Patient-reported non-adherence and immunosuppressant trough levels are associated with rejection after renal transplantation

Study protocol for the development and validation of a questionnaire evaluating predisposition to immunosuppressant medication non-adherence of kidney pre-transplant patients. The KATITA project

Non-adherence to immunosuppressive medication after kidney transplant is an important cause of graft rejection and loss. Approaches to minimization of non-adherence have focused on the identification of episodes of medication non-adherence, but by then irreparable harm to the graft may already have occurred, and a more effective approach would be to adopt preventive measures in patients who may have difficulty in adhering to medication. The aim of this study protocol is to develop and validate a clinical questionnaire for assessing, in kidney transplant candidate patients in the pre-transplant setting, the predisposition to non-adherence to immunosuppressive medication. In this multicenter, prospective study, a pilot questionnaire in Brazilian Portuguese language, composed of Likert-scaled statements expressing patients' beliefs, behaviors and barriers regarding medication taking will be assembled from a literature review, from focus groups, and an expert panel. The pilot questionnaire will be administered to a minimum of 300 patients in kidney transplant waiting lists and exploratory factor analysis will be used for development of the definitive questionnaire. A random subsample of a minimum of 60 patients will have the scale re-administered after one month for evaluation of test-retest reliability. A multicenter, external validation study will include 364 kidney transplant candidates who will be evaluated immediately before surgery and at months 3, 6 and 12 post-transplant for assessment of concurrent validity, by comparison with two scales that assess medication non-adherence, and for determination of predictive validity using a triangulation method for assessment of medication non-adherence. Structural validity will be assessed with confirmatory factor analysis using structural equation modeling. Cross-cultural generalizability and validity will be assessed by a multicenter study, in which a translation of the scale to another language will be administered to kidney transplant candidate patients from a different culture, with a subsample being selected for test-retest. This study will be conducted in Spain with a Spanish translation of the scale.

A Descriptive, Correlational Study of Perceptions of Adult Kidney Transplant Recipients and Those Waiting for a Kidney Transplant About Managing Their Medications During a Pandemic

Introduction: Little is known about COVID-19 impact on patient medication management. Research Question: The aim was to describe medication management, healthcare team interactions, and adherence during the COVID-19 pandemic in kidney transplant patients and those on the kidney transplant wait list. Design: Using a descriptive, correlational design 340 adults from a midwestern US transplant program were recruited. The Managing Medications in the Midst of a Pandemic Survey measured healthcare team encounters and medication management. The Basel assessment of adherence to medications scale measured medication adherence. Results: The response rate was 35% (119/340). During the pandemic, 88% had practiced/were currently practicing socially distancing, 85% had worn/were currently wearing a face mask in public, 18% had been/were currently diagnosed with COVID-19 and 82% received the vaccine. Medication management: 76% planned and organized their own medications. Healthcare team interactions: 89% met in the office, 20% via phone, 12% telehealth, and 13% delayed seeing a healthcare provider because of COVID-19 concerns. Pharmacy interactions: 11% changed their method of obtaining medications from pharmacy due to social distancing. Medication adherence implementation was problematic with 19% missing a dose; results from the binary logistic regression suggested that those with higher levels of education were more likely to report missing a dose. Conclusions: Patients acted to prevent COVID-19 but some still contracted the virus. The pandemic changed healthcare team medication management interactions. Adherence implementation problems were nearly 20%. Findings are relevant to the transplant healthcare team to understand the impact of a pandemic on patient/team interactions and medication adherence.

The effect of tacrolimus conversion from immediate- to extended-release formulation on renal function in renal transplant patients: a meta-analysis

Objective: Tacrolimus formulation affects the outcomes of a renal transplant, while the effect of its immediate- to extended-release conversion remains controversial. This meta-analysis aimed to compare the renal function before and after tacrolimus immediate- to extended-release conversion in renal transplant patients. Methods: PubMed, Cochrane, Embase, CNKI, CQVIP, and Wanfang databases were searched for articles regarding the effect of tacrolimus conversion from immediate- to extended-release formulation on renal function in renal transplant patients. The data on serum creatinine (Scr) or the estimated glomerular filtration rate (eGFR) before and after conversion were extracted and analyzed. Results: Ten studies with 743 renal transplant patients were included. Scr was reduced after conversion versus before conversion [mean difference (MD) (95% confidence interval (CI)): -8.00 (-14.33; -1.66) μmol/L, p = 0.01]. However, eGFR only showed an increased trend after conversion versus before conversion (MD (95% CI): 2.21 (-1.62, 6.03) mL/min/1.73 m2, p = 0.26) but without statistical significance. Furthermore, in patients with a follow-up duration ≥48 weeks, Scr was decreased after conversion versus before conversion (p = 0.005), but eGFR remained unchanged (p = 0.68). However, in patients with a follow-up duration <48 weeks, both Scr (p = 0.36) and eGFR (p = 0.24) were not different before conversion versus after conversion. Moreover, publication bias risk was low, and robustness assessed by sensitivity analysis was generally good. Conclusion: This meta-analysis favors studies indicating that the conversion of tacrolimus from an immediate-release to an extended-release formulation could improve the kidney function to some extent in renal transplant patients, and this advancement may be related to the administration period.

Psychometric Properties of the BAASIS: A Meta-analysis of Individual Participant Data

BACKGROUND

Nonadherence to immunosuppressives, a risk factor for poor posttransplant outcomes, can be assessed by self-report using the Basel Assessment of Adherence to Immunosuppressive Medications Scale (BAASIS). Available in written and interview versions, and previously validated on content, the BAASIS is widely used in research and clinical practice. The aim of this study was to investigate its psychometric properties.

METHODS

Using a literature search and our BAASIS database, this meta-analysis identified completed studies in adult transplant recipients whose data were usable to examine the BAASIS' reliability and 3 validity aspects: (1) relationships with other variables (electronic monitoring, other self-report scales, tacrolimus blood-level variability, collateral report, depressive symptoms, psycho-behavioral constructs, and interventions); (2) response processes; and (3) internal structure. Testing used random-effects logistic regressions.

RESULTS

Our sample included 12 109 graft recipients from 26 studies. Of these 26, a total of 20 provided individual participant data. Evidence of the BAASIS' stability over time supports its reliability. Validity testing of relationships with other variables showed that BAASIS-assessed nonadherence was significantly associated with the selected variables: electronically monitored nonadherence ( P < 0.03), other self- and collaterally-reported nonadherence ( P < 0.001), higher variability in tacrolimus concentrations ( P = 0.02), higher barriers ( P < 0.001), lower self-efficacy ( P < 0.001), lower intention ( P < 0.001), and higher worries ( P = 0.02). Nonadherence also decreased after regimen change interventions ( P = 0.03). Response process evaluation indicated good readability and slightly higher nonadherence with the written version. Structurally, items on taking and timing shared variability.

CONCLUSIONS

The BAASIS shows good validity and reliability as a self-report instrument to assess medication nonadherence in transplantation.

Appointment Nonadherence and Graft Outcomes in Living Donor Kidney Transplantation

BACKGROUND

Medication nonadherence is associated with worse graft outcomes but is hard to recognize in clinical settings due to its self-reporting nature. We hypothesized that appointment nonadherence might be associated with worse graft outcomes in living donor kidney transplantation.

METHODS

We included 167 adult living-donor kidney transplants whose grafts survived >2 years from April 2011 to May 2020. Thirty-two cases of appointment nonadherence were identified and compared with the controls (n = 135).

RESULTS

Younger age, male sex, higher body weight, and parent donor were significantly observed in the appointment nonadherence group. The appointment nonadherence group was significantly associated with worse graft survival (5 years: 82.3% vs 98.9%, P < .001, 10 years: 67.2% vs 89.6%, P < .001), de novo donor-specific antibody production, acute rejection, as well as the decline of graft function. Furthermore, appointment nonadherence had a 4-fold higher risk of graft loss after an adjustment with recipient age, sex, body weight, and donor type (adjusted hazard ratio: 3.93, 95% CI: 1.15-13.42, P = .029).

CONCLUSIONS

Appointment nonadherence might be an alternative predictor for worse graft outcomes after living donor kidney transplantation.

[Medication adherence in renal transplantation: Evaluation, predictive factors and impact on humoral alloreactivity]

OBJECTIVES

The aims of this study were to assess medication adherence to immunosuppressive treatment in kidney transplanted patients, to identify predictive factors of medication non-adherence and to analyse its impact on the development of Donor Specific Antibodies (DSA) de novo, biomarkers of rejection in transplant recipients.

