Interventions to improve medication adherence in adult kidney transplant recipients: a systematic review.

In kidney transplantation, adherence to immunosuppressive therapy is paramount for long-term graft survival. This systematic review aimed to assess the effectiveness of interventions to improve medication adherence in adult kidney transplantation.

The transplant team's support of kidney transplant recipients to take their prescribed medications: a collective responsibility.

AIMS AND OBJECTIVES: To obtain an understanding of how health professionals support the kidney transplant patient to take their medications as prescribed long term. BACKGROUND: Kidney transplantation requires stringent adherence to complex medication regimens to prevent graft rejection and to maintain general well-being. Medication nonadherence is common in kidney transplantation, emerging in the first few months post-transplantation, leading to poor patient outcomes. DESIGN: Exploratory qualitative design. METHODS: Five focus groups were conducted with a total of seven renal nurse transplant coordinators, two renal transplant nurse unit managers, seven nephrologists, seven pharmacists, four social workers, and one consumer representative representing all five hospitals offering adult kidney transplantation in Victoria, Australia in 2014. The views of two general practitioners who were unable to attend the focus groups were incorporated into the data set. All data underwent thematic analysis. RESULTS: Analysis revealed that adherence was a collective responsibility involving the whole of the transplant team and the patient via education blitz in hospital, identifying and managing nonadherence, promotion of self-advocacy, and the partnership between the patient and health professional. Patients were directed how to take their complex medications to be self-empowered, yet the partnership between the patient and health professional limited the patient's voice. CONCLUSION: Although medication adherence was a collective responsibility, communication was often one-way chiefly as a result of staffing and time constraints, hindering effective partnerships necessary for medication adherence. Expert skills in communication and adherence counselling are necessary to identify barriers affecting medication adherence. Patients need to be systematically screened, prepared and supported long-term within an accommodating healthcare system for the reality of caring for their transplanted kidney. RELEVANCE TO CLINICAL PRACTICE: Kidney transplant recipients require systematic preparation and quality long-term follow-up to adhere to their prescribed medications.

Stressors and coping resources of Australian kidney transplant recipients related to medication taking: a qualitative study

AIM: To understand the stressors related to life post-kidney transplantation, with a focus on medication adherence, and the coping resources people use to deal with these stressors. BACKGROUND: Although kidney transplantation offers enhanced quality and years of life for patients, the management of a kidney transplant post-surgery is a complex process. DESIGN: A descriptive exploratory study. METHOD: Participants were recruited from five kidney transplant units in Victoria, Australia. From March to May 2014, patients who had either maintained their kidney transplant for ≥ 8 months or had experienced a kidney graft loss due to medication non-adherence were interviewed. All audio-recordings of interviews were transcribed verbatim and underwent Ritchie and Spencer's framework analysis. RESULTS: Participants consisted of fifteen men and ten women aged 26 - 72 years old. All identified themes were categorised into: 1) Causes of distress and 2) Coping resources. Post-kidney transplantation, causes of distress included the regimented routine necessary for graft maintenance, and the everlasting fear of potential graft rejection, contracting infections and developing cancer. Coping resources utilised to manage the stressors were firstly, a shift in perspective about how easy it was to manage a kidney transplant than to be dialysis-dependent and secondly, receiving external help from fellow patients, family members and healthcare professionals in addition to utilising electronic reminders. CONCLUSION: An individual well-equipped with coping resources is able to deal with stressors better. It is recommended that changes, such as providing regular reminders about the lifestyle benefits of kidney transplantation, creating opportunities for patients to share their experiences and promoting the utilisation of a reminder alarm to take medications, will reduce the stress of managing a kidney transplant.

Prevention of transnational transplant-related crimes—What more can be done?

Many nations are able to prosecute transplant-related crimes committed in their territory, but transplant recipients, organ sellers and brokers, and transplant professionals may escape prosecution by engaging in these practices in foreign locations where they judge the risk of criminal investigation and prosecution to be remote.Methods. The Declaration of Istanbul Custodian Group convened an international working group to evaluate the possible role of extraterritorial jurisdiction in strengthening the enforcement of existing laws governing transplant-related crimes across national boundaries. Potential practical and ethical concerns about the use of extraterritorial jurisdiction were examined, and possible responses were explored. Results. Extraterritorial jurisdiction is a legitimate tool to combat transplant-related crimes. Further, development of a global registry of transnational transplant activities in conjunction with a standardized international referral system for legitimate travel for transplantation is proposed as a mechanism to support enforcement of national and international legal tools. Conclusions. States are encouraged to include provisions on extraterritorial jurisdiction in their laws on transplant-related crimes and to collaborate with professionals and international authorities in the development of a global registry of transnational transplant activities. These actions would assist in the identification and evaluation of illicit activities and provide information that would help in developing strategies to deter and prevent them.

