Adherence to Immunosuppressive Medications in Kidney Transplant Patients at Three Centers in Khartoum State, Sudan: A Cross-sectional Hospital Study
Keywords:
kwd
Abstract
Background: Graft survival post-kidney transplantation is of paramount importance
to patients and nephrologists. Nonadherence to immunosuppressive therapy can be
associated with deterioration of renal function and graft rejection. This study aimed
to evaluate the adherence to immunosuppressive medications in kidney transplant
patients at three centers in Khartoum, Sudan.
Methods: In this descriptive cross-sectional hospital-based survey, 277 post-kidneytransplant patients were recruited. Data were collected using a questionnaire and
analyzed using the SPSS v.23. Our scoring method was calculated based on Morisky
Medication Adherence Scale (MMAS-8) related to immunosuppressive medications
and was expressed as questions in the questionnaire; every correct answer was given
one mark, then the marks were gathered and their summation was expressed.
Results: Overall, 33% ,45%, and 22% of the studied participants reported high, medium,
and low adherence, respectively. The major factor for nonadherence was forgetfulness
affecting 36.1% of those who did not adhere. The cost of the immunosuppressive
medications did not negatively affect any of the participants’ adherence (100%).
However, a significant association was seen between adherence and occupational
status, duration of transplantation, shortage of immunosuppressants, recognizing the
name of immunosuppressant, side effect, and forgetfulness (P-values = 0.002, 0.01,
0.006 , 0.000, 0.022, and 0.000, respectively). Logistic regression analysis showed a
significant association with occupational status, side effects, and forgetfulness.
References
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transplantation: A French observational study. Transplantation Journal, 95(2):326–
32. https://doi.org/10.1097/TP.0b013e318271d7c1
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Outcomes among adult kidney transplant recipients. 30(10):1294–305.
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immunosuppressive over nonimmunosuppressive medications in kidney
transplant recipients. Transplantation Proceedings [Internet], 42(9):3578–3585.
https://doi.org/10.1016/j.transproceed.2010.08.027
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J. W., & van Dijk, J. P. (2014). Adherence in patients in the first year after kidney
transplantation and its impact on graft loss and mortality: A cross-sectional and
prospective study. Journal of Advanced Nursing, 70(12), 2871–2884.
[6] Al, O. H. (2015). Low adherence to immunosuppressants is associated with symptom
experience among kidney transplant recipients. Transplantation Proceedings, 2711,
10–14.
[7] Chisholm, M. A., Vollenweider, L. J., Mulloy, L. L., Jagadeesan, M., Wynn, J. J., Rogers,
H. E., Wade, W. E., & DiPiro, J. T. (2000). Renal transplant patient compliance with
free immunosuppressive medications. Transplantation, 70(8):1240–124.
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S. (2010). Non-adherence to immunosuppressive medication in renal transplant
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N., & De Geest, S. (2007). Prevalence and risk factors of non-adherence with
immunosuppressive medication in kidney transplant patients. American Journal of
Transplantation,7(1):108–116.
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and validation of the immunosuppressant therapy adherence instrument (ITAS).
Patient Education and Counseling, 59(1), 13–20.
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Vanrenterghem, Y. (2004). Prospective study on late consequences of subclinical
non-compliance with immunosuppressive therapy in renal transplant patients.
American Journal of Transplantation, 4(9), 1509–1513.
[14] Evans, R. W., Applegate, W. H., Briscoe, D. M., Cohen, D. J., Rorick, C. C., Murphy, B. T.,
& Madsen, J. C. (2010). Cost-related immunosuppressive medication nonadherence
among kidney transplant recipients. Clinical Journal of the American Society of
Nephrology, 5(12), 22–25.
[15] James, A., & Mannon, R. B. (2015). The cost of transplant immunosuppressant
therapy: Is this sustainable? Current Transplantation Reports, 2(2), 113–121.
[16] Griva, K., Davenport, A., Harrison, M., & Newman, S. P. (2012). Forgetfulness
and clinical markers of medication intake. Non-adherence to immunosuppressive
medications in kidney transplantation: Intent vs. forgetfulness and clinical markers
of medication intake. Annals of Behavioral Medicine, 44(1), 85–93.
