Non‐adherence in pediatric liver transplant recipients − an assessment of risk factors and natural history

Abstract

Despite the fact that non-adherence to medical therapy is one of the major causes of late morbidity and mortality in pediatric liver transplant recipients, little is known of the risk factors involved in this behavior. Three cases of fatal non-adherence are reported. Factors associated with non-adherence were investigated by performing a retrospective chart review of a panel of 27 variables in an age-matched cohort of 15 pediatric liver transplant recipients. The most striking differences between the severely non-adherent group and the age-matched cohort included history of substance abuse, child abuse (physical or sexual), not having two parents at home, having received public assistance, having been diagnosed with a psychiatric disorder, and history of school dropout. In addition it appeared that a pretransplant diagnosis of autoimmune hepatitis was associated with more significant medical sequelae related to non-adherence. These findings are preliminary owing to the retrospective design of this study, but could be used as a starting point for a prospective study of this important phenomenon.

Complex Traumatic Stress in the Pediatric Medical Setting

“…In one study, children who had been physically or sexually abused had poorer adherence rates following a liver transplant than children who had not experienced abuse (Shemesh et al, 2007). This may have contributed to the increased transplant rejection and mortality rates of abused children (Lurie et al, 2000). Complex traumatic stress may influence adherence differently across various developmental stages.…”

Adolescent Exploratory Behavior—What Do Trainees Know?

“…They have also been shown to be significant factors in non-adherence in adolescent chronic disease management [3,4]. Of particular concern are the findings that exploratory behaviors cluster in adolescents, especially in those who are depressed, homeless, young offenders, or who have other problems that place them at risk [5].…”

“…Early uptake of smoking has been associated with engaging in multiple health risk behaviors [5], and early intervention may enable the focusing of services to support young people and prevent the clustering of risk behaviors. These behaviors not only have an impact on acute health in otherwise "well" adolescents but also have a large impact on disease management, complication rate, and compliance in adolescents with chronic disease [3,4]. There is substantial evidence that treatment for substance misuse is effective in adults and that some interventions are appropriately delivered by generalists; however the translation of this to adolescents is a newly emerging field [10].…”

Recent advances in pediatric liver transplantation

“…Anastomotic strictures are usually treated with dilatation or reexploration; strictures caused by HAT may require retransplantation. Nonadherence to immunosuppressive regimens is an unfortunate cause of late morbidity, mortality, and allograft loss [98,99]. Unfortunately, no regimens have been characterized that improve adherence in transplant recipients.…”