Renal transplantation in patients with primary immunoglobulin A nephropathy

Background. Opinions on the clinical course and outcome of renal transplantation in patients with primary immunoglobulin A nephropathy (IgAN) have been controversial.
Methods. We conducted a retrospective single-centre study on 542 kidney transplant recipients over the period 1984–2001. Long-term outcome and factors affecting recurrence in recipients with primary IgAN were analysed.
Results. Seventy-five patients (13.8%) had biopsy-proven IgAN as the cause of renal failure, and their mean duration of follow-up after transplantation was 100 ± 5.8 months. Fourteen (18.7%) of the 75 patients had biopsy-proven recurrent IgAN, diagnosed at 67.7 ± 11 months after transplantation. The risk of recurrence was not associated with HLA DR4 or B35. Graft failure occurred in five (35.7%) of the 14 patients: three due to IgAN and two due to chronic rejection. Three (4.9%) of the 61 patients without recurrent IgAN had graft failure, all due to chronic rejection. Graft survival was similar between living-related and cadaveric/living-unrelated patients (12-year graft survival, 88 and 72%, respectively, P = 0.616). Renal allograft survival within the first 12 years was better in patients with primary IgAN compared with those with other primary diseases (80 vs 51%, P = 0.001). Thereafter, IgAN patients showed an inferior graft survival (74 vs 97% in non-IgAN patients, P = 0.001).
Conclusions. Our data suggested that around one-fifth of patients with primary IgAN developed recurrence by 5 years after transplantation. Recurrent IgA nephropathy in allografts runs an indolent course with favourable outcome in the first 12 years. However, the contribution of recurrent disease to graft loss becomes more significant on long-term follow up.

Impaired muscle Ca2+ and K+ regulation contribute to poor exercise performance post-lung transplantation

Lung transplant recipients (LTx) exhibit marked peripheral limitations to exercise. We investigated whether skeletal muscle Ca2+ and K+ regulation might be abnormal in eight LTx and eight healthy controls. Peak oxygen consumption and arterialized venous plasma [K+] (where brackets denote concentration) were measured during incremental exercise. Vastus lateralis muscle was biopsied at rest and analyzed for sarcoplasmic reticulum Ca2+ release, Ca2+ uptake, and Ca2+-ATPase activity rates; fiber composition; Na+-K+-ATPase (K+-stimulated 3-O-methylfluorescein phosphatase) activity and content ([3H]ouabain binding sites); as well as for [H+] and H+-buffering capacity. Peak oxygen consumption was 47% less in LTx (P < 0.05). LTx had lower Ca2+ release (34%), Ca2+ uptake (31%), and Ca2+-ATPase activity (25%) than controls (P < 0.05), despite their higher type II fiber proportion (LTx, 75.0 ± 5.8%; controls, 43.5 ± 2.1%). Muscle [H+] was elevated in LTx (P < 0.01), but buffering capacity was similar to controls. Muscle 3-O-methylfluorescein phosphatase activity was 31% higher in LTx (P < 0.05), but [3H]ouabain binding content did not differ significantly. However, during exercise, the rise in plasma [K+]-to-work ratio was 2.6-fold greater in LTx (P < 0.05), indicating impaired K+ regulation. Thus grossly subnormal muscle calcium regulation, with impaired potassium regulation, may contribute to poor muscular performance in LTx.

Medicine non-adherence in kidney transplantation

Background: The increasing prevalence of chronic kidney disease, the relative shortage of kidney donors and the economic- and health-related costs of kidney transplant rejection make the prevention of adverse outcomes following transplantation a healthcare imperative. Although strict adherence to immunosuppressant medicine regimens is key to preventing kidney rejection, evidence suggests that adherence is sub-optimal. Strategies need to be developed to help recipients of kidney transplants adhere to their prescribed medicines. Findings: This review has found that a number of factors contribute to poor adherence, for example, attitudes towards medicine taking and forgetfulness. Few investigations have been conducted, however, on strategies to enhance medicine adherence in kidney transplant recipients. Strategies that may improve adherence include pharmacist-led interventions (incorporating counselling, medicine reviews and nephrologist liaison) and nurse-led interventions (involving collaboratively working with recipients to understand their routines and offering solutions to improve adherence). Strategies that have shown to have limited effectiveness include supplying medicines free of charge and providing feedback on a participant's medicine adherence without any educational or behavioural interventions. Conclusion: Transplantation is the preferred treatment option for people with end-stage kidney disease. Medicine non-adherence in kidney transplantation increases the risk of rejection, kidney loss and costly treatments. Interventions are needed to help the transplant recipient take all their medicines as prescribed to improve general well-being, medicine safety and reduce healthcare costs. © 2014 European Dialysis and Transplant Nurses Association/European Renal Care Association.

