Transplant regimen adherence for kidney recipients by engaging information technologies (TAKE IT): Rationale and methods for a randomized controlled trial of a strategy to promote medication adherence among transplant recipients

Phenotyping Adherence Through Technology-Enabled Reports and Navigation (the PATTERN Study): Qualitative Study for Intervention Adaptation Using the Exploration, Preparation, Implementation, and Sustainment Framework

BACKGROUND

Older adults with multiple chronic conditions (MCC) and polypharmacy often face challenges with medication adherence. Nonadherence can lead to suboptimal treatment outcomes, adverse drug events, and poor quality of life.

OBJECTIVE

To facilitate medication adherence among older adults with MCC and polypharmacy in primary care, we are adapting a technology-enabled intervention previously implemented in a specialty clinic. The objective of this study was to obtain multilevel feedback to inform the adaptation of the proposed intervention (Phenotyping Adherence Through Technology-Enabled Reports and Navigation [PATTERN]).

METHODS

We conducted a formative qualitative study among patients, clinicians, and clinic administrators affiliated with a large academic health center in Chicago, Illinois. Patient eligibility included being aged 65 years or older, living with MCC, and contending with polypharmacy. Eligibility criteria for clinicians and administrators included being employed by any primary care clinic affiliated with the participating health center. Individual semistructured interviews were conducted remotely by a trained member of the study team using interview guides informed by the Exploration, Preparation, Implementation, and Sustainment Framework. Thematic analysis of interview audio recordings drew from the Rapid Identification of Themes from Audio Recordings procedures.

RESULTS

In total, we conducted 25 interviews, including 12 with clinicians and administrators, and 13 with patients. Thematic analysis revealed participants largely found the idea of technology-based medication adherence monitoring to be acceptable and appropriate for the target population in primary care, although several concerns were raised; we discuss these in detail.

CONCLUSIONS

Our medication adherence monitoring intervention, adapted from specialty care, will be implemented in primary care. Formative interviews, informed by the Exploration, Preparation, Implementation, and Sustainment Framework and conducted among patients, clinicians, and administrators, have identified intervention adaptation needs. Results from this study could inform other interventions using the patient portal with older adults.

Cross-cultural validation of the Spanish version of the Kidney AlloTransplant Immunosuppressive Therapy Adherence Questionnaire (KATITA-25)

The KATITA-25 (Kidney AlloTransplant Immunosuppressive Therapy Adherence) Questionnaire is a multidimensional self-administered scale developed in Brazilian Portuguese that measures the predisposition for non-adherence to immunosuppressive medication in candidate patients for kidney transplantation, in the pre-transplant setting. The aim of this study was the cross-cultural validation of the Spanish version of the KATITA-25 scale. The translation/back-translation method was used, followed by cognitive interviews and a pre-test. The Spanish version of KATITA-25 was administered to 163 candidate patients for kidney transplantation from 2 kidney transplant centres and 2 dialysis centres in Catalonia, Spain. The scale was re-administered to the first 79 patients included into the study, after a 2 to 4 weeks interval. Internal consistency was assessed using Cronbach's alpha, test-retest reliability with the intraclass correlation coefficient (ICC); construct validity with goodness of fit indices after confirmatory factor analysis using structural equation modelling. The Cronbach's alpha of the Spanish version was 0.83, the ICC was 0.86. Confirmatory factor analysis showed adequate fit of the structural model. Overall, the analytical results closely resembled those obtained in the validation of the original scale. In conclusion, this cross-cultural validation study showed adequate reliability and construct validity of the Spanish version of the KATITA-25 questionnaire.