METHODS

A cross-sectional single-centre study was conducted to assess medication adherence to immunosuppressive treatment with the BAASIS (Basel Assessment of Adherence Scale for Immunosuppressives) self-report questionnaire. Univariate and multivariate analyses were performed to determine non-adherence predictive factors and its role in the development of DSA de novo.

RESULTS

A total of 212 renal transplanted patients completed the BAASIS questionnaire: 36,3 % were non-adherent to their immunosuppressive treatment. Patient's age and taking azathioprine were independent predictors of non-adherence and "married or living together" family status was a protective factor in the multivariate analysis. Medication non-adherence was associated with DSA de novo development in the multivariate model and it multiplied their risk of development by 3.

CONCLUSIONS

This study, which detected a large proportion of patients who did not adhere to immunosuppressive treatment, highlighted non-adherence predictors and showed the association between non-adherence and development of DSA de novo. In case of non-adherent behavior, it is crucial to set up a personalised support for patients with a multidisciplinary approach of therapeutic education, in which the clinical pharmacist has a role.

Efficacy of Tacrolimus in Uveitis, and the Usefulness of Serum Tacrolimus Levels in Predicting Disease Control. Results from a Single Large Center

AIMS

To evaluate the efficacy of tacrolimus in patients with noninfectious uveitis, as well as the usefulness of serum tacrolimus concentration measurements in predicting disease control.

METHODS

A retrospective review was carried out on 71 eligible patients from a single specialist uveitis center for minimum 1-year follow-up. Analysis was carried out on disease activity, visual acuity, and trough serum tacrolimus concentrations (STC).

RESULTS

At 1-year follow-up, disease control was achieved in 49 patients (69.0%), this was significantly more likely in patients with trough STC levels above 5 ng/mL (88% vs 53%, p = .002). There was a significant reduction in oral prednisolone (dose ≥7.5 mg, 86% vs 54%, p < .0001). Tacrolimus was discontinued in 12 patients (17%) due to side effects.

DISCUSSION

In this study cohort, oral tacrolimus was effective and well tolerated in the treatment of noninfectious uveitis. Trough STC between 5 ng/mL and 10 ng/ml was associated with better disease control at 1-year follow-up.

Directly observed therapy to promote medication adherence in adolescent heart transplant recipients

PURPOSE

HT recipients experience high levels of medication non-adherence during adolescence. This pilot study examined the acceptability and feasibility of an asynchronous DOT mHealth application among adolescent HT recipients. The app facilitates tracking of patients' dose-by-dose adherence and enables transplant team members to engage patients. The DOT application allows patients to self-record videos while taking their medication and submit for review. Transplant staff review the videos and communicate with patients to engage and encourage medication adherence.

METHODS

Ten adolescent HT recipients with poor adherence were enrolled into a single-group, 12-week pilot study examining the impact of DOT on adherence. Secondary outcomes included self-report measures from patients and parents concerning HRQOL and adherence barriers. Long-term health outcomes assessed included AR and hospitalization 6 months following DOT.

FINDINGS

Among 14 adolescent HT patients approached, 10 initiated the DOT intervention. Of these, 8 completed the 12-week intervention. Patients and caregivers reported high perceptions of acceptability and accessibility. Patients submitted 90.1% of possible videos demonstrating medication doses taken. MLVI values for the 10 patients initiating DOT decreased from 6 months prior to the intervention (2.86 ± 1.83) to 6 months following their involvement (2.08 ± 0.87) representing a 21.7% decrease in non-adherence, though not statistically significant given the small sample size.

CONCLUSIONS

Result of this pilot study provides promising insights regarding the feasibility, acceptability, and potential impact of DOT for adolescent HT recipients. Further randomized studies are required to confirm these observations.

Application of Rapid Rehabilitation Surgical Nursing Combined With Continuous Nursing in Self-Care Ability, Medication Compliance and Quality of Life of Renal Transplant Patients

Objective

To explore the effects of rapid rehabilitation surgery (FTS) nursing combined with continuous nursing on self-care ability, medication compliance and quality of life of patients after renal transplantation.

Methods

Sixty patients who received kidney transplantation in our hospital from January 2019 to January 2021 were randomly divided into the control group and the observation group with 30 patients in each group according to the random number table method. The control group was given FTS nursing, while the observation group was given continuous nursing on the basis of the control group. General data were collected and compared between the two groups. Postoperative indexes such as the time of first intake and the like of patients in the two groups were recorded. The patients' comfort, self-care ability, medication compliance and quality of life after renal transplantation were evaluated in the two groups. During the follow-up, the hospitalization of patients with complications was recorded.

Results

There was no significant difference in the first intake, blood glucose, creatinine, urea nitrogen, blood potassium or postoperative hospital stay between the two groups (P > 0.05). There was no significant difference in the postoperative physical, mental, psychological, social and environmental dimensions between the two groups (P > 0.05). The scores of cognitive symptom management, exercise and communication with doctors in the two groups in post-intervention were higher than those in pre-intervention, and the scores in the observation group in post-intervention were higher than those in the control group (P < 0.05). The medication compliance in the observation group (93.33%) was higher than that in the control group (70.00%) (χ² = 5.455, P = 0.020). In post-intervention, the scores of quality of life of the observation group were higher than those of the control group (P < 0.05). The admission rate of complications in the observation group (10.00%) was lower than that in the control group (30.00%) (χ² = 3.750, P = 0.035).

Conclusion

FTS nursing can help renal transplantation patients to obtain more stable postoperative blood pressure, renal function and other indicators and comfort. On this basis, combined with continuous nursing can improve patients' self-care ability and medication compliance, which is of great significance to improve the quality of life of patients.

Tacrolimus trough levels in kidney transplant recipients

BACKGROUND

It is very important that kidney transplant recipients (KTRs) take immunosuppressive drugs to prevent graft rejection. This study aimed to identify the tacrolimus trough levels (TTL)-mean, TTL-standard deviation (SD), and TTL- coefficient of variation (CV) as well as factors affecting these values over a 2-year period in clinically stable patients > 5 years after kidney transplantation (KT).

METHODS

This retrospective study analyzed data from 248 adult outpatients > 5 years after KT. Medical chart data, including TTL, graft rejection, and tacrolimus dose change during a 2-year period, between January 2017 and December 2018, were collected. Multivariable regression analyses were conducted to determine the factors influencing the TTL-mean, TTL-SD, and TTL-CV.

RESULTS

The TTL-mean, TTL-SD, and TTL-CV were 6.00 ± 1.07 ng/mL, 1.51 ± 1.09 ng/mL, and 0.25 ± 0.14, respectively. The TTL-mean, TTL-SD, and TTL-CV did not differ according to sex, type of donor, retransplant, pretransplant kidney disease, body mass index, or posttransplant time; hence, they are stable in kidney transplant recipients > 5 years after KT. The higher the TTL-mean, the higher the TTL-SD. Age and the TTL-SD significantly predicted the TTL-mean (p < .001). Tacrolimus dose change and the TTL-mean significantly predicted the TTL-SD (p < .001). Tacrolimus dose change significantly predicted the TTL-CV (p = .008).

CONCLUSION

In clinically stable KTRs, TTL-SD and TTL-CV change sensitively in relation to tacrolimus dose changes. Therefore, changes in TTL-SD and TTL-CV in stable KTRs with no tacrolimus dose change require medical interest and attention.

No Apparent Influence of Nonadherence on Tacrolimus Intrapatient Variability in Stable Kidney Transplant Recipients

BACKGROUND

High intrapatient variability (IPV) in tacrolimus exposure has been associated with an increased risk of graft rejection and graft loss. It has been suggested that medication nonadherence has high impact on IPV. The objective of this study is to assess the relationship between tacrolimus IPV and medication nonadherence in stable kidney transplant recipients.

METHODS

This study was conducted within the Reducing Renal Function Deterioration trial (Netherlands Trial Register: NTR7256), which included stable kidney transplant recipients. Nonadherence was assessed quantitatively by electronic monitoring (EM) and qualitatively using the composite adherence score (CAS) consisting of patient self-reporting (Immunosuppressant Therapy Adherence Scale), a physician report, and the tacrolimus trough concentrations (C0). IPV in tacrolimus C0 and area under the concentration-time curves (AUCs) was evaluated at 5 and 3 sampling instances, respectively.

