Kidney Retransplant After Graft Loss From Nonadherence - The Effect of a Contract.

Abstract

Background: Non-adherence (NA) is associated with rejection and graft loss(GL) after transplant(Tx). When a kidney Tx recipient loses a graft to NA, our practice has been to require that the patient admits the NA behavior, pledges and has a strategy for how to maintain adherence to all labs, medications and appointments in order to be considered for reTx. We hypothesized that addition of an actual written contract may help decrease repeat NA after reTx. Methods: We studied kidney reTx done after GL from prior NA since 9/2003. Beginning in 2009 we began requiring completion of a written contract for those with prior GL due to NA, thus dividing the recipients into a no contract group (NCG) (N=29) and a contract group (CG) (N=17). We compared these two groups to determine if the addition of a contract was associated with any change in postTx outcome. Results: Demographics are shown in Table 1. The NCG had decreased AR-free survival (p=0.18) and death censored graft survival (DCGS)(0.15) when compared to the CG. Importantly, the CG had significantly decreased late (>6 mo) acute rejection (LAR) (7.7%) vs the NCG (45.8%)(p=0.03) with a trend toward better LAR-free survival at 36 months (p=0.12). Patient survival was not different (p=0.46). No GL in either group was due to repeat NA, but 3 patients (10%) in the NCG had repeat NA behaviors vs 0 in the CG.Table: No Caption available.Figure: No Caption available.Conclusion: Tools for improving adherence may result in improved postTx outcomes, especially in those known to be at risk for NA. When reTxs were done after GL from NA, recipients who had participated in a written contract had less LAR, and trends toward less AR and increased DCGS, which may be due to improved adherence. Because of these observations, we will continue to require successful completion of a contract in order to achieve reTx after prior graft loss due to NA.