Transplant recipient, care partner, and clinician perceptions of medication adherence monitoring technology: A mixed methods study

Medication nonadherence is a leading cause of graft loss. Adherence monitoring technologies-reminder texts, smart bottles, video-observed ingestion, and digestion-activated signaling pills-may support adherence. However, patient, care partner, and clinician perceptions of these tools are not well studied. We conducted qualitative individual semistructured interviews and focus groups among 97 participants at a single center: kidney and liver transplant recipients 2 weeks to 18 months posttransplant, their care partners, and transplant clinicians. We assessed adherence practices, reactions to monitoring technologies, and opportunities for care integration. One-size-fits-all approaches were deemed infeasible. Interviewees considered text messages the most acceptable approach; live video checks were the least acceptable and raised the most concerns for inconvenience and invasiveness. Digestion-activated signaling technology produced both excitement and apprehension. Patients and care partners generally aligned in perceptions of adherence monitoring integration into clinical care. Key themes were importance of routine, ease of use, leveraging technology for actionable medication changes, and aversion to surveillance. Transplant clinicians similarly considered text messages most acceptable and video checks least acceptable. Clinicians reported that early posttransplant use and real-time adherence tracking with patient feedback may facilitate successful implementation. The study provides initial insights that may inform future adherence technology implementation.

Evaluación del uso de la Aplicación Renal Health por parte de los receptores de trasplante renal

Resumen Objetivo: evaluar el uso de la aplicación Renal Health por parte de los receptores de trasplante renal. Método: estudio observacional retrospectivo con una muestra compuesta por usuarios que se registraron en la sección de trasplantados renales dentro de la aplicación desde julio de 2018 hasta abril de 2021. Se recolectaron las siguientes variables: datos demográficos, ingreso de datos, tiempo de uso, registros de peso, presión arterial, glucosa en sangre, creatinina, esquemas de medicación, consultas y exámenes. Se realizó un análisis descriptivo de los datos. Resultados: Ocurrieron 1.823 descargas de la aplicación y 12,3% se registró en la sección de trasplantados, la mayoría del sudeste de Brasil (44,9%), con edad de 36±11 años y del sexo femenino (59,1%). De la muestra, 35,1% ingresó información como: creatinina (62%), peso (58,2%) y presión arterial (51,8%). La mayoría utilizó la aplicación durante un día (63,3%) y el 13,9% más de cien días. Quienes lo usaron por más de un día (36,7%), agregaron peso (69%), programación de consultas (69%), medicación (65,5%) y creatinina (62%). Conclusión: la sección para trasplantados renales de la aplicación Renal Health despertó interés en la población joven, pero mostró baja adherencia en los meses evaluados. Estos resultados ofrecen una perspectiva relevante en la implementación de tecnologías mHealth en el trasplante renal.

Avaliação do uso do aplicativo Renal Health por transplantados renais

Resumo Objetivo: avaliar o uso do aplicativo Renal Health por transplantados renais. Método: estudo observacional retrospectivo com amostra composta por usuários que realizaram cadastro na seção para transplantados renais do aplicativo de julho de 2018 a abril de 2021. Foram coletadas as seguintes variáveis: dados demográficos, inserção de dados, tempo de uso, registros de peso, pressão arterial, glicemia, creatinina, horários das medicações, consultas e exames. Realizou-se análise descritiva dos dados. Resultados: houve 1.823 downloads do aplicativo e 12,3% cadastraram-se na seção para transplantados renais, a maioria do Sudeste do Brasil (44,9%), com 36±11 anos e do sexo feminino (59,1%). Da amostra, 35,1% inseriram informações como creatinina (62%), peso (58,2%) e pressão arterial (51,8%). A maioria utilizou o aplicativo por um dia (63,3%) e 13,9% por mais de cem dias. Os que utilizaram por mais de um dia (36,7%), inseriram peso (69%), agendaram consultas (69%), medicações (65,5%) e creatinina (62%). Conclusão: a seção para transplantados renais do aplicativo Renal Health despertou interesse na população jovem, mas apresentou baixa adesão ao longo dos meses avaliados. Esses resultados oferecem perspectiva relevante na implementação de tecnologias mHealth no transplante renal.