RESULTS

Data of 64 kidney transplant recipients (43 males, 21 females; mean age 53.6 years), mean time post-transplantation 5.4 years, were collected. Mean missed tacrolimus intake was 7% (0.3%-13.4%) based on EM, missing one intake every 2 weeks. Based on the CAS, 68.9% of the patients were categorized as nonadherent. The mean IPV was 17.9% (4.4%-65.3%) and 20.2% (2.5%-51.6%) for tacrolimus C0 and AUCs, respectively. The nonadherence data displayed a nonparametric distribution, with nonadherence scores mostly in the lower ranges. There was no significant difference in the mean IPV between adherent and nonadherent patients. There were no differences in EM, CAS, physician report, or time-in-therapeutic range, but patients with a low AUC IPV showed a slightly higher Immunosuppressant Therapy Adherence Scale score than those with a high AUC IPV (P = 0.035).

CONCLUSIONS

There was no apparent relationship between IPV and nonadherence in this motivated kidney transplant recipient population, with one missed tacrolimus dose every 2 weeks.

Age and sex determine conversion from immediate-release to extended-release tacrolimus in a multi-center cohort of Canadian pediatric renal transplant recipients

ER-Tac, taken once per day, is associated with improved adherence. This study examined the potential patient and clinical factors that influence clinicians to convert pediatric patients from immediate-release to ER-Tac. This prospective multi-center observational study followed Canadian pediatric kidney transplant recipients up to 5 years post-transplant. Cox Proportional Hazards Regression was used to examine the influence of factors on conversion to ER-Tac. Sixty-six participants were included in this analysis. For every additional year of age at the time of transplant, the likelihood of conversion was more than doubled (HR 2.54, CI 1.83, 3.54, P < 0.001). The impact of age reduced by three percent for every month after transplant (HR 0.97, CI 0.95, 0.98, P < 0.001). Girls were more likely to be converted than boys (HR 3.78, CI 1.35, 10.6, P 0.01). Adherence measures (MAM-MM and tacrolimus trough variability), individual barriers to adherence, renal function, HLA mismatch, and rejection were not significant predictors of conversion in the final regression model. ER-Tac was preferentially prescribed to older age and female patients. Female sex and adolescence are both associated with worse graft outcomes, but we found no link between individualized markers of adherence/graft risk and conversion. Clinicians appeared to be using demographic features to distinguish patients at perceived higher risk and converted accordingly, without a case-by-case evaluation of who is more susceptible to poor outcomes.

Retrospective Analysis of Tacrolimus Intrapatient Variability as a Measure of Medication Adherence

Background:

Increased intrapatient variability (IPV) in tacrolimus levels is associated with graft rejection, de novo donor-specific antibodies, and graft loss. Medication nonadherence may be a significant contributor to high IPV.

Objective:

The objective of this study is to determine the utility of tacrolimus IPV in detecting nonadherence by examining the relationship between self-reported adherence and tacrolimus coefficient of variability (COV), a measure of IPV.

Design:

Retrospective cohort study.

Setting:

St. Michael’s Hospital, Toronto, Ontario.

Patients:

All patients who were at least 1-year post-kidney transplant as of March 31, 2019, prescribed tacrolimus as an immunosuppressant and had a self-reported adherence status. Patients were excluded from the primary analysis of examining the correlation between COV and self-reported adherence if they lacked a calculatable COV.

Measurements:

Self-reported adherence, COV, demographic data, transplant, and medication history.

Methods:

A modified Basel Assessment of Adherence to Immunosuppressive Medications Scale (BAASIS) administered by healthcare professionals to assess self-reported adherence was used. The COV of tacrolimus trough levels was calculated and its correlation to BAASIS response was noted. The median COV was used as a cutoff to examine the characteristics of patients deemed “high COV” and “low COV.”

Results:

A total of 591 patients fit the initial criteria; however, only 525 had a recent calculatable COV. Overall, 92.38% of the population were adherent by self-report. Primary analysis identified a COV of 25.2% and 29.6% in self-reported adherent and nonadherent patients, respectively, though the result was not significant (P = .2). Secondary analyses showed a significant correlation between younger age at transplant and at the time of adherence self-reporting with nonadherence (P = .01). In addition, there was a strong correlation between those nonadherent with routine post-transplant blood work and younger age (P < .01).

Limitations:

The limitations included modified nonvalidated BAASIS questionnaire, social desirability bias, BAASIS only administered in English, and patients with graft failure not active in clinic not being captured.

Conclusions:

The COV should not be used as the sole method for determining medication adherence. However, COV may have some utility in capturing individuals who are not adherent to their blood work or patients who are having a poor response to tacrolimus and should be switched to another medication.

Prevalence of Non-Adherence to Immunosuppressive Medications in Kidney Transplant Recipients: Barriers and Predictors

Background

Non-adherence to immunosuppressant therapy (IST) is a major risk factor for graft rejection. Limited reports are available regarding the prevalence of non-adherence to IST in kidney transplant recipients (KTRs) as well as the predictors and barriers of non-adherence.

Material/Methods

The study included ambulatory KTRs, ≥18 years of age, with a functional kidney, from January 2017 to November 2018. The primary outcome was the prevalence of non-adherence, assessed with: 1) A telephone interview to complete the Arabic-translated and validated Immunosuppressant Therapy Adherence Instrument Scale (ITAS) and 2) IST serum blood levels within therapeutic levels. The secondary outcomes were the barriers to adherence using the validated Immunosuppressant Therapy Barriers of Adherence Scale (ITBS).

Results

We enrolled 102 of 141 patients screened. The mean±SD for age, body mass index, and the baseline of the estimated glomerular filtration rate were 45.5±15.6 years, 29.1±6 kg/m², and 72.7±21.9 ml/min/1.73 m², respectively. The prevalence of non-adherence was 5.9%, 95% CI (2.19–12.36%) and 14.7%, 95% CI (8.47–23.09%) using the ITAS and the average blood serum drug levels, respectively. The concordance of the 2 methods demonstrated an agreement of 81.3%, kappa of 0.01, and 95% CI (−0.16 to 0.18). The median, interquartile range (IQR) for ITBS, and uncontrollable and controllable barriers for adherence were 21, (18–25), 15, (12–18), and 6, (5–8), respectively.

Conclusions

The current study demonstrated a low to moderate prevalence of non-adherence to IST in KTRs. The barriers for adherence with IST necessitate additional targeted interventions to manage and optimize therapeutic and clinical outcomes.

Renal Function and Patient-Reported Outcomes in Stable Kidney Transplant Patients Following Conversion From Twice-Daily Immediate-Release Tacrolimus to Once-Daily Prolonged-Release Tacrolimus: A 12-Month Observational Study in Routine Clinical Practice in Germany (ADAGIO)

INTRODUCTION

This 12-month, noninterventional study on routine clinical practice in Germany evaluated renal function in stable kidney transplant recipients converted from immediate-release tacrolimus (IR-T) to prolonged-release tacrolimus (PR-T).

METHODS

Renal function was assessed in 183 patients by estimated glomerular filtration rate using the modification of diet in renal disease-4 formula. Self-reported gastrointestinal health-related quality of life, adherence, satisfaction with PR-T, suspected rejection episodes, and safety were also assessed at conversion and at 3, 6, and 12 months.

RESULTS

Conversion from IR-T to PR-T resulted in stable kidney function over 12 months, with a difference in estimated glomerular filtration rate between the first and final visits of 0.1 mL/min/1.73 m² (95% confidence interval, -1.6, 1.8). Eight patients experienced an acute rejection episode (4.4%). At each assessment, gastrointestinal health-related quality of life was low and adherence was high. Most patients reported that they were very satisfied (69.8%) or satisfied (28.1%) with PR-T at the final visit. Among patients reporting a preference, 78.4% preferred PR-T, 2.2% preferred IR-T, and 19.4% reported no preference. The safety profile of PR-T was consistent with that previously described.

CONCLUSION

Conversion of stable kidney transplant recipients from IR-T to PR-T provided stable kidney and graft function over 12 months (Verband Forschender Arzneimittelhersteller--registered study: NIS ADV-02).

Tacrolimus intrapatient variability in solid organ transplantation: A multiorgan perspective

BACKGROUND

Tacrolimus therapy in solid organ transplant (SOT) recipients is challenging due to its narrow therapeutic window and pharmacokinetic variability both between patients and within a single patient. Intrapatient variability (IPV) of tacrolimus trough concentrations has become a novel marker of interest for predicting transplant outcomes. The purpose of this review is to evaluate the association of tacrolimus IPV with graft and patient outcomes and identify interventions to improve IPV in SOT recipients.

