring to “always taking the medication without exception.”

Differences in psychosocial and behavioral profiles between heart failure patients admitted to cardiology and geriatric wards

BACKGROUND

Heart failure represents a growing epidemic, primarily in the elderly. Development and implementation of management programs designed for use in daily clinical practice remains a major challenge.

AIMS

This study aimed at profiling a hospitalized heart failure population in view of medical, behavioral, educational, psychosocial and health resources utilization parameters stratified by admission to cardiology and geriatric wards.

METHODS AND RESULTS

Using a descriptive comparative design, 109 European heart failure patients admitted to cardiology (42%) and geriatric wards (58%) were included. Significant differences (all P<0.0001) were identified between the two groups. Patients admitted to cardiology had a mean age of 68.5, 33% were women, and the mean ejection fraction was 38%. Patients admitted to geriatrics had a mean age of 85, 68% were women, and the mean ejection fraction was 56%. Sixty-six percent were admitted for cardiac reasons. Medical, educational, behavioral, psychosocial and health resources utilization data were retrieved from medical files as well as by patient and family interviews. Results showed significant differences between groups. Patients admitted to geriatric wards received significantly less ACE inhibition and beta-blockers. Moreover, these patients were significantly less knowledgeable, showed poorer self-management, poorer hearing, more cognitive impairment, a higher degree of depressive symptomatology, more problems with ADL and IADL, and used significantly more home health care services compared to patients admitted to cardiology wards.

CONCLUSION

The characteristics of the heart failure population at large are quite different from those of populations included in large-scale therapeutic trials. Findings from this study provide options for tailored management strategies for both profiled subgroups.

A review of the literature on the economics of noncompliance. Room for methodological improvement

Therapeutic noncompliance is a major issue in health care, having important negative consequences for clinical outcome as well as for health-care costs. This paper reviews the literature on the economics of therapeutic noncompliance, identifies methodological shortcomings and formulates recommendations for future economic research in this area. Medication noncompliance was explored more extensively, as the majority of articles dealt exclusively with this aspect of therapy. Eighteen studies were assessed according to their definition and measurement of medication noncompliance, study design, and identification and valuation of costs and outcomes. Very diverse designs and often invalid methods for calculating costs were found. Medication noncompliance is often ill-defined and measured in an inaccurate way. The economic consequences of therapeutic noncompliance have rarely been investigated according to the standard principles of good economic evaluation. Six studies examined both costs and consequences of noncompliance in a cost-outcome description or a cost-benefits, cost-effectiveness or cost-utility analysis. Eight studies dealt with the economic value of compliance-enhancing interventions. In general, studies on the economic consequences of noncompliance lack methodological rigour and fail to meet qualitative standards. There is a clear need for more and better research on the impact of noncompliance, on the cost-effectiveness of interventions and the potential of compliance-enhancing interventions to improve patient outcomes and/or reduce health-care costs.

The dialysis diet and fluid non-adherence questionnaire: validity testing of a self-report instrument for clinical practice

This study evaluated the validity of the dialysis diet and fluid non-adherence questionnaire (DDFQ) as a self-report instrument for clinical practice. The DDFQ was designed to measure non-adherence behaviour with diet and fluid guidelines in patients treated with hospital-based haemodialysis in Flanders (Belgium). In a multicentre cross-sectional study design, 564 patients from 10 dialysis centres in Flanders completed the DDFQ Criterion and construct validity of the instrument were substantiated using correlation techniques between the DDFQ and biochemical and biological ratings of non-adherence. The results of this study suggest that the DDFQ is a valid self-report instrument to assess non-adherence behaviour in haemodialysis patients in Flanders and probably also in other cultures.

Psychosocial assessments and outcomes in organ transplantation

A qualitative review was conducted to define the term psychosocial as applied to transplant patients and to summarize evidence regarding the role and impact of psychosocial assessments and outcomes across the transplant process. English-language case series and empirical studies from January 1970 through April 1990 that were abstracted in Medline and Psychological Abstracts or listed in publications' bibliographies were used as data sources. A qualitative analysis was performed to determine the depth of the case reports and whether the empirical reports obtained statistically reliable, clinically significant findings. The authors conclude that psychosocial assessments differ in content and application to candidate selection depending on the transplant program. Psychosocial status before transplant does not consistently affect medical outcomes after transplant. Psychosocial status generally improves with transplant, although difficulties are prevalent in psychological adjustment and in compliance with medical regimens. Psychiatric history can predict psychological outcomes after transplant but does not consistently predict compliance. Social supports and coping strategies strengthen psychosocial outcomes. Posttransplant psychosocial outcomes may predict physical morbidity and mortality.