Hazardous drinking by older adults with chronic conditions during the COVID-19 pandemic: Evidence from a Chicago-based cohort

BACKGROUND

It is unclear how older adults with chronic conditions, who have greater risk of alcohol-related adverse outcomes, used alcohol throughout the COVID-19 pandemic. We assess changes in hazardous drinking prevalence May 2020-December 2021 and factors associated with hazardous drinking.

METHODS

Data are from structured phone interviews of older adults (age 60+) with chronic conditions (e.g., hypertension, diabetes, pulmonary disease, heart disease) in a Chicago-based longitudinal cohort (Chicago COVID-19 Comorbidities survey, Waves 3-7, n = 247). We tested differences in the prevalence of hazardous drinking (defined as AUDIT-C score of 3+ for women and 4+ for men) across waves for the full sample, by demographic group (sex, race, and ethnicity), and by chronic condition burden (<3 conditions, 3+ conditions). Generalized estimating equations investigated associations of hazardous drinking with sociodemographic and pandemic coping-related factors (stress, loneliness, outside contacts, depression, anxiety).

RESULTS

Participants were 66.8% female; 27.9% non-Hispanic Black, 14.2% Hispanic, 4.9% other race. Hazardous drinking was reported by 44.9% of participants in May 2020, but declined to 23.1% by July-August 2020 and continued to slowly decline to 19.4% by September-December 2021. Differences from May 2020 were significant at the 0.05 level. Subgroups followed similar trajectories. Hazardous drinking prevalence was initially higher but declined more among men than women, consistently higher among non-Hispanic White respondents than among Hispanic and non-Hispanic Black respondents, and declined more rapidly among adults with 3+ chronic conditions. In adjusted models, race and ethnicity were associated with lower prevalence of hazardous drinking (non-Hispanic Black: adjusted prevalence ratio [aPR] = 0.50, 95% confidence interval [CI] = 0.33, 0.74; other race: aPR = 0.26, 95% CI = 0.09, 0.81, compared with non-Hispanic White). No coping-related factors were significantly associated with hazardous drinking.

CONCLUSION

Among a cohort of older adults with chronic conditions, almost half engaged in hazardous drinking in early summer of the COVID-19 pandemic. While prevalence fell, these rates reinforce the need for alcohol screening and intervention in clinical settings among this population.

Patient randomised controlled trial of technology enabled strategies to promote treatment adherence in liver transplantation: rationale and design of the TEST trial

BACKGROUND AND AIMS

Liver transplantation is a life-saving procedure for end-stage liver disease. However, post-transplant medication regimens are complex and non-adherence is common. Post-transplant medication non-adherence is associated with graft rejection, which can have long-term adverse consequences. Transplant centres are equipped with clinical staff that monitor patients post-transplant; however, digital health tools and proactive immunosuppression adherence monitoring has potential to improve outcomes.

METHODS AND ANALYSIS

This is a patient-randomised prospective clinical trial at three transplant centres in the Northeast, Midwest and South to investigate the effects of a remotely administered adherence programme compared with usual care. The programme monitors potential non-adherence largely levering text message prompts and phenotypes the nature of the non-adhere as cognitive, psychological, medical, social or economic. Additional reminders for medications, clinical appointments and routine self-management support are incorporated to promote adherence to the entire medical regimen. The primary study outcome is medication adherence via 24-hour recall; secondary outcomes include additional medication adherence (ASK-12 self-reported scale, regimen knowledge scales, tacrolimus values), quality of life, functional health status and clinical outcomes (eg, days hospitalised). Study implementation, acceptability, feasibility, costs and potential cost-effectiveness will also be evaluated.

ETHICS AND DISSEMINATION

The University of Pennsylvania Review Board has approved the study as the single IRB of record (protocol # 849575, V.1.4). Results will be published in peer-reviewed journals and summaries will be provided to study funders.

TRIAL REGISTRATION NUMBER

NCT05260268.