[17] Gheith, O. A., El-Saadany, S. A., Abuo Donia, S. A., & Salem, Y. M. Compliance of
kidney transplant patients to the recommended lifestyle behaviours: Single centre
experience. International Journal of Nursing Practice, 14(5), 398–407.
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W. (2013). The role of goal cognitions, illness perceptions and treatment beliefs
in self-reported adherence after kidney transplantation: A cohort study. Journal of
Psychosomatic Research, 75(3), 229–234.
[19] Russell, C. L., Cetingok, M., Hamburger, K. Q., Owens, S., Thompson, D., Hathaway, D.,
Winsett, R. P., Conn, V. S., Madsen, R., Sitler, L., & Wakefield, M. R. (2010). Medication
adherence in older renal transplant recipients. Clinical Nursing Research, 19(2), 95–
112.
[20] Denhaerynck, K., Dobbels, F., Cleemput, I., Desmyttere, A., Schäfer-Keller, P., Schaub,
S., & De Geest, S. (2005, October). Prevalence, consequences, and determinants
of nonadherence in adult renal transplant patients: A literature review. Transplant
International, 18(10), 1121–1133. https://doi.org/10.1111/j.1432-2277.2005.00176.x
[21] Bunzel, B., & Laederach-Hofmann, K. (2000, September). Solid organ transplantation:
Are there predictors for posttransplant noncompliance? A literature overview. Transplantation, 70(5), 711–716. https://doi.org/10.1097/00007890-200009150-00001
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L. M., Burroughs, T. E., & Bunnapradist, S. (2007, December). A retrospective
analysis of immunosuppression compliance, dose reduction, and discontinuation in kidney transplant recipients. American Journal of Transplantation, 7(12), 2704–2711.
https://doi.org/10.1111/j.1600-6143.2007.01966.x
[23] Chisholm-Burns, M. A., Kwong, W. J., Mulloy, L. L., & Spivey, C. A. (2008, July). Nonmodifiable characteristics associated with nonadherence to immunosuppressant
therapy in renal transplant recipients. American Journal of Health-System Pharmacy,
65(13), 1242–1247. https://doi.org/10.2146/ajhp070630
[24] Tielen, M., van Exel, J., Laging, M., Beck, D. K., Khemai, R., van Gelder, T.,
Betjes, M. G., Weimar, W., & Massey, E. K. (2014). Attitudes to medication after
kidney transplantation and their association with medication adherence and graft
survival: A 2-year follow-up study. Journal of Transplantation, 2014, 675301.
https://doi.org/10.1155/2014/675301
[25] Germani, G., Lazzaro, S., Gnoato, F., Senzolo, M., Borella, V., Rupolo, G., Cillo, U.,
Rigotti, P., Feltrin, G., Loy, M., Martin, A., Sturniolo, G. C., & Burra, P. (2011, JanuaryFebruary). Nonadherent behaviors after solid organ transplantation. Transplantation
Proceedings, 43(1), 318–323. https://doi.org/10.1016/j.transproceed.2010.09.103
[26] Chisholm, M. A., Kwong, W. J., & Spivey, C. A. (2007, November). Associations
of characteristics of renal transplant recipients with clinicians’ perceptions of
adherence to immunosuppressant therapy. Transplantation, 84(9), 1145–1150.
https://doi.org/10.1097/01.tp.0000287189.33074.c8
[27] Lin, S. Y., Fetzer, S. J., Lee, P. C., & Chen, C. H. (2011, December). Predicting
adherence to health care recommendations using health promotion behaviours
in kidney transplant recipients within 1-5 years post-transplant. Journal of Clinical
Nursing, 20(23–24), 3313–3321. https://doi.org/10.1111/j.1365-2702.2011.03757.x\
[28] Fine, R. N., Becker, Y., De Geest, S., Eisen, H., Ettenger, R., Evans, R., Rudow,
D. L., McKay, D., Neu, A., Nevins, T., Reyes, J., Wray, J., & Dobbels, F. (2009,
January). Nonadherence consensus conference summary report. American Journal
of Transplantation, 9(1), 35–41. https://doi.org/10.1111/j.1600-6143.2008.02495.x
[29] Nevins, T. E., & Thomas, W. (2009, March). Quantitative patterns of azathioprine adherence after renal transplantation. Transplantation, 87(5), 711–718.
https://doi.org/10.1097/TP.0b013e318195c3d5
[30] Morisky, D. E., Green, L. W., & Levine, D. M. (1986, January). Concurrent and predictive
validity of a self-reported measure of medication adherence. Medical Care, 24(1), 67–
74. https://doi.org/10.1097/00005650-198601000-00007
[31] Zelikovsky, N., Schast, A. P., Palmer, J., Meyers, K. E., Zelikovsky, N., & Aileen, P.