METHODS

A systematic review of the literature was performed using PubMed and Embase from database inception to September 20, 2020. Studies were eligible only if they evaluated an association between tacrolimus IPV and transplant outcomes. Both pediatric and adult studies were included. Measures of variability were limited to standard deviation, coefficient of variation, and time in therapeutic range.

RESULTS

Forty-four studies met the inclusion criteria. Studies were published between 2008 and 2020 and were observational in nature. Majority of data were published in adult kidney transplant recipients and identified an association with rejection, de novo donor specific antibody (dnDSA) formation, graft loss, and patient survival. Evaluation of IPV-directed interventions was limited to small preliminary studies.

CONCLUSIONS

High tacrolimus IPV has been associated with poor outcomes including acute rejection, dnDSA formation, graft loss, and patient mortality in SOT recipients. Future research should prospectively explore IPV-directed interventions to improve transplant outcomes.

Depression, Immunosuppressant Levels, and Clinical Outcomes in Postlung Transplant Recipients

OBJECTIVE

Posttransplant depression has been linked to increased risk for adverse outcomes in lung transplant patients. Maintaining target serum immunosuppressant levels is also essential for optimal lung transplant clinical outcome and may be a crucial predictor of outcomes. Because depression could affect medication nonadherence, resulting in out-of-range immunosuppressant levels, we examined the relationship between posttransplant depression, immunosuppressant medication trough level variability, indexed by out-of-range values on clinical outcomes and coefficient of variability, and clinical outcomes.

METHOD

A consecutive series of 236 lung transplant recipients completed the Center for Epidemiological Studies-Depression two-month posttransplant. Immunosuppressant trough levels (i.e., tacrolimus or cyclosporine) within the range of individualized immunosuppressant targets were obtained at three-, six-, nine-month follow-up clinic visits. Clinical outcomes including hospitalizations and mortality were obtained from medical records.

RESULTS

Fourteen percent of patients were classified as depressed (Center for Epidemiological Studies-Depression ≥16), 144 (61%) of patients had at least 25% out-of-range immunosuppressant values, and the average coefficient of variability was 36%. Over a median of 2.6 years (interquartile range = 1.2), 32 participants died (14%) and 144 (61%) had at least one unplanned, transplant-related hospitalization. Both depression (hazard ratio = 1.45 (1.19, 1.76), p < . 01) and immunosuppressant variation (immunosuppressant out-of-range: hazard ratio = 1.41 (1.10, 1.81), p < .01) independently predicted more frequent hospitalizations and higher mortality.

CONCLUSIONS

Early posttransplant depression was associated with significantly worse clinical outcomes. While immunosuppressant level variability is also related to adverse outcomes, such variability does not account for increased risk observed with depression.

Prospective single-centre clinical observational study on electronically monitored medication non-adherence, its psychosocial risk factors and lifestyle behaviours after heart transplantation: a study protocol

INTRODUCTION

In heart transplant recipients (HTRs), non-adherence (NA) to immunosuppressive (IS) medication and to recommended lifestyle behaviours are a common phenomenon and associated with higher risk of allograft rejection, organ loss and mortality. Risk factors for NA are highly diverse and still insufficiently researched. Precise measures of NA and an accurate understanding of its aetiology are of undisputable importance to detect patients at risk and intervene accordingly. The aim of this study is to assess the accuracy and concordance of different measures for NA as well as to determine potential risk factors.

METHODS AND ANALYSIS

This is a single-centre prospective observational trial. HTRs who are at least aged 18 are no less than 6 months post-transplant and receive tacrolimus (Prograf or Advagraf), cyclosporine (Sandimmun) or everolimus (Certican) as their prescribed IS medication are eligible for participation. We only include patients during the phase of medication implementation. At study enrolment, we assess depression, health-related quality of life, self-efficacy, social support, attachment, experiences and attitudes towards IS medication, emotional responses after transplantation, satisfaction with information about IS medication and perceptions and beliefs about medications. We further ask patients to rate their lifestyle behaviours concerning alcohol, smoking, diet, physical activity, sun protection and appointment keeping via questionnaires. Three different measurement methods for NA are applied at T0: self-reports, physician's estimates and IS trough levels. NA is monitored prospectively using an electronic multicompartment pillbox (MEMS, VAICA) over a 3-month period. Meanwhile, participants receive phone calls every second week to obtain additional self-reports, resulting in a total of seven measurement points.

ETHICS AND DISSEMINATION

The study was approved by the Clinical Ethics Committee of the University Hospital Erlangen (Friedrich-Alexander-University, Erlangen-Nürnberg). Written informed consent is attained from all participants. The results of this study will be published in peer-reviewed journals and presented at conferences.

TRIAL REGISTRATION NUMBER

DRKS00020496.

Comparison of a home-based (multi) systemic intervention to promoting Medication AdheRence and Self-management among kidney transplant recipients with care-as-usual: the MARS randomized controlled trial protocol

Background

After kidney transplantation non-adherence and inadequate self-management undermine clinical outcomes and quality of life. Both have been demonstrated to be substantial in all age groups. However, interventions promoting adherence and self-management among kidney transplant recipients that have proven to be effective are scarce. In this study we aim to develop and test an intervention to optimize adherence and self-management. In this article we describe the background and design of the trial entitled ‘promoting Medication AdheRence and Self-management among kidney transplant recipients’ (MARS-trial)’.

Methods/design

This is a single-center, parallel arm randomized controlled trial. Nonadherent kidney transplant recipients aged 12 years or older are eligible for inclusion. Patients will be randomly assigned to either the experimental or a control group. The control group will receive care-as-usual. The experimental group will receive care-as-usual plus the MARS-intervention. The MARS-intervention is an outreaching intervention, based on the principles of (multi) systemic therapy which means involving the social network. A standardized intervention protocol is used for consistency but we will tailor the behavior change techniques used to the specific needs and determinants of each patient. The primary outcome of medication adherence will be measured using electronic monitoring. Secondary outcome measures regarding medication adherence and self-management are also assessed. Data is collected at baseline (T0), after a run-in period (T1), at six months post-baseline/end of treatment (T2) and after a six month follow-up period (T3).

Discussion

We combined elements of (multi) systemic therapy and evidence-based behavior change techniques to create an outreaching and highly individualized intervention. In this trial we will investigate the impact on medication adherence and self-management after kidney transplantation.

Trial registration

Netherlands Trial Register,trial number NTR7462. Registered 7th September 2018, https://www.trialregister.nl/trial/7264

Kidney Transplantation and "Sex Mismatch": A 10-Year Single-Center Analysis

Background

The effect of a relative disproportion in the size of a transplanted kidney (KT) on graft function and survival is well documented. However, the importance of the H-Y antigen (male donor and female recipient) has not been unambiguously confirmed.

Material/Methods

Our retrospective analysis consists of 230 deceased donor/recipient pairs. The aim of the study was to determine the effect of sex mismatch between donors and recipients on the function of the graft and the graft and patient survival.

Results

In the group of male donors, a statistically significantly lower value of the eGFR (estimated glomerular filtration rate) was recorded for female recipients in the fifth year after the KT (=0.0047). The male donor/female recipient group was an independent risk factor for: eGFR (<60 ml/min (CKD-EPI, Chronic Kidney Disease Epidemiology Collaboration) in the third year after KT [HR 0.1618; (P=0.0004)], acute rejection in the first year after KT [HR 1.8992; (P=0.0387)], and the 5-year graft survival was significantly worse in this group. By adjusting the results for age and induction, this group was at significantly higher risk for decreased graft function (eGFR <30 ml/min) if the age of the donor was ≤50 years old and the recipient was >45 years old in the fifth year [HR 11.1676; (P=0.0139)], the age of the donor was ≤50 years old/recipient was ≤45 years old in the third year [HR 1.2500; (P=0.0050)], and also in the fifth year after KT [HR 8.1993; (P=0.0183)].

Conclusions

Based on our analysis, the differences in the incidence of acute rejection episodes as well as in graft survival among the different groups of patients were confirmed. The group with the highest risk, in cases of an acute rejection episode, is a male donor/female recipient.

Accuracy and concordance of measurement methods to assess non-adherence after renal transplantation - a prospective study

Background

Non-adherence (NA) to immunosuppressants (IS) among renal transplant recipients (RTRs) is associated with higher risk of allograft rejection, graft loss, and mortality. A precise measurement of NA is indispensable, although its prevalence differs greatly depending on the respective measurement methods. The objective of this study was to assess the accuracy and concordance of different measurement methods of NA in patients after renal transplantation.

