Adherence to the medical regimen during the first two years after lung transplantation.
ABSTRACT Despite the importance of adherence to the medical regimen for maximizing health after lung transplantation, no prospective studies report on rates or risk factors for nonadherence in this patient population. Whether adherence levels differ in lung versus other types of transplant recipients is unknown.
A total of 178 lung recipients and a comparison group of 126 heart recipients were enrolled. Adherence in nine areas was assessed in separate patient and family caregiver interviews 2, 7, 12, 18, and 24 months posttransplant. Potential risk factors for nonadherence were obtained at the initial assessment.
Cumulative incidence rates of persistent nonadherence (i.e., nonadherence at > or =2 consecutive assessments) were significantly lower (P<0.05) in lung recipients than heart recipients for taking immunosuppressants (13% nonadherent vs. 21%, respectively), diet (34% vs. 56%), and smoking (1% vs. 8%). Lung recipients had significantly higher persistent nonadherence to completing blood work (28% vs. 17%) and monitoring blood pressure (70% vs. 59%). They had a high rate of spirometry nonadherence (62%; not measured in heart recipients). The groups did not differ in nonadherence to attending clinic appointments (27%), exercise (44%), or alcohol limitations (7%). In both groups, poor caregiver support and having only public insurance (e.g., Medicaid) increased nonadherence risk in all areas.
Lung recipients were neither uniformly better nor worse than heart recipients in adhering to their regimen. Lung recipients have particular difficulty with some home monitoring activities. Strategies to maximize adherence in both groups should build on caregiver support and on strengthening financial resources for patient healthcare requirements.
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ABSTRACT: In patients with primary cadaveric renal transplants and stable allograft function, we assessed the impact of tapering or discontinuing cyclosporine A (CsA) for financial reasons. Forty-two patients whose CsA was discontinued ("no-dose") and 29 patients whose CsA was tapered to 100 to 150 mg/d ("low-dose"; mean, 1.7 mg/kg/d) were examined. Results were compared with 70 age- and race-matched control patients maintained on at least 200 mg/d of CsA (mean, 3.9 mg/kg/d). Follow-up time for all patients averaged 55 +/- 18 months. Late acute rejection episodes occurred more frequently in no-dose than in low-dose (P = 0.017) or control (P = 0.001) patients. In the no-dose group, blacks experienced a greater number of late acute rejections than whites. These late acute rejections often coincided with the discontinuation of CsA and contributed to an increased rate of allograft loss in blacks in the no-dose group compared with black and white controls (P = 0.011). In contrast, no increase in late acute rejection episodes occurred in blacks tapered to low doses of CsA. Black patients who remained on low doses of CsA also exhibited a trend toward allograft survival that was intermediate between that of control and no-dose patients. In those patients who retained functional allografts, mean serum creatinine concentration did not differ between the study groups at the beginning and end of the follow-up period. These findings support continuance of CsA in black primary cadaveric renal transplant patients, even if dosages must be reduced to 100 to 150 mg/d.(ABSTRACT TRUNCATED AT 250 WORDS)American Journal of Kidney Diseases 02/1993; 21(1):9-15. · 5.43 Impact Factor
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ABSTRACT: The efficacy of cardiovascular risk-reduction programs has been established. However, the extent to which risk-reduction interventions are effective may depend on adherence. Non-compliance, or non-adherence, may occur with any of the recommended or prescribed regimens and may vary across the treatment course. Compliance problems, whether occurring early or late in the treatment course, are clinically significant, as adherence is one mediator of the clinical outcome. This article, which is based on a review of the empirical literature of the past 20 years, addresses compliance across four regimens of cardiovascular risk reduction: pharmacological therapy, exercise, nutrition, and smoking cessation. The criteria for inclusion of a study in this review were: (a) focus on cardiovascular disease risk reduction; (b) report of a quantitative measure of compliance behavior; and (c) use of a randomized controlled design. Forty-six studies meeting these criteria were identified. A variety of self-report, objective, and electronic measurement methods were used across these studies. The interventions employed diverse combinations of cognitive, educational, and behavioral strategies to improve compliance in an array of settings. The strategies demonstrated to be successful in improving compliance included behavioral skill training, self-monitoring, telephone/mail contact, self-efficacy enhancement, and external cognitive aids. A series of tables summarize the intervention strategies, compliance measures, and findings, as well as the interventions demonstrated to be successful. This review reflects the progress made over two decades in compliance measurement and research and, further, advances made in the application of behavioral strategies to the promotion of cardiovascular risk reduction.Annals of Behavioral Medicine 02/1997; 19(3):239-63. · 4.20 Impact Factor
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ABSTRACT: Chronic rejection after lung transplantation, manifesting as bronchiolitis obliterans syndrome (BOS), has become the dominant challenge to long-term patient and graft survival. In order to elucidate risk factors for development of BOS we utilized the 1995 revision of the working formulation for the classification of lung allograft rejection (), and devised a quantitative method to retrospectively study lung transplant biopsies from all patients who survived at least 90 d. All transbronchial biopsies were regraded 0 to 4 for acute perivascular rejection and lymphocytic bronchitis/bronchiolitis (LBB), and the grades were totaled over a period of time to give two scores, respectively, for each patient. Also examined were timing of acute rejection and LBB episodes and decreased immunosuppression defined as two or more cyclosporine A levels < 200 ng/ml. Sixty-six patients with BOS and 68 with no BOS (NBOS) satisfied our criteria for inclusion in the study. Demographics including age, sex, and primary diagnoses were similar. The mean perivascular score for BOS was 6.2 over a mean follow-up of 822 d (range, 113 to 2,146) compared with 3.2 for NBOS over 550 d (range, 97 to 1,734) mean follow-up. Airway scores were 5.3 and 1.7, respectively, for the same follow-up periods. There was no correlation between length of follow-up and rejection or LBB scores, although mean length of follow-up for the two groups was significantly different. Late acute rejection and LBB were significantly associated with BOS as was decreased immunosuppression. In addition to perivascular rejection, LBB, late acute rejection, and decreased immunosuppression are significant risk factors for the development of BOS. Analysis of the current data leads us to believe that LBB, in the absence of infection, is in fact a manifestation of acute rejection, with similar implications for graft function as acute perivascular rejection.American Journal of Respiratory and Critical Care Medicine 03/1999; 159(3):829-33. · 11.08 Impact Factor