(2008, May). Perceived barriers to adherence among adolescent renal transplant candidates. Pediatric Transplantation, 12(3), 300–308. https://doi.org/10.1111/j.1399-
3046.2007.00886.x
[32] Schaeffner, E. S., Mehta, J., & Winkelmayer, W. C. (2008, May). Educational
level as a determinant of access to and outcomes after kidney transplantation
in the United States. American Journal of Kidney Diseases, 51(5), 811–818.
https://doi.org/10.1053/j.ajkd.2008.01.019
[33] Tong, A., Howell, M., Wong, G., Webster, A. C., Howard, K., & Craig, J. C. (2011,
January). The perspectives of kidney transplant recipients on medicine taking: A
systematic review of qualitative studies. Nephrology, Dialysis, Transplantation, 26(1),
344–354. https://doi.org/10.1093/ndt/gfq376
[34] Orr, A., Orr, D., Willis, S., Holmes, M., & Britton, P. (2007, August). Patient perceptions of
factors influencing adherence to medication following kidney transplant. Psychology
Health and Medicine, 12(4), 509–517. https://doi.org/10.1080/13548500701294556
[35] Gordon, E. J., Prohaska, T. R., Gallant, M. P., & Siminoff, L. A. (2007, December).
Adherence to immunosuppression: A prospective diary study. Transplantation
Proceedings, 39(10), 3081–3085. https://doi.org/10.1016/j.transproceed.2007.02.100
[36] Cukor, D., Ver Halen, N., Pencille, M., Tedla, F., Salifu, M., & Medicine, O. (2018). A
pilot randomized controlled trial to promote immunosuppressant adherence in adult
kidney transplant recipients. Nephron, 135, 6–14.
E., Morelon, E., Girardot-Seguin, S., Mendes, L., Misdrahi, D., Cassuto, E., &
Merville, P. (2013). Factors predictive of medication nonadherence after renal
transplantation: A French observational study. Transplantation Journal, 95(2):326–
32. https://doi.org/10.1097/TP.0b013e318271d7c1
[2] Patzer, R. E., Serper, M., Reese, P. P., Przytula, K., Koval, R., Ladner, D. P., et al. (2017).
Outcomes among adult kidney transplant recipients. 30(10):1294–305.
[3] Terebelo, S., & Markell, M. (2010). Preferential adherence to
immunosuppressive over nonimmunosuppressive medications in kidney
transplant recipients. Transplantation Proceedings [Internet], 42(9):3578–3585.
https://doi.org/10.1016/j.transproceed.2010.08.027
[4] Paper, O. (2014). Adherence in kidney transplant patients. 351–356.
[5] Prihodova, L., Nagyova, I., Rosenberger, J., Majernikova, M., Roland, R., Groothoff,
J. W., & van Dijk, J. P. (2014). Adherence in patients in the first year after kidney
transplantation and its impact on graft loss and mortality: A cross-sectional and
prospective study. Journal of Advanced Nursing, 70(12), 2871–2884.
[6] Al, O. H. (2015). Low adherence to immunosuppressants is associated with symptom
experience among kidney transplant recipients. Transplantation Proceedings, 2711,
10–14.
[7] Chisholm, M. A., Vollenweider, L. J., Mulloy, L. L., Jagadeesan, M., Wynn, J. J., Rogers,
H. E., Wade, W. E., & DiPiro, J. T. (2000). Renal transplant patient compliance with
free immunosuppressive medications. Transplantation, 70(8):1240–124.
[8] Manuscript A. (2015). NIH Public Access. NIH Public Access. 98(8):878–884.
[9] Schmid-Mohler, G., Pechula Thut, M., Wüthrich, R. P., Denhaerynck K., & De Geest,
S. (2010). Non-adherence to immunosuppressive medication in renal transplant
recipients within the scope of the integrative model of behavioral prediction: A crosssectional study. Clinical Transplantation, 24(7):213–222.
