Impact of Recipient Non-adherence on Long-Term Transplant Outcome. Literature review and experience of the University of Minnesota.

Abstract

In the last 2 decades, there has been a significant after-transplantation improvement of patient and graft survival in short-term. But there has not been a parallel improvement in the long-term outcome. A potentially remediable cause for the late graft loss is the non-adherence. It is not possible to precisely quantify if the percentage of graft loss is actually due to non-adherence. Quantifying the graft loss to the non-adherence is not possible, since there are many aspects in the post-transplant adherence (e.g., intake of immunosuppressive and other medications, attending clinic appointments), we do not have a reliable means to measure, and there is a lack of a clear definition on what is non-adherence (e.g., how much medication and/or how many clinic appointments must a recipient miss to be classified as non-adherent?). Several studies in kidney, heart, and liver transplant recipients have shown a clear association between non-adherence and an increased incidence of acute rejection episodes, chronic rejection (chronic allograft nephropathy, or coronary artery disease), late graft loss, and need for re-transplantation. Such outcomes have significant economic consequences for the Healthcare System. Some factors must be considered, in order to decide whether or not to perform the re-transplantation in patients with graft loss due to non-adherence. For heart and liver patients who refuse the re-transplantation, the consequence is death; but for patients with kidney failure, dialysis provides a treatment option. Our policy is to consider such patients for a second transplant if they can show their adherence to the dialysis regimen for a minimum of 6 months period. We will not perform a third kidney transplant in a patient who lost his previous two ones due to non-adherence.