Design and methods

This was a single-center prospective observational study. At baseline (T0), NA was measured via physicians’ estimates (PE), self-reports (SR), and tacrolimus trough level variability (CV%) in 78 RTRs. A Visual Analogue Scale (VAS, 0–100%) was applied both for SR and PE. In addition, we used BAASIS© for SR and a 5-point Likert scale for PE. NA was measured prospectively via electronic monitoring (EM, VAICA©) during a three month period. Meanwhile, all participants received phone calls in a two week interval (T1-T6) during which SRs were given.

Results

Seventy-eight RTRs participated in our study. At t0, NA rates of 6.4%, 28.6%, and 15.4% were found for PE, SR, and CV%, respectively. No correlation was found between these methods. During the study, the percentages of self-reported and electronically monitored adherence remained high, with a minimum mean of 91.2% for the strictest adherence measure (Timing Adherence ±30 min). Our results revealed a moderate to high association between SR and EM. In contrast to PE and CV%, SR significantly predicted electronically monitored adherence. Overall, a decreasing effect of electronically monitored adherence was found for both taking and timing adherence (±2 h, ±30 min) over the course of the study.

Discussion

The moderate to high concordance of SR and EM suggests that both methods measure NA equally accurately. SR seems to be a method that can adequately depict electronically monitored NA and may represent a good and economical instrument to assess NA in clinical practice. The increased adherence at the beginning of the study and its subsequent decrease suggests an intervention effect. Surveillance of IS intake via EM with intermittent phone calls could improve adherence on a short-term basis. To establish long-term effects, further research is necessary.

Predictors of neuropsychological functioning and medication adherence in pediatric heart transplant recipients referred for neuropsychological evaluation

Children who undergo heart transplantation are at risk for long-term neurodevelopmental sequelae secondary to heart disease and its treatment. Detailed neuropsychological profiles in clinical sample status post-pediatric heart transplantation are sparse in the literature, and there is little information regarding predictors of neuropsychological functioning or how it relates to medication adherence in this population. The present study examined these questions in a retrospective analysis of 27 pediatric heart transplantation recipients referred for clinical neuropsychological evaluation. The sample demonstrated mild-to-moderate decrements across domains of neuropsychological functioning. Children with premorbid congenital heart disease performed more poorly in working memory, word reading, and parent-rated conceptual adaptive skills compared to children with premorbid cardiomyopathy. Additionally, a higher number of rejection episodes were related to poorer verbal memory. Children with parent-reported attention problems had better adherence to immunosuppressant medication, which may have represented greater caregiver involvement in medication management. Taken together, clinically referred children with history of heart transplantation showed broad-based difficulties across neuropsychological domains according to formal testing and parent rating scales. This population requires routine neuropsychological monitoring and intervention.

Assessment of rejection risk following subtherapeutic calcineurin inhibitor levels after pediatric heart transplantation

CNIs are the mainstay of immunosuppressive therapy after pediatric HTx. While regular laboratory surveillance is performed to ensure blood levels are within targeted range, the risk of acute rejection associated with subtherapeutic CNI levels has never been quantified. This is a retrospective single-center review of 8413 CNI trough levels in 138 pediatric HTx recipients who survived >1 year after HTx. Subtherapeutic CNI levels were defined as <50% of the lower limit of target range. The risk of acute, late (>12 months post-transplant) rejection following recipients' subtherapeutic CNI levels was assessed using time-varying multivariable Cox proportional hazards analysis. We found that 79 of 138 recipients (57%) had at least one subtherapeutic CNI level on routine surveillance laboratories during a mean follow-up of 5.5 ± 3.6 years. Following an episode of subtherapeutic levels, 17 recipients (22%) had biopsy-proven rejection within the next 3 months; the majority (9/17) within the first 2 weeks. After presenting with subtherapeutic CNI levels, recipients incurred a 6.1 times increased risk of acute rejection in the following 3 months (HR = 6.11 [2.41, 15.51], P = <.001). Age at HTx, HLA sensitization, or positive crossmatch were not associated with acute late rejection, but rejection in the first post-transplant year was (HR 2.61 [1.27, 5.35], P = .009). Thus, maintaining therapeutic CNI levels is the most important factor in preventing acute rejection in recipients who are >12 months after pediatric HTx. Recipients who present with subtherapeutic CNI levels on surveillance monitoring are 6.1 times more likely to develop rejection in the following 3 months.

Optimization of Electronically Monitored Non-Adherence in Highly Adherent Renal Transplant Recipients by Reducing the Dosing Frequency - A Prospective Single-Center Observational Study

BACKGROUND

Non-adherence (NA) after renal transplantation poses a major risk for allograft rejection, graft loss, and patient mortality. Yet, there is still ambiguity about its etiology and its possible relationships with patient-related factors. In order to prevent poor outcomes after transplantation, it is crucial to gain a more refined understanding of potential determinants, to identify patients at risk, and to intervene accordingly. The objective of this study was to assess potential risk factors of NA by prospectively applying electronic monitoring.

MATERIALS AND METHODS

This was a single-center prospective observational study. Prior to study initiation, sociodemographic, biomedical, and psychosocial variables (depression, health-related quality of life, self-efficacy, social support, attachment, experiences and attitudes towards immunosuppressive medication, emotional responses after organ transplantation, satisfaction with information about immunosuppressive medication, and perceptions and beliefs about medications) were assessed. Thereafter, immunosuppressive adherence behavior was measured prospectively via electronic monitoring (EM, VAICA©) during a 3-month period to receive the percentage frequency of Taking and Timing Adherence (±2h, ±30min) for each patient. Focus of this study was the phase of medication implementation.

RESULTS

A total of 78 patients participated in our study (mean age 55.28, 56% male). We found rates of 99.39% for Taking Adherence, 98.34% for Timing Adherence ±2h, and 93.34% for Timing Adherence ±30min, respectively.  Multiple regression analyses revealed that the type of medication could significantly predict Taking Adherence. Patients receiving Advagraf© (once daily) depicted better Taking Adherence than patients receiving Prograf© (twice daily) (p=0.04). No associations were found for Timing Adherence (±2h, ±30min). Sociodemographic, biomedical, or psychosocial variables were not found to be associated with adherence behavior.

DISCUSSION

In highly adherent populations, only a few factors can be altered to improve adherence. Changing the immunosuppressive regimen from twice-daily to once-daily could be an option for optimizing adherence. However, risk factors for NA could be different in a less adherent population.

Adherence profiles in kidney transplant patients: Causes and consequences

OBJECTIVE

Adherence is a dynamic phenomenon and a critical determinant of transplant patients outcome. The objective of this longitudinal study was to explore adherence in kidney transplant patients followed-up for up to three years after transplantation.

METHODS

Adherence was repeatedly estimated using the Morisky-Green-Levine 4-Item Medication Adherence Scale, in two successive cohorts of 345 (EPIGREN) and 367 (EPHEGREN) kidney transplant recipients. Mixed effect modeling with latent processes and latent classes was used to describe adherence time-profiles.

RESULTS

Two latent classes were identified. The adherent class represented 85% of the patients. Patients of the poorer-adherence class displayed a lower adherence at one month (p<10^-3), which worsened over time. Good adherence was associated with age >50 years, fewer depression episodes (5% vs. 13%, p = 0.001) and a better mental health component of quality of life (MCS-SF36 47 ± 11 vs. 41 ± 13, p = 0.015). Survival without acute rejection episodes was longer in the adherent class (p = 0.004).

CONCLUSIONS

The risk of poor adherence in renal transplant patients can be detected as early as one month post-transplantation, using appropriate and easy tools adapted to routine monitoring.

PRACTICE IMPLICATIONS

An early focus on vulnerable patients should allow putting into place actions in order to reduce the risk of poor outcome related to poor adherence.

Association of medication non-adherence with short-term allograft loss after the treatment of severe acute kidney transplant rejection

Background

Medication non-adherence is a risk factor for acute kidney transplant rejection. The association of non-adherence with short-term allograft loss in patients who develop acute rejection and are subsequently treated with maximal therapy is unknown.

Methods

We conducted a retrospective single center cohort study of adult patients who developed acute rejection from January 2003 to December 2017 and were treated with lymphocyte depletion. Clinicopathologic characteristics including adherence status were collected and descriptive statistics utilized to compare groups. The primary outcome was all-cause graft loss at 6 months after acute rejection treatment. A multivariable logistic regression quantified the association of non-adherence with the outcome.