COVID-19 Vaccination Status and Operative Outcomes after Kidney Transplantation

BACKGROUND

Kidney transplantation remains the best available treatment for end-stage renal disease. However, promoting graft longevity and preventing allosensitization requires strict adherence with a stringent immunosuppression regimen. The COVID-19 pandemic has offered new challenges for kidney transplant patients and many transplant centers are denying transplantation to unvaccinated patients. The aim of this study was to evaluate whether unvaccinated patients had inferior adherence after kidney transplantation along with a reduction in graft survival.

STUDY DESIGN

Patients undergoing a deceased donor kidney transplantation at a single academic medical center from February 2021 to May 2022 were retrospectively reviewed. February 2021 was chosen as the start date for record review because it was 3 months after the first COVID-19 vaccination was authorized for emergency use. Patients were considered to be vaccinated if they received at least 1 dose of any mRNA vaccine by their transplantation date.

RESULTS

Of the 301 patients who met study criteria, 234 were vaccinated and 67 were unvaccinated. Cohorts stratified by vaccination status were well matched. Younger age was an independent risk factor for nonvaccination. Interestingly, unvaccinated patients had worse postoperative adherence with a greater average number of missed postoperative clinic visits (p = 0.03) and a strong trend toward missing 3 or more postoperative clinic visits (p = 0.07). Finally, unvaccinated patients had statistically more subtherapeutic tacrolimus troughs (p = 0.01).

CONCLUSIONS

Patients not vaccinated against COVID-19 had higher rate of postoperative nonadherence in key areas of immunosuppression monitoring and clinic visit attendance. Providers should be cognizant that an unvaccinated status may be a harbinger for poor adherence; therefore, stricter strategies for patient outreach are critical to ensure graft success in this vulnerable patient population.

Post-liver transplantation patient experience

Given improvements in post-transplant patient and graft survival, there is a growing need to focus on patient experience and health-related quality of life (HRQOL). Though liver transplantation can be life-saving, it can also be associated with significant morbidity and complications. Patient HRQOL improves after transplantation, but it may not improve to that of age-matched cohorts. Understanding patient experience and the factors that contribute to it, including physical and psychological health, immunosuppression and medication adherence, return to employment or school, financial burden, and expectations, helps when thinking creatively about potential interventions to improve HRQOL.

Evaluation of the use of a Renal Health application by kidney transplant recipients

OBJECTIVE

to evaluate the use of a renal health application by kidney transplant recipients.

METHOD

a retrospective, observational study with a sample composed of individuals registered in the kidney transplant section of the application from July of 2018 to April of 2021. Demographic data, data entry, time of use, weight, blood pressure, blood glucose, creatinine, medication schedules, appointments, and tests were the variables collected. Descriptive analysis of the data was performed.

RESULTS

eight hundred and twenty-three downloads of the application were identified, and 12.3% of those were registered as kidney transplant recipients, the majority from southeastern Brazil (44.9%), 36±11 years old, and female (59.1%). Of the sample, 35.1% entered information such as creatinine (62%), weight (58.2%), and blood pressure (51.8%). Most used the application for one day (63.3%) and 13.9% for more than one hundred days. Those who used it for more than one day (36.7%) recorded weight (69%), medication intake (65.5%) and creatinine (62%), and scheduled appointments (69%).

CONCLUSION

the kidney transplant recipient section of the Renal Health application generated interest in the young population, but showed low adherence throughout the assessed months. These results offer a relevant perspective on the implementation of mHealth technologies in kidney transplantation.

