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Non-Adherence and Graft Failure in Adult Liver Transplant Recipients

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Abstract

Background

Non-adherence to medical therapy after liver transplantation is confounded by different methods of measurement.

Aims

(1) To compare the performance of three different methods of measuring non-adherence: (a) biochemical (standard deviation [SD] tacrolimus levels), (b) clinician report, (c) self-report. (2) To identify pre-transplant predictors of post-transplant non-adherence. (3) To evaluate whether SD tacrolimus is an accurate predictor of graft outcomes.

Methods

In this retrospective cohort study, charts of adult recipients of a liver transplant 2003–2009 (sample A, n = 444) were reviewed to determine pre-transplant predictors of non-adherence and clinician report of non-adherence. SD tacrolimus levels were measured between 6 and 18 months post-transplant. A subset of sample A (n = 122) completed a survey on non-adherence. The three methods were compared using linear and logistic regression. Multivariable analysis was used to investigate pre-transplant predictors of non-adherence. In sample B (transplant recipients 1995–2003, n = 544) Cox regression was used to determine the relationship between SD immunosuppressant level and graft failure.

Results

Non-adherence was found in 22–62 % of subjects, with the highest rates indicated by self-report. Clinician report of non-adherence was associated with both self-report and SD tacrolimus. On multivariable analysis, unemployment at time of listing and chart evidence of pre-transplant non-adherence were significant predictors of higher SD of tacrolimus. History of substance abuse and pre-transplant chart evidence of non-adherence were also significant independent predictors of post-transplant chart evidence of non-adherence. Drug variability in the immediate post-transplant setting was independently associated with graft failure over time (hazard ratio 1.005 per unit increase in standard deviation, p = 0.04).

Conclusions

Non-adherence among liver transplant recipients is a common problem associated with increased risk of graft failure. SD tacrolimus can be used to measure non-adherent behavior and perhaps target patients for behavioral interventions.

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Authors and Affiliations

  1. University of Michigan Medical School, M4101 Medical Sciences I, SPC 5624, 1301 Catherine Road, Ann Arbor, MI, 48109, USA

    Sarah R. Lieber

  2. Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA

    Michael L. Volk

  3. Center for Bioethics and Social Sciences in Medicine, University of Michigan Health System, Ann Arbor, MI, USA

    Michael L. Volk

Authors
  1. Sarah R. Lieber
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  2. Michael L. Volk
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Correspondence to Sarah R. Lieber.

Appendix: Survey Materials

Appendix: Survey Materials

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Lieber, S.R., Volk, M.L. Non-Adherence and Graft Failure in Adult Liver Transplant Recipients. Dig Dis Sci 58, 824–834 (2013). https://doi.org/10.1007/s10620-012-2412-0

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  • DOI: https://doi.org/10.1007/s10620-012-2412-0

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