[10] Denhaerynck, K., Steiger, J., Bock, A., Schäfer-Keller, P., Köfer, S., Thannberger,
N., & De Geest, S. (2007). Prevalence and risk factors of non-adherence with
immunosuppressive medication in kidney transplant patients. American Journal of
Transplantation,7(1):108–116.
[11] Chisholm, M. A., Lance, C. E., Williamson, G. M., & Mulloy, L. L. (2005). Development
and validation of the immunosuppressant therapy adherence instrument (ITAS).
Patient Education and Counseling, 59(1), 13–20.
[12] The New England Journal of Medicine. (1992).
[13] Vlaminck, H., Maes, B., Evers, G., Verbeke, G., Lerut, E., Van Damme, B., &
Vanrenterghem, Y. (2004). Prospective study on late consequences of subclinical
non-compliance with immunosuppressive therapy in renal transplant patients.
American Journal of Transplantation, 4(9), 1509–1513.
[14] Evans, R. W., Applegate, W. H., Briscoe, D. M., Cohen, D. J., Rorick, C. C., Murphy, B. T.,
& Madsen, J. C. (2010). Cost-related immunosuppressive medication nonadherence
among kidney transplant recipients. Clinical Journal of the American Society of
Nephrology, 5(12), 22–25.
[15] James, A., & Mannon, R. B. (2015). The cost of transplant immunosuppressant
therapy: Is this sustainable? Current Transplantation Reports, 2(2), 113–121.
[16] Griva, K., Davenport, A., Harrison, M., & Newman, S. P. (2012). Forgetfulness
and clinical markers of medication intake. Non-adherence to immunosuppressive
medications in kidney transplantation: Intent vs. forgetfulness and clinical markers
of medication intake. Annals of Behavioral Medicine, 44(1), 85–93.
[17] Gheith, O. A., El-Saadany, S. A., Abuo Donia, S. A., & Salem, Y. M. Compliance of
kidney transplant patients to the recommended lifestyle behaviours: Single centre
experience. International Journal of Nursing Practice, 14(5), 398–407.
[18] Massey, E. K., Tielen, M., Laging, M., Beck, D. K., Khemai, R., van Gelder, T., & Weimar,
W. (2013). The role of goal cognitions, illness perceptions and treatment beliefs
in self-reported adherence after kidney transplantation: A cohort study. Journal of
Psychosomatic Research, 75(3), 229–234.
[19] Russell, C. L., Cetingok, M., Hamburger, K. Q., Owens, S., Thompson, D., Hathaway, D.,
Winsett, R. P., Conn, V. S., Madsen, R., Sitler, L., & Wakefield, M. R. (2010). Medication
adherence in older renal transplant recipients. Clinical Nursing Research, 19(2), 95–
112.
[20] Denhaerynck, K., Dobbels, F., Cleemput, I., Desmyttere, A., Schäfer-Keller, P., Schaub,
S., & De Geest, S. (2005, October). Prevalence, consequences, and determinants
of nonadherence in adult renal transplant patients: A literature review. Transplant
International, 18(10), 1121–1133. https://doi.org/10.1111/j.1432-2277.2005.00176.x
[21] Bunzel, B., & Laederach-Hofmann, K. (2000, September). Solid organ transplantation:
Are there predictors for posttransplant noncompliance? A literature overview. Transplantation, 70(5), 711–716. https://doi.org/10.1097/00007890-200009150-00001
[22] Takemoto, S. K., Pinsky, B. W., Schnitzler, M. A., Lentine, K. L., Willoughby,
L. M., Burroughs, T. E., & Bunnapradist, S. (2007, December). A retrospective
analysis of immunosuppression compliance, dose reduction, and discontinuation in kidney transplant recipients. American Journal of Transplantation, 7(12), 2704–2711.
https://doi.org/10.1111/j.1600-6143.2007.01966.x
[23] Chisholm-Burns, M. A., Kwong, W. J., Mulloy, L. L., & Spivey, C. A. (2008, July). Nonmodifiable characteristics associated with nonadherence to immunosuppressant
therapy in renal transplant recipients. American Journal of Health-System Pharmacy,
65(13), 1242–1247. https://doi.org/10.2146/ajhp070630
[24] Tielen, M., van Exel, J., Laging, M., Beck, D. K., Khemai, R., van Gelder, T.,
Betjes, M. G., Weimar, W., & Massey, E. K. (2014). Attitudes to medication after
kidney transplantation and their association with medication adherence and graft
survival: A 2-year follow-up study. Journal of Transplantation, 2014, 675301.