Assessment of the Effectiveness of Patient Education and Interviews in Improving Medication Adherence of Renal Transplant Recipients

Background Non-compliance with immunosuppressive drugs has been reported as the most significant cause of graft loss. Since non-compliance with immunosuppressive drugs is preventable, certain approaches based on the risk factors and causes of non-compliance can help eliminate this problem. Aims The purpose of this study is to assess the effectiveness of patient education and interviews in improving medication adherence of renal-transplant recipients. Materials and methods This study was designed as a randomized controlled trial. Using the G*Power program, the sample size was calculated as 60 subjects, with 30 in both the intervention group and control group. Data collection tools included a patient information form, a pretest-posttest, a drug monitoring form for kidney transplant patients, the Immunosuppressive Therapy Adherence Scale, measurement of tacrolimus blood levels, and a training booklet.  Results The mean knowledge score in the intervention group was 12.17±3.39 at baseline, and it increased to 20.73±1.57 after the intervention. The mean scores on the Immunosuppressant Therapy Adherence Scale were 11.67±0.55 and 10.70±0.99 in the intervention group and control group, respectively. There was a statistically significant difference between the pre-test and post-test means on the Immunosuppressant Therapy Adherence Scale in the intervention group. The mean Immunosuppressant Therapy Adherence Scale score was higher in the intervention group. In the measurement of tacrolimus blood levels, medication adherence was found the be higher in the intervention group. The difference between the groups was statistically significant. There was a positive correlation between the tacrolimus blood levels and the Immunosuppressant Therapy Adherence Scale scores in both groups. Conclusions To conclude, our results have demonstrated that patient education and interviews improve immunosuppressant medication adherence in renal transplant recipients. Using direct or indirect methods proved similar outcomes, suggesting that both evaluation methods are safe.

Interventions for increasing immunosuppressant medication adherence in solid organ transplant recipients

BACKGROUND

Non-adherence to immunosuppressant therapy is a significant concern following a solid organ transplant, given its association with graft failure. Adherence to immunosuppressant therapy is a modifiable patient behaviour, and different approaches to increasing adherence have emerged, including multi-component interventions. There has been limited exploration of the effectiveness of interventions to increase adherence to immunosuppressant therapy.

OBJECTIVES

This review aimed to look at the benefits and harms of using interventions for increasing adherence to immunosuppressant therapies in solid organ transplant recipients, including adults and children with a heart, lung, kidney, liver and pancreas transplant.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 14 October 2021 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

All randomised controlled trials (RCTs), quasi-RCTs, and cluster RCTs examining interventions to increase immunosuppressant adherence following a solid organ transplant (heart, lung, kidney, liver, pancreas) were included. There were no restrictions on language or publication type.

DATA COLLECTION AND ANALYSIS

Two authors independently screened titles and abstracts of identified records, evaluated study quality and assessed the quality of the evidence using the GRADE approach. The risk of bias was assessed using the Cochrane tool. The ABC taxonomy for measuring medication adherence provided the analysis framework, and the primary outcomes were immunosuppressant medication initiation, implementation (taking adherence, dosing adherence, timing adherence, drug holidays) and persistence. Secondary outcomes were surrogate markers of adherence, including self-reported adherence, trough concentration levels of immunosuppressant medication, acute graft rejection, graft loss, death, hospital readmission and health-related quality of life (HRQoL). Meta-analysis was conducted where possible, and narrative synthesis was carried out for the remainder of the results.

