Adherence to Immunosuppressive Medications in Kidney Transplant Patients at Three Centers in Khartoum State, Sudan: A Cross-sectional Hospital Study
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
Conclusion: Only one-third of the participants were classed as “highly adherent” to their immunosuppressant medications. Factors that can affect adherence to immunosuppressant medications were occupational status, side effects, and forgetfulness.
 Couzi, L., Moulin, B., Morin, M., Albano, L., Godin, M., Barrou, B., Alamartine, 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
 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.
 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
 Paper, O. (2014). Adherence in kidney transplant patients. 351–356.
 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.
 Al, O. H. (2015). Low adherence to immunosuppressants is associated with symptom experience among kidney transplant recipients. Transplantation Proceedings, 2711, 10–14.
 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.
 Manuscript A. (2015). NIH Public Access. NIH Public Access. 98(8):878–884.
 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.
 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.
 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.
 The New England Journal of Medicine. (1992).
 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.
 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.
 James, A., & Mannon, R. B. (2015). The cost of transplant immunosuppressant therapy: Is this sustainable? Current Transplantation Reports, 2(2), 113–121.
 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.
 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.
 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.
 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.
 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
 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
 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
 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
 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
 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, January- February). Nonadherent behaviors after solid organ transplantation. Transplantation Proceedings, 43(1), 318–323. https://doi.org/10.1016/j.transproceed.2010.09.103
 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
 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\
 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
 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
 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
 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
 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
 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
 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
 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
 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.