https://doi.org/10.1155/2014/675301
[25] Germani, G., Lazzaro, S., Gnoato, F., Senzolo, M., Borella, V., Rupolo, G., Cillo, U.,
Rigotti, P., Feltrin, G., Loy, M., Martin, A., Sturniolo, G. C., & Burra, P. (2011, JanuaryFebruary). Nonadherent behaviors after solid organ transplantation. Transplantation
Proceedings, 43(1), 318–323. https://doi.org/10.1016/j.transproceed.2010.09.103
[26] Chisholm, M. A., Kwong, W. J., & Spivey, C. A. (2007, November). Associations
of characteristics of renal transplant recipients with clinicians’ perceptions of
adherence to immunosuppressant therapy. Transplantation, 84(9), 1145–1150.
https://doi.org/10.1097/01.tp.0000287189.33074.c8
[27] Lin, S. Y., Fetzer, S. J., Lee, P. C., & Chen, C. H. (2011, December). Predicting
adherence to health care recommendations using health promotion behaviours
in kidney transplant recipients within 1-5 years post-transplant. Journal of Clinical
Nursing, 20(23–24), 3313–3321. https://doi.org/10.1111/j.1365-2702.2011.03757.x\
[28] Fine, R. N., Becker, Y., De Geest, S., Eisen, H., Ettenger, R., Evans, R., Rudow,
D. L., McKay, D., Neu, A., Nevins, T., Reyes, J., Wray, J., & Dobbels, F. (2009,
January). Nonadherence consensus conference summary report. American Journal
of Transplantation, 9(1), 35–41. https://doi.org/10.1111/j.1600-6143.2008.02495.x
[29] Nevins, T. E., & Thomas, W. (2009, March). Quantitative patterns of azathioprine adherence after renal transplantation. Transplantation, 87(5), 711–718.
https://doi.org/10.1097/TP.0b013e318195c3d5
[30] Morisky, D. E., Green, L. W., & Levine, D. M. (1986, January). Concurrent and predictive
validity of a self-reported measure of medication adherence. Medical Care, 24(1), 67–
74. https://doi.org/10.1097/00005650-198601000-00007
[31] Zelikovsky, N., Schast, A. P., Palmer, J., Meyers, K. E., Zelikovsky, N., & Aileen, P.
(2008, May). Perceived barriers to adherence among adolescent renal transplant candidates. Pediatric Transplantation, 12(3), 300–308. https://doi.org/10.1111/j.1399-
3046.2007.00886.x
[32] Schaeffner, E. S., Mehta, J., & Winkelmayer, W. C. (2008, May). Educational
level as a determinant of access to and outcomes after kidney transplantation
in the United States. American Journal of Kidney Diseases, 51(5), 811–818.
https://doi.org/10.1053/j.ajkd.2008.01.019
[33] Tong, A., Howell, M., Wong, G., Webster, A. C., Howard, K., & Craig, J. C. (2011,
January). The perspectives of kidney transplant recipients on medicine taking: A
systematic review of qualitative studies. Nephrology, Dialysis, Transplantation, 26(1),
344–354. https://doi.org/10.1093/ndt/gfq376
[34] Orr, A., Orr, D., Willis, S., Holmes, M., & Britton, P. (2007, August). Patient perceptions of
factors influencing adherence to medication following kidney transplant. Psychology
Health and Medicine, 12(4), 509–517. https://doi.org/10.1080/13548500701294556
[35] Gordon, E. J., Prohaska, T. R., Gallant, M. P., & Siminoff, L. A. (2007, December).
Adherence to immunosuppression: A prospective diary study. Transplantation
Proceedings, 39(10), 3081–3085. https://doi.org/10.1016/j.transproceed.2007.02.100
[36] Cukor, D., Ver Halen, N., Pencille, M., Tedla, F., Salifu, M., & Medicine, O. (2018). A
pilot randomized controlled trial to promote immunosuppressant adherence in adult
kidney transplant recipients. Nephron, 135, 6–14.
Published
2022-10-03
Section
Review article
