Adherence in liver transplant recipients

Abstract

Adherence to a medical regimen has been defined as the extent to which a patient's behavior coincides with clinical prescriptions. In liver transplant patients, adherence to immunosuppressive therapy and to medical indications in general is crucial for short-and long-term outcomes. Nonadherence to immunosuppression carries a risk of graft rejection and potential graft loss, whereas nonadherence to general medical indications (eg, avoiding alcohol intake and smoking after transplantation) may be associated with other complications such as de novo tumors and increasing health care costs. Among adult liver transplant patients, the rate of nonadherence to immunosuppressive drugs ranges from 15% to 40%, whereas the rate of nonadherence to clinical appointments ranges from 3% to 47%. The wide range of reported rates is due to different definitions of the term nonadherence and the variety of methods used to measure adherence in the medical literature. Nonadherence seems to be nearly 4 times higher in pediatric and adolescent patients versus adult transplant recipients. Several nonadherence risk factors, such as high medication costs, psychiatric disorders, the conviction that the medication is harmful, and side effects of immunosuppressive therapy, have been described among adult liver transplant patients. The risk factors for nonadherence in pediatric and adolescent liver transplant patients are psychological distress, the functional status of their families, and the impact of immunosuppressive side effects on their physical appearance. A single approach to promoting adherence to general medical prescriptions has been proved to be ineffectual, so a multidisciplinary strategy should be adopted to achieve significant improvements in this field. The aim of this review is to analyze the published literature on adherence in liver transplant patients with a particular focus on the reported prevalence and the identified risk factors. Patients have been split into 2 age groups (adults and children/adolescents) because the scale of the problem and the potential risk factors differ in the 2 groups.

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“…The rate of patients who reported being late in taking their immunosup pressive drugs dramatically decreased after conversion (50% vs 6.3%) and so did the percentage of patients who reported forgetting to take their immunosuppressive medications at least once per month (46.9% vs 15.6%). 16 These results are encouraging and need to be confirmed in a larger series. In addition, a recent large retrospective analysis of the European Liver Transplant Registry identified significant impro vements in long-term graft and patient survival rates in patients treated with once-daily tacrolimus compared with regular twicedaily tacrolimus in primary LT recipients over 3 years of treatment.…”

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“…Immunosuppressant nonadherence was higher in our cohort versus the reported rates of nonadherence, which range from 15% to 40% in the LT population. [1][2][3] One possible explanation for this result is that our study cohort comprised a more nonadherent patient population. This retrospective analysis did not require patient consent, thus avoiding the usual selection bias against participation of nonadherent patients in research.…”

“…[1][2][3][4] Psychosocial assessments before LT are performed with the hope that early detection of risk can lead to better selection of candidates or inform interventions that may mitigate identified risk before or after transplant. 5 In turn, such evaluations have become standard practice in most transplant programs.…”

Immunosuppressant Therapy Adherence Scale for Transplant Recipients: The Study of Validity and Reliability

“…[2][3][4][5][6][7][8][9][10][11] Reasons for nonadherence are varied and include, but are not limited to, high costs of IST, adverse drug effects, confusion regarding dosing schedule, psychiatric disorders, beliefs that IST is not effective, health care and work related problems, traveling away from home, and changes in recommended doses of therapy. 4,[11][12][13][14][15] Although various methods have been used to assess nonadherence, no one measure is currently considered the gold standard. 16 To implement strategic interventions targeting IST nonadherence in practice-based settings, measures of nonadherence are needed that are valid and reliable as well as inexpensive, practical, and easily administered.…”