Association of medication non-adherence with short-term allograft loss after the treatment of severe acute kidney transplant rejection

Ahmed Al-Sheyyab,Stefanie Bala,Meghan E Kapp,Beatrice P Concepcion,Rachel C Forbes,Mohammed Shwetar,Nikita Wilson,Everly Ramos,Laura Binari,J Harold Helderman,Khaled Abdel-Kader

doi:10.1186/s12882-019-1563-z

Ahmed Al-Sheyyab, Stefanie Bala + Show 9 more

Open Access

https://doi.org/10.1186/s12882-019-1563-z

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Abstract

BackgroundMedication non-adherence is a risk factor for acute kidney transplant rejection. The association of non-adherence with short-term allograft loss in patients who develop acute rejection and are subsequently treated with maximal therapy is unknown.MethodsWe conducted a retrospective single center cohort study of adult patients who developed acute rejection from January 2003 to December 2017 and were treated with lymphocyte depletion. Clinicopathologic characteristics including adherence status were collected and descriptive statistics utilized to compare groups. The primary outcome was all-cause graft loss at 6 months after acute rejection treatment. A multivariable logistic regression quantified the association of non-adherence with the outcome.ResultsA total of 182 patients were included in the cohort, of whom 71 (39%) were non-adherent. Compared to adherent patients, non-adherent patients were younger (mean age 37y vs 42y), more likely to be female (51% vs 35%) and developed acute rejection later (median 2.3y vs 0.5y from transplant). There were no differences in estimated glomerular filtration rate or need for dialysis on presentation, Banff grade, or presence of antibody mediated rejection between the 2 groups. Overall, 48 (26%) patients lost their grafts at 6 months after acute rejection treatment. In adjusted analysis, non-adherence was associated with all-cause graft loss at 6 months after acute rejection treatment [OR 2.64 (95% CI 1.23–5.65, p = 0.012].ConclusionsAfter adjusting for common confounders, non-adherent patients were at increased risk for short-term allograft loss after a severe acute rejection despite lymphocyte depletion. This finding may aid clinicians in risk stratifying patients for poor short-term outcomes and treatment futility.

Highlights

Medication non-adherence is a risk factor for acute kidney transplant rejection
Non-adherent patients were generally younger at the time of rejection, were more likely to be female and treated with a steroid withdrawal protocol, attained a lower nadir serum creatinine (SCr), and developed acute rejection later compared to adherent patients
We found estimated glomerular filtration rate (eGFR) to be an important predictor of allograft loss after acute rejection but did not find Banff grade to be a significant factor

Summary

Introduction

Medication non-adherence is a risk factor for acute kidney transplant rejection. The association of non-adherence with short-term allograft loss in patients who develop acute rejection and are subsequently treated with maximal therapy is unknown. Acute kidney transplant rejection is a major cause of allograft loss. Clinical decision making to proceed with T-lymphocyte depleting therapy in a patient with severe acute rejection can at times be challenging. Identifying clinical predictors for short-term allograft loss despite aggressive acute rejection treatment may aid clinicians in risk stratifying patients for treatment futility and individualizing treatment decisions. A clinician may decide to forego additional treatment and to focus instead on end-stage renal disease (ESRD) planning in a patient who is unlikely to respond to treatment or whose allograft is likely to fail within a few months despite T-lymphocyte depleting therapy

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