Elsevier

Transplantation Proceedings

Volume 34, Issue 7, November 2002, Pages 2768-2770
Transplantation Proceedings

Advances in clinical organ transplantation: renal: adult
Noncompliance as a cause of renal graft loss

https://doi.org/10.1016/S0041-1345(02)03403-6Get rights and content

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Patients and methods

The case material included all 1027 renal transplants performed at our hospital between May 1977 and December 1999, and having at least 12 months follow-up. The patient demographic profiles are presented in Table 1.

Noncompliance was diagnosed when the patient admitted to having discontinued the immunosuppressive medications as the cause of graft dysfunction.

Acute and chronic rejection were diagnosed according to clinical and histopathologic criteria.

Immunosuppressive medications as well as

Results

There were 448 graft losses during the entire follow-up period (43.6%) among which 238 were due to rejection (77 acute and 161 chronic). De novo glomerulosclerosis was observed in nine biopsy specimens. One hundred forty-one recipients died with functioning grafts and 59 lost their graft due to other causes.

The interruption of immunosuppressive treatment by the patients was diagnosed in 5.2% (n = 53) of recipients, leading to graft loss in 4.8% (n = 47). Six patients received a second kidney

Discussion

Even though there are some reports of up to 75%,3 of patients occassionally discontinuing their medicines after transplantation, we had 5% graft loss due to this cause. This finding seems reasonable when compared to the literature that reports a 0.6 to 13% rate.4 In the present report, we only diagnosed noncompliance when the patient confessed it. A recent European Multicenter Survey, estimated the rate of noncompliance to average 7%.4

The main impact of noncompliance is on late immunologic

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    Another explanation for the lack of improvement in clinical outcomes could be due, on the one hand, to the fact that most RCTs were not powered for clinical outcomes and, on the other hand, the relatively short overall median study period, as intervention effects on medication adherence are typically observed after a short period of time, whereas clinical outcomes such as graft loss or death may occur later. Considering the negative consequences of medication non-adherence [2–10], routine adherence support in clinical practice is essential. Medication adherence intervention studies should follow the same rigor as any RCT.

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    Moreover, in patients with early declining compliance, defined as those who skipped at least 2 more days of medication during the second month posttransplant compared to their first month, the odds for experiencing later acute rejection was 13.9 times higher than for patients with steady adherence (95% CI, 2.9 to 68, P = .0011) and the adjusted odds of graft loss were 4.3 times higher (95% CI, 1.1 to 16, P = .0321). In an evaluation of renal transplants (n = 1027) carried out at a single site, Michelon et al reported on the 5-year survival of grafts and compared the survival rates among adherent and nonadherent patients.44 Among the patients evaluated, there were 448 graft losses (43.6%), of which 238 were due to rejection (77 acute and 161 chronic).

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