Understanding Medication Nonadherence after Kidney Transplant

Abstract

Alloimmunity remains a barrier to long-term graft survival that necessitates lifelong immunosuppressive therapy after renal transplant. Medication nonadherence has been increasingly recognized as a major impediment to achieving effective immunosuppression. Electronic medication monitoring further reveals that nonadherence manifests early after transplant, although the effect is delayed. The etiology of nonadherence is multifactorial, with the strongest risk factors including past nonadherence and being an adolescent or young adult. Other risk factors with smaller but consistently important effects include minority race/ethnicity, poor social supports, and poor perceived health. In children, risk factors related to parental and child psychologic and behavioral functioning and parental distress and burden are also important. Qualitative systematic reviews highlight the need to tailor interventions to each transplant recipient's unique needs, motivations, and barriers rather than offer a one size fits all approach. To date, relatively few interventions have been studied, and most studies conducted were underpowered to allow definitive conclusions. If the kidney transplant community's goal of "one transplant for life" is to become a reality, then solutions for medication nonadherence must be found and implemented.

Keywords: rejection; renal transplantation; transplant outcomes.

Figure 1.

Major categories of risk factors for nonadherence in chronic disease based on reviews of the empirical literature (the work by Sabaté and World Health Organization). For each of the five categories of risk factors identified, examples are provided to illustrate findings specific to studies of kidney transplant recipients.

Figure 2.

Themes reflecting challenges and decisions about medication taking after kidney transplantation. Results from qualitative studies in adults are modified from Tong et al., with permission.