Impact of medication non-adherence on survival after pediatric heart transplantation in the USA

SummaryBackground and objectives The complexity of CKD management in children is increased by the number of comorbid conditions. This study assessed the prevalence of comorbidities in pediatric CKD and the frequency with which multiple comorbidities present together by assessing prevalent medication use by CKD stage and diagnosis and their association with clinical or sociodemographic factors. The association between number and frequency of dosing of medications prescribed and self-report of nonadherence was also assessed.Design, setting, participants, & measurements In this cross-sectional analysis of the Chronic Kidney Disease in Children study, medication use at study entry grouped by indication was examined by CKD stage, diagnosis, age, race, ethnicity, income, and CKD duration. Multivariate adjusted predictors of medication use and clustering were examined. Nonadherence was assessed by self-report of missed medications in the past 7 days.Results The 558 eligible participants had a median age of 11 years and median GFR of 44 ml/min per 1.73 m 2 ; 62% of participants were male and 78% had nonglomerular kidney disease. The number of medications for treatment of CKD comorbidities increased with advanced CKD stage (2.5-fold for stages IV versus II; P,0.001) and glomerular disease (1.4-fold versus nonglomerular; P,0.001). Three distinct medication clusters were identified that corresponded to treatment of glomerular disease, advanced renal tubular dysfunction, and proteinuric complications, respectively. Nonadherence was associated with increased medication dosing frequency (administration .2 times/d; P,0.001) but not the number of medications.Conclusions Medical therapy for children with CKD is complex and is affected by glomerular diagnosis, CKD stage, and medication frequency. The need for CKD-related medication treatment cannot be easily predicted by CKD staging alone. Poorer adherence was associated with increased medication frequency, but not with the number of medical problems needing treatment. Consolidating medical treatment and reducing medication frequency may improve adherence rates in children with CKD.

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“…This contrasts with other reports that suggest greater nonadherence among African-American patients (23)(24)(25)(26)(27).…”

Section: Discussioncontrasting

confidence: 99%

Medication Treatment Complexity and Adherence in Children with CKD

Blydt-Hansen

Pierce

Cai

et al. 2014

Clinical Journal of the American Society of Nephrology

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“…As observed in the kidney transplant population (44) (49). Adolescent age at transplant was independently associated with reports of nonadherence, and 56% of patients with two or more reports of nonadherence died within 2 years.…”

Section: Discussionmentioning

confidence: 54%

“…We also noted higher graft loss rates in patients with coronary artery disease or myocarditis as their primary heart disease than in patients with cardiomyopathy. A previous study also showed higher risks of death from rejection for patients with myocarditis than for those with cardiomyopathy (49). The reasons for this association are unknown.…”

Section: Discussionmentioning

confidence: 90%

High Risk of Graft Failure in Emerging Adult Heart Transplant Recipients

Foster

Dahhou

Zhang

et al. 2015

American Journal of Transplantation

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Emerging adulthood (17-24 years) is a period of high risk for graft failure in kidney transplant. Whether a similar association exists in heart transplant recipients is unknown. We sought to estimate the relative hazards of graft failure at different current ages, compared with patients between 20 and 24 years old. We evaluated 11 473 patients recorded in the Scientific Registry of Transplant Recipients who received a first transplant at <40 years old and had at least 6 months of graft function. Timedependent Cox models were used to estimate the association between current age (time-dependent) and failure risk, adjusted for time since transplant and other potential confounders. Failure was defined as death following graft failure or retransplant; observation was censored at death with graft function. There were 2567 failures. Crude age-specific graft failure rates were highest in 21-24 year olds (4.2 per 100 person-years). Compared to individuals with the same time since transplant, 21-24 year olds had significantly higher failure rates than all other age periods except 17-20 years (HR 0.92 [95%CI 0.77, 1.09]) and 25-29 years (0.86 [0.73, 1.03]). Among young first heart transplant recipients, graft failure risks are highest in the period from 17 to 29 years of age.Abbreviations: HLA, human leukocyte antigen; HR, hazard ratio; IQR, interquartile range; SES, socioeconomic status; SRTR, Scientific Registry of Transplant Recipients

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“…Prior data have shown higher reported rates of non-compliance among race/ethnic minorities, particularly blacks, compared with whites. 18,23 However, medication non-adherence is often closely associated with socioeconomic status, with prior data showing that a lack of private insurance often decreases adherence to immunosuppressive therapy. 24 Moreover, we lacked information on race/ethnic differences in genotypes that contribute to higher clearance and lower bioavailability of immunosuppressants.…”

Section: Discussionmentioning

confidence: 99%