MAIN RESULTS

Forty studies involving 3896 randomised participants (3718 adults and 178 adolescents) were included. Studies were heterogeneous in terms of the type of intervention and outcomes assessed. The majority of studies (80%) were conducted in kidney transplant recipients. Two studies examined paediatric solid organ transplant recipients. The risk of bias was generally high or unclear, leading to lower certainty in the results. Initiation of immunosuppression was not measured by the included studies. There is uncertain evidence of an association between immunosuppressant medication adherence interventions and the proportion of participants classified as adherent to taking immunosuppressant medication (4 studies, 445 participants: RR 1.09, 95% CI 0.95 to 1.20; I² = 78%). There was very marked heterogeneity in treatment effects between the four studies evaluating taking adherence, which may have been due to the different types of interventions used. There was evidence of increasing dosing adherence in the intervention group (8 studies, 713 participants: RR 1.14, 95% CI 1.03 to 1.26, I² = 61%).  There was very marked heterogeneity in treatment effects between the eight studies evaluating dosing adherence, which may have been due to the different types of interventions used. It was uncertain if an intervention to increase immunosuppressant adherence had an effect on timing adherence or drug holidays. There was limited evidence that an intervention to increase immunosuppressant adherence had an effect on persistence. There was limited evidence that an intervention to increase immunosuppressant adherence had an effect on secondary outcomes. For self-reported adherence, it is uncertain whether an intervention to increase adherence to immunosuppressant medication increases the proportion of participants classified as medically adherent to immunosuppressant therapy (9 studies, 755 participants: RR 1.21, 95% CI 0.99 to 1.49; I² = 74%; very low certainty evidence). Similarly, it is uncertain whether an intervention to increase adherence to immunosuppressant medication increases the mean adherence score on self-reported adherence measures (5 studies, 471 participants: SMD 0.65, 95% CI -0.31 to 1.60; I² = 96%; very low certainty evidence). For immunosuppressant trough concentration levels, it is uncertain whether an intervention to increase adherence to immunosuppressant medication increases the proportion of participants who reach target immunosuppressant trough concentration levels (4 studies, 348 participants: RR 0.98, 95% CI 0.68 to 1.40; I² = 40%; very low certainty evidence). It is uncertain whether an intervention to increase adherence to immunosuppressant medication may reduce hospitalisations (5 studies, 460 participants: RR 0.67, 95% CI 0.44 to 1.02; I² = 64%; low certainty evidence). There were limited, low certainty effects on patient-reported health outcomes such as HRQoL. There was no clear evidence to determine the effect of interventions on secondary outcomes, including acute graft rejection, graft loss and death. No harms from intervention participation were reported.

AUTHORS' CONCLUSIONS

Interventions to increase taking and dosing adherence to immunosuppressant therapy may be effective; however, our findings suggest that current evidence in support of interventions to increase adherence to immunosuppressant therapy is overall of low methodological quality, attributable to small sample sizes, and heterogeneity identified for the types of interventions. Twenty-four studies are currently ongoing or awaiting assessment (3248 proposed participants); therefore, it is possible that findings may change with the inclusion of these large ongoing studies in future updates.

Information and Communication Technologies in Lung Transplantation: Perception of Patients and Medical Teams

Optimal therapeutic management is a major determinant of patient prognosis and healthcare costs. Information and communication technologies (ICTs) represent an opportunity to enhance therapeutic management in complex chronic diseases, such as lung transplantation (LT). The objective of this study was to assess the preferences of LT patients and healthcare professionals regarding ICTs in LT therapeutic management. A cross-sectional opinion survey was conducted among lung transplant patients and healthcare professionals from the French lung transplantation centers. Five ICTs were defined (SMS, email, phone, internet, and smartphone application) in addition to face-to-face communication. An unsupervised approach by Principal Component Analysis (PCA) identified lung transplant patient profiles according to their preferences for ICTs. Fifty-three lung transplant patients and 15 healthcare professionals of the French LT centers were included. Both expected ICTs for treatment management and communication. Phone call, face-to-face, and emails were the most preferred communication tools for treatment changes and initiation. PCA identified four ICTs-related profiles (“no ICT”, “email”, “SMS”, and “oral communication”). “Email” and “oral communication” profiles are mainly concerned with treatment changes and transmission of new prescriptions. The “SMS” profile expected reminders for healthcare appointments and optimizing therapeutic management. This study provides practical guidance to enhance LT therapeutic management by ICT intervention. The type of ICT used should take into account patient profiles to improve adherence and thereby the prognosis. A combination of strategies including information, education by a multidisciplinary team, and reminders is a promising approach to ensure an optimal management of our patients.