Results

A total of 182 patients were included in the cohort, of whom 71 (39%) were non-adherent. Compared to adherent patients, non-adherent patients were younger (mean age 37y vs 42y), more likely to be female (51% vs 35%) and developed acute rejection later (median 2.3y vs 0.5y from transplant). There were no differences in estimated glomerular filtration rate or need for dialysis on presentation, Banff grade, or presence of antibody mediated rejection between the 2 groups. Overall, 48 (26%) patients lost their grafts at 6 months after acute rejection treatment. In adjusted analysis, non-adherence was associated with all-cause graft loss at 6 months after acute rejection treatment [OR 2.64 (95% CI 1.23–5.65, p = 0.012].

Conclusions

After adjusting for common confounders, non-adherent patients were at increased risk for short-term allograft loss after a severe acute rejection despite lymphocyte depletion. This finding may aid clinicians in risk stratifying patients for poor short-term outcomes and treatment futility.

Immunosuppression following organ transplantation. Part 2: complications and their management

Advances in the care of patients who have had a solid organ transplant has led to a growing population of post-transplant patients, who are also living for longer. As a result of their longer life expectancy, transplant recipients often face a multitude of challenges, including optimising their immunosuppressive regimens and managing potential complications. Life-threatening infections, malignancies, and organ-specific toxicities are the complications post-transplant patients commonly encounter and these complications are often associated with increased morbidity and mortality, adverse graft functioning and survival, profound impairment in the patient's quality of life, and significant healthcare burden. This article, the second of two parts, gives an overview of the issues involved in the care of patients who are receiving immunosuppressants. The common complications encountered by post-transplant patients are discussed and their assessment, management, prevention and treatment explored.

Medication non-adherence after kidney transplantation: A critical appraisal and systematic review

Medication non-adherence is one of the most important causes for shortened graft survival subsequently leading to a reduction in kidney graft survival results. Our aim was to provide an overview of its prevalence, risk factors, diagnostic methods and interventions to improve adherence in kidney transplant recipients. Therefore, we systematically searched the databases PubMed, COCHRANE Library, Web of Science and EMBASE for studies addressing "medication adherence", "compliance", "adherence", "kidney transplantation" and "life style factors". We identified 96 studies that satisfied our inclusion criteria. A problematic lack of a uniformly accepted definition for non-adherence was found, consequently leading to a wide range in non-adherence prevalence (36-55%). Using one uniformly accepted non-adherence definition should therefore be encouraged. A wide range in diagnostic methods makes it difficult to accurately detect non-adherence. Heterogeneous results of intervention studies make it difficult to select the best adherence enhancing method, challenging the battle against medication non-adherence. Literature suggests a combination of personalized interventions, based on patient-specific non-adherent behavior, to be most successful in improvement of adherence. High quality diagnostic methods and multidisciplinary, personalized interventions with focus on relevant clinical outcome are essential in overcoming medication non-adherence in kidney transplant recipients.

Factors influencing caspofungin plasma concentrations in kidney transplant patients with high incidence of invasive fungal infections

WHAT IS KNOWN AND OBJECTIVE

Caspofungin is commonly used in kidney transplant patients for prophylaxis or treatment of invasive fungal infections (IFIs) caused by Candida spp. and Aspergillus spp. Factors such as concomitant medications, co-morbidity and rejection often cause caspofungin pharmacokinetic parameters alterations in kidney transplant patients. Here, we aimed to investigate factors influencing caspofungin plasma concentrations and evaluate its prophylaxis and treatment efficiency for IFIs in kidney transplant patients.

METHODS

The prophylaxis and treatment efficiency of caspofungin for IFIs were assessed in 164 kidney transplant patients in the study. Six hundred and fifty-two caspofungin trough concentrations (C_min ) from the 164 patients were monitored by the liquid chromatography-tandem mass spectrometry method. Basic demographic variables, baseline disease, surgery, rejection, indwelling catheter, coinfection, concomitant medication and other caspofungin-related factors were collected. Univariate and multivariate analyses were used to assess factors influencing caspofungin plasma concentrations.

RESULTS AND DISCUSSION

The success rates were 94.96% (132/139) for caspofungin prevention and 80% (20/25) for caspofungin for IFIs. Caspofungin C_min in the kidney recipients varied largely compared with healthy volunteers (0.10-12.25 mg/L vs. 1.12-1.78 mg/L). Caspofungin C_min significantly increased in patients with continuous renal replacement therapy before transplantation (P = .001), concomitant medication of cyclosporine A (CsA, P = .009), ALB concentration of > 30 g/L (P = .019).

WHAT IS NEW AND CONCLUSION

This is an uncontrolled observational study of caspofungin as prophylaxis or treatment for IFIs in kidney transplant patients. Caspofungin could be an effective and well-tolerated option for antifungal prophylaxis and treatment in kidney transplant patients, and a number of factors could influence caspofungin C_min in these patients.

Dietary Patterns of Patients with Chronic Kidney Disease: The Influence of Treatment Modality

BACKGROUND

We analyzed the dietary patterns of Brazilian individuals with a self-declared diagnosis of chronic kidney disease (CKD) and explored associations with treatment modality.

METHODS

Weekly consumption of 14 food intake markers was analyzed in 839 individuals from the 2013 Brazil National Health Survey with a self-declared diagnosis of CKD undergoing nondialysis (n = 480), dialysis (n = 48), or renal transplant (n = 17) treatment or no CKD treatment (n = 294). Dietary patterns were derived by exploratory factor analysis of food intake groups. Multiple linear regression models, adjusted by sociodemographic and geographical variables, were used to evaluate possible differences in dietary pattern scores between different CKD treatment groups.

RESULTS

Two food patterns were identified: an "Unhealthy" pattern (red meat, sweet sugar beverages, alcoholic beverages, and sweets and a negative loading of chicken, excessive salt, and fish) and a "Healthy" pattern (raw and cooked vegetables, fruits, fresh fruit juice, and milk). The Unhealthy pattern was inversely associated with nondialysis and dialysis treatment (β: -0.20 (95% CI: -0.33; -0.06) and β: -0.80 (-1.16; -0.45), respectively) and the Healthy pattern was positively associated with renal transplant treatment (β: 0.32 (0.03; 0.62)).

CONCLUSIONS

Two dietary patterns were identified in Brazilian CKD individuals and these patterns were linked to CKD treatment modality.

Differences in Pathologic Features and Graft Outcomes of Rejection on Kidney Transplant

BACKGROUND

Rejection is still a barrier to long-term allograft survival, but there are not many reports of clinical outcomes according to rejection types. The purpose of this study was to investigate differences in pathologic features and graft outcomes of rejection on kidney transplant (KT).

MATERIALS AND METHODS

We retrospectively analyzed 139 kidney transplant recipients diagnosed to rejection by allograft biopsy results between 2006 and 2018. We divided kidney transplant recipients into 3 groups as follows: T cell-mediated rejection (TCMR), antibody-mediated rejection, and mixed rejection. We investigated clinical characteristics, pathologic findings, death-censored graft survival rates, and patient survival rates among the 3 groups.

RESULTS

Mean follow-up duration was 113.5 (SD, 80.6) months. The mixed rejection group was the youngest significantly. There were no significant differences of the proportion of sex, KT type, KT number, number of HLA mismatches, induction immunosuppressant, and maintenance immunosuppressant among the 3 groups. In pathologic findings, microvascular inflammation and C4d were significantly different among the 3 groups. Death-censored graft survival of mixed rejection was the least. In multivariate analysis, recipient age, TCMR, and positive C4d were the risk factors associated with graft failure. However, patient survival rates showed no significant differences among the 3 groups.

CONCLUSIONS

Our study showed that mixed rejection had poor prognosis in comparison with TCMR and antibody-mediated rejection groups, and TCMR and positive C4d were the most important risk factors for graft survival. Therefore, constant monitoring through allograft biopsy and early treatment for rejection are very important in post-transplant clinical outcomes.

Renal transplantation for lupus nephritis: non-adherence and graft survival

OBJECTIVES

Poor adherence to immunosuppressive treatment is common in patients with systemic lupus erythematosus and may identify those with lupus nephritis (LN) who have a poorer prognosis. Non-adherence has also been reported to be a potential adverse outcome predictor in renal transplantation (rTp). We investigated whether non-adherence is associated with increased rTp graft rejection and/or failure in patients with LN.