Nephrologists' management of patient medications in kidney transplantation: results of an online survey

Rationale, aims and objectives: Medication adherence is essential in kidney transplant recipients to reduce the risk of rejection and subsequent allograft loss. The aim of this study was to delineate what 'usual care' entails, in relation to medication management, for adult kidney transplant recipients. Methods: An online survey was developed to explore how nephrologists promote and assess medication adherence, the management of prescriptions, the frequency of clinic appointments and the frequency of clinical screening tests. Nephrologists from all acute kidney transplant units in Victoria, Australia, were invited to participate. Data were collected between May and June 2014. Results: Of 60 nephrologists invited to participate, 22 completed the survey (response rate of 36.6%). Respondents had a mean age of 49.1±10.1 years, with a mean of 20.1±9.9 years working in nephrology and 14 were men. Descriptive analysis of responses showed that nephrologists performed frequent screening for kidney graft dysfunction that may indicate medication non-adherence, maintained regular transplant clinic visits with patients and emphasized the importance of medication education. However, time constraints during consultations impacted on extensive patient education and the long-term medication follow-up support was often delivered by the renal transplant nurse coordinator or pharmacist. Conclusions: This study highlighted that nephrologists took an active approach in the medication management of kidney transplant recipients, which may assist with facilitating long-term graft survival. Ultimately, promoting medication adherence needs to be patient centred, involving an interdisciplinary team of nephrologists, pharmacists and renal transplant nurse coordinators, working together with the patient to establish optimal adherence.

Microvascular disease after renal transplantation

Background/Aims: Individuals who reach end-stage kidney disease (CKD5) have a high risk of vascular events that persists even after renal transplantation. This study compared the prevalence and severity of microvascular disease in transplant recipients and patients with CKD5. Methods: Individuals with a renal transplant or CKD5 were recruited consecutively from renal clinics, and underwent bilateral retinal photography (Canon CR5-45, Canon). Their retinal images were deidentified and reviewed for hypertensive/microvascular signs by an ophthalmologist and a trained grader (Wong and Mitchell classification), and for vessel caliber at a grading centre using a computer-assisted method and Knudtson’s modification of the Parr-Hubbard formula. Results: Ninety-two transplant recipients (median duration 6.4 years, range 0.8 to 28.8) and 70 subjects with CKD5 were studied. Transplant recipients were younger (p<0.001), with a higher eGFR (p< 0.001), but were just as likely to have a moderate-severe hypertensive/microvascular retinopathy (46/92, 50%) as subjects with CKD5 (38/70, 54%; OR 0.84, CI 0.45 to 1.57, p=0.64), and had similar mean arteriole and venular calibres (135.1 ± 7.5 μm and 137.9 ± 14.9 μm, p=0.12; and 199.1 ± 17.8 μm and 202.4 ± 27.8 μm, p=0.36, respectively). Arteriole and venular caliber were not different in nine patients examined before and after transplantation (p=0.62 and p=0.11, respectively). Conclusions: Hypertensive/microvascular disease occurred just as often and was generally as severe in transplant recipients and subjects with CKD5. Microvascular disease potentially contributes to increased cardiac events post- transplantation.

The long road from the kidney bazaar: a commentary on Pakistan’s progress towards self-sufficiency in organ transplantation

The dark history of transplant tourism in Pakistan demonstrates the hazards of unregulated cross-border markets in human organs. Trading on existing national and international social inequities, ‘transplant tourism’ offers dubious benefits for transplant recipients and attractive profits to those facilitating the industry at the expense of the world’s poor. The impact of Pakistan’s 2007 Transplantation of Human Organs and Tissue Ordinance and the sustained efforts of transplant professionals and societal groups led by the Sindh Institute of Urology and Transplantation, show that organ trading can be effectively discouraged and equitable programs of organ procurement and transplantation pursued despite multiple challenges. In this paper, the factors that have contributed to Pakistan’s progress towards self-sufficiency in organ transplantation are identified and discussed. The case of Pakistan highlights the need for countries to protect their own organ and tissue providers who may be vulnerable in the global healthcare market. Pakistan provides an excellent example for other countries in the region and throughout the world to consider when regulating their own transplantation programs and considering the pursuit of national self-sufficiency.

