Detecting, preventing and treating non-adherence to immunosuppression after kidney transplantation

Abstract

Medication non-adherence (MNA) is a major issue in kidney transplantation and it is associated with increased risk of rejection, allograft loss, patients’ death, and higher healthcare costs. Despite its crucial importance, it is still unclear what are the best strategies to diagnose, prevent, and treat MNA. MNA can be intentional (deliberate refusal of adhere to a prescribed medication) or unintentional (non-deliberate missing the prescribed medication). Its diagnosis may rely on direct methods, aiming at measuring drug ingestions, or indirect methods, which analyze the habits of patients to check their adherence to correct drug dose (taking adherence) and intervals (time adherence). Identifying individual risk factors for MNA may provide the basis for a personalized approach to the treatment of MNA. Randomized control trials performed so far tested a combination of strategies, such as enhancing medication adherence through the involvement of healthcare personnel involved in drug distribution, the use of electronic reminders, therapy simplification, or various multidisciplinary approaches to maximize the correction of individual risk factors. Although most of these approaches reduced MNA in the short-term, the long-term effects on MNA, and, more importantly, on clinical outcomes remain unclear. In this review, we provide a critical appraisal of traditional and newer methods for detecting, preventing, and treating non-adherence to immunosuppression after kidney transplantation from the perspective of the practicing physician.

Reliability and Validity of the Japanese Version of the Basel Assessment of Adherence to Immunosuppressive Medications Scale in Kidney Transplant Recipients

“…27 MNA in younger patients is related to factors such as lifestyle disruptions, active social life, and high empowerment (health locus of control and self-efficacy), whereas MNA in older patients is related to factors such as forgetfulness, need for care, complexity of medication regimen, and side effects. 50 Furthermore, adherent KTRs took a greater number of medications than nonadherent KTRs in this study. In general, taking more medications is associated with other therapyrelated factors for MNA, including complexity of medication regimen, frequent changes in medication regimen, side effects, and more comorbidity.…”

“… 27 MNA in younger patients is related to factors such as lifestyle disruptions, active social life, and high empowerment (health locus of control and self-efficacy), whereas MNA in older patients is related to factors such as forgetfulness, need for care, complexity of medication regimen, and side effects. 50 …”

Development and Internal Validation of a Questionnaire Assessing Predisposition to Nonadherence to Immunosuppressive Medication in Kidney Pretransplant Patients

“…Medication nonadherence is, of course, a major concern in pretransplant assessment, and several risk factors for nonadherence have been identified, including history of nonadherence, measured, for example, by number of missed hemodialysis sessions, coexisting affective disorders, chronic alcoholism, and substance abuse. However, general consensus is that those risk factors only loosely predict which patients will be nonadherent posttransplant, 49 and their importance in transplant candidate assessment is neither as contraindications for transplant, nor for patient selection, not even for repositioning within the waiting list, but only for identification of patients at high risk for posttransplant medication nonadherence, which will allow more intensive monitoring and intervention to promote better adherence. 50 Therefore, the KATITA-25 questionnaire may be an important addition to the assessment of transplant candidates, by evaluating the patients' predisposition to nonadherence based on their own beliefs, concerns and general attitudes toward medications, in addition to disclosing the relative importance of each behavioral dimension associated with nonadherence.…”

“…Although nonintentional nonadherence may be improved by pharmaceutical counseling and medication reminders, intentional nonadherence is difficult to identify and usually resistant to standard treatment strategies. 49 In this regard, an important benefit of the KATITA-25 questionnaire may be in the identification of the tendency to intentional medication nonadherence because its 3 dimensions express traits related to refusal of taking the medication. Carelessness combines a somewhat unconcerned attitude toward the importance of taking the medication as prescribed, with forgetting the administration times, which is a frequent feature of nonadherence in different patients.…”

Case Report: Long-term observations from the tacrolimus weaning randomized clinical trial depicts the challenging aspects for determination of low-immunological risk patients

“…Indeed, risk of nephropathy recurrence ( 37 , 38 ) or adherence to treatment are important in this setting. The latter may be difficult to assess and maintain in the long-term, thus requiring a close follow-up to detect earlier potential issues, especially if maintenance therapy has been reduced ( 39 ).…”