METHODS

Patients with LN undergoing rTp in two major London hospitals were retrospectively included. Medical and electronic records were reviewed for documented concerns of non-adherence as well as laboratory biochemical drug levels. The role of non-adherence and other potential predictors of graft rejection/failure including demographics, comorbidities, age at systemic lupus erythematosus and LN diagnosis, type of LN, time on dialysis prior to rTp and medication use were investigated using logistic regression.

RESULTS

Out of 361 patients with LN, 40 had rTp. During a median follow-up of 8.7 years, 17/40 (42.5%) of these patients had evidence of non-adherence. A total of 12 (30.0%) patients experienced graft rejection or failure or both. In the adherent group 2/23 (8.7%) had graft rejection, whilst in the non-adherent this rose to 5/17 (29.4%, p = 0.11). Graft failure was seen in 5/23 (21.7%) patients from the adherent group and 4/17 (23.5%) in the non-adherent group ( p = 0.89). Non-adherent patients had a trend towards increased graft rejection, hazard ratio 4.38, 95% confidence interval = 0.73-26.12, p = 0.11. Patients who spent more time on dialysis prior to rTp were more likely to be adherent to medication, p = 0.01.

CONCLUSION

Poor adherence to immunosuppressive therapy is common and has been shown to associate with a trend towards increased graft failure in patients with LN requiring rTp. This is the first paper to report that shorter periods on dialysis prior to transplantation might lead to increased non-adherence in lupus patients.

Randomised controlled trial of a video intervention and behaviour contract to improve medication adherence after renal transplantation: the VECTOR study protocol

INTRODUCTION

Non-adherence after kidney transplantation contributes to increased rejections, hospitalisations and healthcare expenditures. Although effective adherence interventions are sorely needed, increasing education and support to transplant recipients demands greater use of care providers' time and resources in a healthcare system that is stretched. The objective of this clinical trial is to determine the effectiveness of an electronically delivered video series and adherence behaviour contract on improving medication adherence to immunosuppressant medications.

METHODS AND ANALYSIS

A multicentre, parallel arm, randomised controlled trial will be conducted with four sites across North America (Saskatoon, Calgary, Halifax, Chicago). Adult patients will be randomised (1:1) to either the intervention (ie, home-based video education +behaviour contract plus usual care) or usual care alone. De novo transplant recipients will be enrolled prior to their hospital discharge and will be provided with electronic access to the video intervention (immediately) and adherence contract (1 month post-transplant). Follow-up electronic surveys will be provided at 3 and 12 months postenrolment. The primary outcome will be adherence at 12 months post-transplant, as measured by self-report Basel Assessment of Adherence to Immunosuppressive medications and immunosuppressant levels. Secondary outcomes include the difference in knowledge score between the intervention and control in groups (measured by the Kidney Transplant Understanding Tool); differences in self-efficacy (Generalised Self-efficacy Scale), Beliefs of Medicine Questionnaire (BMQ), quality of life (Short Form-12), patient satisfaction and cost utilisation. The study aims to recruit at least 200 participants across participating sites.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of Saskatchewan Behavioural Ethics Committee (Beh 18-63), and all patients provide informed consent prior to participating. This educational intervention aims to improve information retention and self-efficacy, leading to improved medication adherence after kidney transplantation, at low cost, with little impact to existing healthcare personnel. If proven beneficial, delivery can be easily implemented into standard of care.

TRIAL REGISTRATION NUMBER

NCT03540121; Pre-results.

Impact of educational levels on survival rate: A cohort study of 2007 living donor liver transplant recipients at a single large center

Among living donor liver transplantation recipients, the impact of educational levels on survival has rarely explored. Thus, the purpose of study is to analyze the survival rate differences across educational levels among recipients who underwent living donor liver transplantation.We retrospectively analyzed 2007 adult recipients who underwent living donor liver transplantation in a single large center. The educational level was divided into three categories: middle school or lower, high school, and college or higher. The primary outcome was all-cause mortality after living donor liver transplantation. Stratified log-rank test and Cox proportional hazard model were employed for statistical analysis.The incidence rates of all-cause mortality were 23.85, 20.19, and 18.75 per 1000 person-year in recipients with middle school or lower, high school, and college or higher education groups, respectively. However, the gender-stratified log-rank test has not shown a statistically significant difference (P = .3107). In the unadjusted model, hazard ratio (HR) was 1.02 [95% confidence interval (CI) = 0.79-1.33] in high school and 1.23 (95% CI = 0.93-1.64) and in middle school or lower educational level, respectively; In the full adjusted model, the HR of high school was 0.98 (95% CI = 0.75-1.28) and the HR of middle school or lower was 1.01 (95% CI = 0.74-1.37).Although study population of this study is large, we could not find significant survival rate differences by the levels of education. Social selection and high compliance rate might contribute to this result.

Prevalence and Risk Factors of Immunosuppressant Nonadherence in Heart Transplant Recipients: A Single-Center Cross-Sectional Study

BACKGROUND

Immunosuppressant nonadherence (INA) has been shown to affect outcomes after solid organ transplantation. The aim of the present study was to determine the prevalence of INA in heart transplant recipients and the associated risk factors of INA.

METHODS

Adult heart transplant recipients who firstly received heart transplantation (discharged for at least 3 months) were consecutively enrolled. Immunosuppressant adherence was assessed using the Basel Assessment of Adherence with Immunosuppressive Medication Scale (BAASIS). INA was categorized into five domains of contributing factors (socio-demographic factors, transplant-related factors, healthcare system access factors, post-transplant treatment-related factors, and patient-related psychosocial factors). These factors were compared between adherent and nonadherent patients. The risk factors of INA were investigated by logistic regression analysis.

RESULTS

A total of 168 heart recipients were ultimately included. Among them, 69 (41.1%) recipients were revealed to be nonadherent. Logistic regression analysis indicated that INA was associated with monthly income<3000 Chinese Yuan (CNY) (OR, 3.11; 95% CI, 1.58-6.12; p=0.001), number of prescribed concomitant drugs (OR, 1.23; 95% CI, 1.12-1.50; p=0.003) and concerns about immunosuppressants (OR, 1.09; 95% CI, 1.01-1.18; p=0.031).

CONCLUSIONS

Heart recipients had a high prevalence of INA. Lower income, greater number of prescribed concomitant drugs, and more concerns about immunosuppressants correlated most with timing nonadherence and taking nonadherence among heart recipients. These findings will be helpful to intervene on and prevent future INA of heart recipients.

Psychological processing of a kidney transplantation, perceived quality of life, and immunosuppressant medication adherence

Introduction: Though psychosocial well-being and quality of life generally improve after transplantation, a relevant proportion of patients suffers from psychosocial problems. Further analysis of the psychological coping after kidney transplantation is needed to identify patients at risk. The aim of this study was to examine the psychological response after kidney transplantation and its associations with health-related quality of life and immunosuppressant medication adherence. Materials and methods: The coping process after kidney transplantation was investigated with the Transplant Effects Questionnaire (TxEQ; subscales: worry, guilt, disclosure, adherence, responsibility) in 267 adult kidney transplant recipients ≥12 months post-transplantation. Furthermore, perceived health-related quality of life, self-reported immunosuppressant medication adherence, and sub-therapeutic immunosuppressant trough levels as biological markers of adherence were assessed. Results: Patients showed moderate scores concerning the subscales "worry", "guilt", and "responsibility" as well as high scores concerning "disclosure". Except for "adherence", all TxEQ subscales were associated with mental, but not with physical health-related quality of life and self-reported adherence. Sub-therapeutic immunosuppressant trough levels were significantly associated only with the TxEQ subscale "worry". Conclusions: The present results suggest a conditional structure in which mental health-related quality of life is negatively associated with worries, guilt, and responsibility and positively with disclosure. Adherence seems to be a complex behavior, which is not necessarily directly associated with the psychological processing of organ transplantations. As mental health-related quality of life is related to this psychological processing, the TxEQ could be used as a screening tool for problematic psychological processing after kidney transplantation.

Long-term Immunosuppression Adherence After Kidney Transplant and Relationship to Allograft Histology

Background

Nonadherence to immunosuppression after kidney transplant is an important contributor to graft failure. Little is known about how nonadherence changes 3 years posttransplant when Medicare coverage of immunosuppression ends and how that nonadherence impacts allograft histology. The goal of this study was to compare rates of nonadherence during posttransplant years 1 to 3 to years 3 to 5 and examine the relationship between nonadherence during years 3 to 5 and 5-year allograft histology.

