Adherence to immunosuppression: a critical aspect for the success of organ transplantation*

Abstract

Organ transplantation has made great strides in reaching its goal as a long-term replacement treatment for irreversible failed organs. However, a significant portion of grafts are lost as a consequence of nonadherence (NA) to immunosuppressants and agents treating co-morbidities. In this issue of Transplant International, Leentje De Bleser and coworkers from Leuven, Belgium, address this important topic in heart, lung and liver transplant recipients. Comparing different methodological approaches and applying combined readouts, they provide a sensitive and alarming picture: 23.9–70% of transplant patients do not take their immunosuppressants as prescribed. Interestingly, lung transplant patients were less compliant than heart or liver transplant recipients in this study explained by the authors with a prolonged recovery after transplantation, younger recipient age and larger amounts of immunosuppressants and co-medications. Although the clinical relevance of NA to medication and clinical appointments has been recognized for many years, imprecise definitions in addition to a lack of standardized methods make existing studies in this field difficult to compare. However, an estimated 20% of late acute rejection episodes and 16% of graft loss have been linked to noncompliance. Poor adherence by 1 year after transplantation has been identified as a significant risk factor for graft loss and patient death [1,2]. The death of one in ten liver transplant recipients has been linked to NA in a study of the Scottish database [3]. Besides, NA represents a significant economic burden for local transplant centers and national healthcare systems. In renal transplantation, NA increased medical costs by more than 12 000$ over a 3-year period, whereas the overall difference in medical costs between a poor compliant and a persistently highly compliant patient exceeded 33 000$ [2]. With its multifactorial and complex etiology, NA has been difficult to analyze and to target. Known risk factors for NA include younger age, psychiatric disorders, and patient’s belief that medication is harmful and has considerable side effects. In a broader sense, cultural, social, and religious belief systems seem to play a role. Economic aspects are of critical importance, particularly in countries without life-long support for Correspondence Stefan G. Tullius MD, PhD, FACS, Division of Transplant Surgery, Brigham & Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA. Tel.: +1 617 732 6446; fax: 617-582-6167; e-mail: stullius@partners.org