Evaluation of a multivariate model predicting noncompliance with medication regimens among renal transplant patients

BACKGROUND

Because noncompliance with medication regimens is a major cause of renal allograft failure, we evaluated the stability over time of two logistic regression models (sets of variables) that predict noncompliance with immunosuppressive regimens.

METHODS

Models were based on questionnaire data from 1402 patients (all over 18, receiving cyclosporine or a cyclosporine-like replacement drug, and with a functioning renal graft). The same questionnaire was completed by a subset of 548 (39.1%) patients approximately 18 months later. The goodness of fit of each model to the new data set was tested.

RESULTS

The noncompliance logistic regression model including patient beliefs as well as patient and transplant characteristics was an excellent fit to the second data set. A noncompliance model composed of only patient and transplant characteristics fit the new data set less well.

CONCLUSIONS

Clinicians and educators need to take explicit account of renal transplant patients' attitudes when evaluating risks of noncompliance and when developing interventions and educational programs to minimize noncompliance.

A pilot study of posttraumatic stress and nonadherence in pediatric liver transplant recipients

BACKGROUND

Symptoms of posttraumatic stress disorder (PTSD) were described in survivors of life-threatening diseases, the trauma being the experiences associated with the disease or its treatment. Their prevalence in liver transplant recipients is unknown. Based on clinical observations, we hypothesize that a significant proportion of pediatric liver transplant recipients suffers from PTSD symptoms. We further hypothesize that nonadherence (noncompliance) to medical management may, in some cases, be associated with these symptoms. Traumatized patients, according to this hypothesis, will avoid taking their medications, because these serve as painful reminders of the disease.

OBJECTIVES

To determine the prevalence of PTSD symptoms in a sample of pediatric liver transplant recipients. To determine whether symptoms of PTSD are associated with nonadherence in these patients. To describe the clinical presentation of PTSD and the management of severe nonadherence in patients who suffer from this disorder.

METHODS

Nineteen pediatric liver transplant recipients and their caretakers were interviewed, using the UCLA Post Traumatic Stress Disorder Reaction Index (PTSRI). Data were obtained on a few demographic parameters and perception of disease threat. Adherence was evaluated by 2 methods: 1) a clinician panel (taking into account the clinical sequelae of severe nonadherence); and 2) computation of the standard deviations (SDs) of consecutive determinations of blood levels of Tacrolimus (a higher SD means higher variability between individual measures and is therefore an indicator of nonadherence). As an illustration of the general phenomenon, we describe 3 cases of liver transplant recipients who were nonadherent and who suffered from PTSD.

RESULTS

Six of 19 patients had positive scores on all 3 components of the PTSRI (PTSD patients). Three of these, and none of the others, were considered significantly nonadherent by the panel. Therefore, nonadherence was significantly associated with the existence of symptoms from all 3 domains of PTSD (Fisher's exact test) in our sample. In particular, a high avoidance score on the PTSRI was highly correlated with panel-determined nonadherence. Further, SD of medication levels were significantly higher in PTSD patients, compared with the rest of our sample. No significant differences were found in perception of disease threat or demographic variables between PTSD patients and the rest of our sample. The 3 cases that we describe became adherent to their medications when symptoms of PTSD subsided during the course of therapy.

CONCLUSIONS

Clinically significant nonadherence, determined by 2 different methods, was associated with the full spectrum of PTSD symptoms in this sample. It was especially associated with a high avoidance score, which suggests that avoidance of reminders of the disease (eg, medications) may be a mechanism of nonadherence. Screening for and management of these symptoms, therefore, may improve adherence. This novel concept may be applicable to other patient populations. However, more data are needed before any definite conclusions can be drawn.

Compliance and noncompliance in kidney transplant patients: cues for transplant coordinators

Maximizing kidney transplant patients' long-term compliance with immunosuppressants is a major challenge to transplant coordinators. Although previous research has found substantial proportions of recipients to be noncompliant, predictors of noncompliance and characteristics of noncompliers remain unclear. In this study of more than 1400 kidney transplant patients, we found noncompliance to be associated with patient and transplant characteristics and with patient beliefs concerning the efficacy of immunosuppressants. Three distinct profiles of noncompliers were identified: accidental noncompliers, invulnerables, and decisive noncompliers. This information can be used by transplant coordinators to recognize cues that predict noncompliance and to work with at-risk patients to forestall or remedy noncompliant behavior.