Methods

We retrospectively analyzed 552 conventional kidney allografts in patients transplanted at our center between January 1, 1999, and June 1, 2010, who used the Mayo Clinic Specialty Pharmacy for the first 5 years posttransplant. Nonadherence was defined as less than 80% proportion of days covered. Overall adherence to immunosuppression appeared to be higher during years 3 and 5 compared to between years 1 and 3 (89.4% vs 82.9%, respectively; P < 0.0001 [paired t test]).

Results

Overall nonadherence during posttransplant years 3 to 5 appeared to be associated with fibrosis and inflammation on 5-year allograft biopsy but not with transplant glomerulopathy (16.9% vs 5.9%, P = 0.004; 10.4% vs 8.5%, P = 0.61, respectively). After adjusting for nonadherence to calcineurin inhibitor and prednisone therapy, only nonadherence to antimetabolite therapy remained significantly associated with 5-year fibrosis and inflammation (odds ratio, 10.6; 95% confidence interval, 1.5-76.1; P = 0.02).

Conclusions

Efforts to improve long-term adherence, possibly through the use of specialty pharmacies and increased adherence to antimetabolite therapy, may improve long-term allograft histology and survival, although further studies are needed to confirm these findings.

Impact of single nucleotide polymorphisms on P450 oxidoreductase and peroxisome proliferator-activated receptor alpha on tacrolimus pharmacokinetics in renal transplant recipients

The P450 oxidoreductase (POR) and peroxisome proliferator-activated receptor alpha (PPARA) genes are associated with the activity of cytochrome P450 enzymes in vivo. We aimed to investigate the impact of single nucleotide polymorphisms (SNPs) in the POR and PPARA genes on the pharmacokinetics of tacrolimus (TAC) in renal transplant recipients. A total of 220 recipients were assessed and 105 recipients were included for final quantitative analysis. Blood samples were collected and DNA was extracted. Targeting sequencing based on next-generation sequencing was applied to detect the SNPs in the POR and PPARA genes. In addition, a systematic review and meta-analysis was performed to comprehensively evaluate the influence of POR and PPARA mutations on the TAC concentrations. A total of 81 SNPs were obtained. Three SNPs (POR*28, Chr7:75619677 and Chr7:75614288) were found to be significantly associated with the TAC pharmacokinetics at 3 months, 6 months, and more than 12 months. No significant association was observed in the combined effect analysis of CYP3A4*1G and CYP3A5*3 with three significant SNPs in the POR gene. Age, post-transplant duration, and the use of sirolimus were identified as the most important factors that influenced the TAC concentrations. A meta-analysis of four studies results and our cohort indicated that compared with recipients carrying the CT or TT genotypes, recipients carrying the CC genotypes of POR*28 showed significantly higher TAC concentrations. Our study suggested the positive influence of mutations in the POR gene on TAC exposure at 3 months after kidney transplantation.

Strategies to Improve Patient Engagement in Young Kidney Transplant Recipients: A Review

Young adult and adolescent kidney transplant recipients have shorter graft survival than older and younger recipients. Although multifactorial, the tendency toward premature graft loss in young kidney transplant recipients has often been attributed to medication nonadherence and the transition from pediatric to adult care. Multiple interventions for medication nonadherence in kidney transplant recipients have been studied. Potential preventative interventions include pre-transplant screening, transition and young adult clinics, technologies such as reminders or mobile applications, and simplification of the post-transplant medication regimen. There are also recent advances in monitoring interventions for nonadherence in transplant recipients, including electronic monitoring devices such as wireless pill bottles and the Ingestible Sensor System, which incorporates ingestible microsensors into medications. Treatment interventions for medication nonadherence include cognitive behavioral programs, behavioral contracts, and screening and treatment for depression. Several of the interventions reviewed are currently available to providers caring for young kidney transplant recipients, without any complex programmatic changes. Further research in all of these areas would be of great value.

Posttransplant Medical Adherence: What Have We Learned and Can We Do Better?

Purpose of review

Non-adherence to the medical regimen after kidney transplantation can contribute to poor clinical outcomes, and strategies to maximize adherence are sought by care providers and patients alike. We assessed recent evidence on prevalence, risk factors, and clinical outcomes associated with non-adherence to the medical regimen after kidney transplantation. We summarized recent clinical trials testing interventions to improve adherence and generated recommendations for future research and clinical practice.

Recent findings

A large evidence base documents rates of non-adherence to each of the multiple components of the regimen, including medication-taking, lifestyle activities, clinical care requirements, and substance use restrictions. Some risk factors for non-adherence are well known but the full range of risk factors remains unclear. Non-adherence to immunosuppressants and to other components of the regimen increases morbidity and mortality risks. Recent interventions, including education and counseling; electronic health strategies; and medication dose modifications, show promise for reducing immunosuppressant non-adherence. However, most of these interventions would be difficult to deploy in everyday clinical practice. Systematic dissemination of efficacious interventions into clinical practice has not been undertaken.

Summary

Rates and risk factors for non-adherence to the medical regimen have been examined and there is evidence that non-adherence may be ameliorated by a range of interventions. Although gaps in the evidence base remain, it would be timely to devote greater efforts to dissemination of findings. Thus, efforts are needed to assist transplant programs in using existing evidence to better identify patients who are non-adherent and to design and implement strategies to reduce or prevent non-adherence.

Psychosocial Variables Associated with Immunosuppressive Medication Non-Adherence after Renal Transplantation

INTRODUCTION

Non-adherence to immunosuppressive medication is regarded as an important factor for graft rejection and loss after successful renal transplantation. Yet, results on prevalence and relationship with psychosocial parameters are heterogeneous. The main aim of this study was to investigate the association of immunosuppressive medication non-adherence and psychosocial factors.

METHODS

In 330 adult renal transplant recipients (≥12 months posttransplantation), health-related quality of life, depression, anxiety, social support, and subjective medication experiences were assessed, and their associations with patient-reported non-adherence was evaluated.

RESULTS

33.6% of the patients admitted to be partially non-adherent. Non-adherence was associated with younger age, poorer social support, lower mental, but higher physical health-related quality of life. There was no association with depression and anxiety. However, high proportions of clinically relevant depression and anxiety symptoms were apparent in both adherent and non-adherent patients.

CONCLUSION

In the posttransplant follow-up, kidney recipients with lower perceived social support, lower mental and higher physical health-related quality of life, and younger age can be regarded as a risk group for immunosuppressive medication non-adherence. In follow-up contacts with kidney transplant patients, physicians may pay attention to these factors. Furthermore, psychosocial interventions to optimize immunosuppressive medication adherence can be designed on the basis of this information, especially including subjectively perceived physical health-related quality of life and fostering social support seems to be of importance.

Mensuração da adesão aos medicamentos imunossupressores em receptores de transplante renal

Resumo Objetivo: Mensurar a adesão aos medicamentos imunossupressores em receptores de transplante renal, utilizando a Basel Assessment of Adherence with Immunosuppressive Medication Scale - BAASIS® e descrever as características sociodemográficas, os fatores clínicos em relação aos imunossupressores e os níveis de creatinina. Métodos: Estudo prospectivo, transversal, realizado no período de 2014 a 2015, no Ambulatório Pós-Transplante do Hospital do Rim (complexo hospitalar da Universidade Federal de São Paulo (UNIFESP)). Resultados: Dos 181 participantes, 53,6% eram homens e a idade dos receptores variou de 18 a 74 anos. A Hipertensão Arterial Sistêmica foi o diagnóstico inicial de Insuficiência Renal Crônica em 38,7% dos receptores. Aproximadamente 95% dos receptores relataram que nunca se esqueceram de tomar o medicamento; 58,6% dos pacientes relataram ter aderido totalmente aos imunossupressores e 41,4% não aderiram a uma ou mais das quatro situações avaliadas pelos itens da BAASIS®. Não foi encontrada correlação significativa pelos itens da BAASIS® entre os níveis de creatinina e o escore total. Conclusão: Foi identificado um alto índice de pacientes que não aderiram ao tratamento imunossupressor (41,4%). Não houve correlação significativa entre o nível de creatinina e a idade do receptor no momento do TxR, bem como o tempo após TxR, tempo de separação do imunossupressor e escore total, e escores dos itens individuais da BAASIS®. Esse estudo mostrou que os receptores negros, do sexo masculino, sem uma rede de apoio familiar, obesos e autônomos são mais propensos a não aderir à terapia imunossupressora. A avaliação da adesão do receptor de transplante renal deve ser considerada durante todas as fases das ações do processo de enfermagem que compõem o plano terapêutico após o transplante renal.