A compilation of consumers' stories: the development of a video to enhance medication adherence in newly transplanted kidney recipients

AIM: To describe the design, development and evaluation of a consumer-centred video, which was underpinned by the Theory of Planned Behaviour and it was created to educate newly transplanted kidney recipients about the importance of medication adherence. BACKGROUND: Kidney transplantation is a treatment whereby medication adherence is critical to ensure long-term kidney graft success. To date, many interventions aimed to improve medication adherence in kidney transplantation have been conducted but consumers remain largely uninvolved in the interventional design. DESIGN: Qualitative sequential design. METHODS: Twenty-two participants who had maintained their kidney transplant for at least 8 months and three participants who had experienced a kidney graft loss due to non-adherence were interviewed from March-May 2014 in Victoria, Australia. These interviews were independently reviewed by two researchers and were used to guide the design of the story plot and to identify storytellers for the video. The first draft of the video was evaluated by a panel of seven experts in the field, one independent educational expert and two consumers using Lynn's content validity questionnaire. The content of the video was regarded as highly relevant and comprehensive, which achieved a score of >3·7 out of a possible 4. RESULTS/FINDINGS: The final 18-minute video comprised 15 sections. Topics included medication management, the factors affecting medication adherence and the absolute necessity of adherence to immunosuppressive medications for graft survival. CONCLUSION: This paper has demonstrated the feasibility of creating a consumer-driven video that supports medication adherence in an engaging way.

Testosterone replacement therapy-perceptions of recipients and partners

Background. The androgenic hormones are important determinants of sexual behaviour in men. Testosterone replacement is important treatment for pituitary disease to maintain normal functioning. Although the physical effects of testosterone replacement have been well documented, little is known about the effects on relationships, particularly from the point of view of the sexual partners of men receiving testosterone replacement.

Aims. This paper reports a study exploring the perceptions of testosterone replacement on well-being and sexual functioning.

Methods. Semi-structured interviews were conducted with five men receiving testosterone implants (recipients), their permanent partners, and five recipients without partners. Recipient serum testosterone concentration was measured at 0, 1 and 4 months after testosterone implantation.

Results. The three groups reported similar effects of testosterone on well-being and sexual functioning. Recipient and partner ratings were also similar. Strength was less affected by decreasing testosterone concentration than energy in men with partners, but both strength and energy declined in men without partners. Decreased testosterone levels had a statistically significantly different effect on libido at time zero between men with and without partners (P < 0·015) and on ability to sustain an erection, but the ability to achieve an erection persisted over the 6 months in both male groups. Intercourse frequency increased from once per week at time 0 to ≥3 per week between 1 and 4 months after implant in men with partners. There were important effects of testosterone deficiency on general and sexual relationships, and these differed between men with partners and those without.

Conclusions. Testosterone has important physical and psychological benefits that may be related to the age at which testosterone replacement commences and the indications for its use. The small sample size may limit the ability to generalize the findings outside the study.

Wait no more : the use of private dental services by welfare recipients in Australia

Dental services in Australia are available both privately and publicly. However, access to public dental services, like access to public hospital services for non-urgent treatment, is subject to a considerable waiting period. Moreover, access to public dental services is restricted to certain categories of welfare beneficiaries who qualify for a health care card. Because of the waiting time for public treatment, there is a frequent call for more public dental resources. This paper addresses the issue of what the waiting time for public dental services represents. One view largely confirmed by our research is that state governments are using the waiting time as a way of trying to push more and more people into the private sector. We find that more and more health care card holders are using the
private sector for dental services.

Professional carers' knowledge and response to depression among their aged-care clients : the care recipients' perspective

Depression is an under-diagnosed disorder among the elderly, even in those who are in receipt of aged-care services. One factor associated with this under diagnosis has been identified as a reluctance amongst the elderly to discuss their mood and emotions with their medical practitioners. The current study focused on why depression is not recognised and acted on by those providing residential or home-based care to older people. We interviewed 15 elderly people residing in high-level or low-level aged-care facilities, and three elderly people who were receiving personal care in their homes. All participants had been identified by their care agencies as depressed. Participants reported their perceptions of their personal carers' knowledge and practices in managing the residents' depression. Although the participants described their carers in positive terms, they were critical of their knowledge and skills in recognising depression, and indicated that the communication between personal carers and care recipients about depressive symptomatology was seriously flawed. Training for personal carers in these areas, and efforts to change organisational culture are recommended.

Depression training program for caregivers of elderly care recipients : implementation and qualitative evaluation

The prevalence of untreated depression is high among older adults who receive care in residential facilities or in their own omes and is associated with reduced quality of life and other medical conditions, Research has suggested a number of rea-p sons for the low detection and treatment rates for this problem, including lack of knowledge and efficacy among those who provide direct care and poor communication between these caregivers and senior staff, and between senior staff and genera practitioners. In this study, we report on the implementation of a training program for care staff that aims to address these issues. Focus groups with participants who completed the training indicated a high level of satisfaction with the program and reported improvements in knowledge, self-efficacy, and communication within services. It is recommended that the program be more systematically evaluated in relation to its longer term effects on care provider practices and the well-being of depressed elderly care recipients.