Early post-transplant medical compliance and mental health predict physical morbidity and mortality one to three years after heart transplantation

BACKGROUND

Poor medical compliance has been held responsible for a large proportion of deaths occurring subsequent to initial postoperative recovery. However, beyond clinical reports, there has been little empirical examination of this issue, or of the extent to which major psychiatric disorder and failure to adjust to the transplant predict long-term physical morbidity and mortality. We prospectively examined whether a full range of compliance behaviors and psychiatric outcomes during the first year post-transplant predicted subsequent mortality and physical morbidity through 3 years post-transplant.

METHODS

A total of 145 heart recipients who had received detailed compliance and mental health assessments during the first year post-transplant were followed up at 3 years post-transplant. Interview data and corroborative information from family members were used to determine compliance in multiple domains, psychiatric diagnoses, and psychiatric symptomatology during the first year post-surgery. Medical record reviews were performed to abstract data on acute graft rejection episodes, incident cardiac allograft disease (CAD) and mortality from 1 to 3 years post-transplant.

RESULTS

After controlling for known transplant-related predictors of outcome, multivariate analyses yielded the following significant (p < 0.05) results: (a) risk of acute graft rejection was 4.17 times greater among recipients who were not compliant with medications; (b) risk of incident CAD was elevated by persistent depression (Odds Ratio, OR = 4.67), persistent anger-hostility (OR = 8.00), medication noncompliance (OR = 6.91), and obesity (OR = 9.92); and (c) risk of mortality was increased if recipients met criteria for Post-Traumatic Stress Disorder related to the transplant (OR = 13.74).

CONCLUSIONS

The findings, plus data we have previously reported that showed which patients are most likely to have compliance and psychiatric problems early post-transplant, suggest that interventions focused on maximizing patients' psychosocial status in these areas may further improve long-term physical health outcomes in this population.

Compliance and noncompliance in patients with a functioning renal transplant: a multicenter study

BACKGROUND

Noncompliance with medication is a major cause of renal allograft failure among adult renal transplant patients. We summarize previous studies of noncompliance and report results of a large, multicenter survey designed to identify variables that (1) affect the likelihood of compliance with immunosuppressive medication regimens and (2) distinguish among noncompliant patients.

METHODS

Questionnaires were distributed to 2500 patients at 56 U.S. transplant centers. Compliance was determined by patient responses to questions concerning whether, within the previous 4 weeks, one or more doses of immunosuppressive medications had been missed. Independent variables included patient and transplant characteristics, memories of dialysis, posttransplant symptoms and beliefs, and beliefs concerning the efficacy and importance of immunosuppressants.

RESULTS

The incidence of noncompliance reported by the 1402 respondents was 22.4%. A logistic regression model that included age, occupation, time since transplant, and three medication-related beliefs was most predictive of the likelihood of compliance. Donor type and histories of diabetes and of infection entered the multivariate model when belief-related variables were excluded. Cluster analyses identified three distinct profiles of noncompliers: accidental noncompliers, invulnerables, and decisive noncompliers.

CONCLUSIONS

Results of this study, which included nearly three times more patients than the largest previously reported study, can be used by clinicians to identify patients likely to become noncompliant, by researchers to develop randomized, prospective clinical trials of interventions designed to increase compliance, and by educators to tailor patient education programs.

Therapeutic drug monitoring in special populations

Therapeutic drug monitoring (TDM) is commonly used to maintain “therapeutic” drug concentrations. Even in compliant patients, with “average” drug kinetics, TDM is useful to identify the causes of unwanted or unexpected responses, prevent unnecessary diagnostic testing, improve clinical outcomes, and even save lives. TDM has greatest promise in certain special populations who are: (a) prone to under- or overrespond to usual dosing regimens, (b) least able to tolerate, recognize, or communicate drug effects, or who are (c) intentionally or accidentally misdosed. TDM is especially useful in patients at the extremes of age, in adolescents, and in patients who are either taking multiple drugs or expressing unusual pharmacokinetics as a result of physiological, environmental, or genetic causes. Less-well-appreciated uses of TDM include prevention of dangerousunderdosing of patients, investigation of adverse drug reactions, and identification of serious medication errors, even for a number of drugs that are not traditionally monitored. TDM can be useful for some drugs in any patient and for most drugs in some special populations.