Describing Predictors Of Regimen Nonadherence Among Kidney Recipients Using Multiple Measures

Introduction: Many kidney recipients struggle with medication adherence and are at greater risk for adverse post-transplant outcomes. Historically, research has focused on single immunosuppressants alone, though all medications within a prescribed regimen are essential for positive outcomes. Research question: Explore predictors of medication regimen nonadherence among a diverse sample of adult kidney recipients by using multiple measures of adherence. Design: A cross-sectional analysis was performed using data from an ongoing clinical trial that enrolled 234 kidney recipients from a large transplant center. We used linear and logit regression models to examine associations of demographic characteristics, social determinants of health, and clinical characteristics with (a) self-reported regimen adherence, measured by the Adherence Starts with Knowledge 12 scale, and (b) immunosuppressant adherence, captured by calculated risk score based on Tacrolimus measurements. Results: Kidney recipients with limited health literacy, overall poorer health, and higher levels of depression demonstrated significantly poorer regimen adherence. Recipients who had dual public/private insurance, took a greater number of medications, and had shorter time since transplant demonstrated significantly poorer immunosuppressant adherence. Conclusion: Social determinants (health literacy and insurance status), and clinical characteristics (overall health status, depression, number of medications, and time since transplant) played significant roles in regimen and immunosuppressant adherence among kidney recipients in our sample. Self-reported adherence, particularly in relation to full medication regimens, can highlight modifiable barriers that might otherwise be overlooked by focusing on adherence to a single immunosuppressant. Depression and health literacy can be assessed and addressed to improve adherence among adult kidney recipients.

Redefining Success After Liver Transplantation: From Mortality Toward Function and Fulfillment

Liver transplantation (LT), the only cure for end-stage liver disease, is a lifesaving, costly, and limited resource. LT recipients (LTRs) are aging with an increasing burden of medical comorbidities. Patient and graft survival rates exceed 70% at 5 years; however, patient-centered health outcomes beyond survival have received relatively little attention. LTRs must have strong self-management skills to navigate health systems, adhere to clinical monitoring, and take complex, multidrug regimens. All of these tasks require formidable cognitive abilities for active learning and problem solving. Yet, LTRs are at higher risk for impaired cognition as a result of the high prevalence of pretransplant hepatic encephalopathy, multiple chronic conditions, alcohol use, physical frailty, sarcopenia, and older age. Cognitive impairment after transplant may persist and has been causally linked to poor self-management skills, worse physical function, and inferior health outcomes in other health care settings, yet its impact after LT is largely unknown. There is a need to study potentially modifiable, posttransplant targets including caregiver support, physical activity, sleep, and treatment adherence to inform future health system responses to promote the long-term health and well-being of LTRs. Prospective, longitudinal data collection that encompasses key sociodemographic, cognitive-behavioral, psychosocial, and medical factors is needed to improve risk prediction and better inform patient and caregiver expectations. Interventions with proactive monitoring, reducing medical complexity, and improved care coordination can be tailored to optimize posttransplant care. We propose a research agenda focused on understudied, potentially modifiable risk factors to improve the long-term health of LTRs. Our conceptual model accounts for cognitive function, caregiver and patient self-management skills, health behaviors, and patient-centered outcomes beyond mortality. We propose actionable health-system, patient, and caregiver-directed interventions to fill knowledge gaps and improve outcomes.

Technology-Enabled Care and Artificial Intelligence in Kidney Transplantation

Purpose of Review

Artificial intelligence (AI), machine learning, and technology-enabled remote patient care have evolved rapidly and have now been incorporated into many aspects of medical care. Transplantation is fortunate to have large data sets upon which machine learning algorithms can be constructed. AI are now available to improve pretransplant management, donor selection, and post-operative management of transplant patients.

Recent Findings

Changes in patient and donor characteristics warrant new approaches to listing and organ acceptance practices. Machine learning has been employed to optimize donor selection to identify patients likely to benefit from transplantation of higher risk organs, increasing organ discard and reducing waitlist mortality. These models have greater precisions and predictive ability than currently employed metrics including the Kidney Donor Profile Index and the expected posttransplant survival models. After transplant, AI tools have been developed to optimize immunosuppression management, track patients adherence, and assess graft survival.

Summary

AI and technology-enabled management tools are now available throughout the transplant journey. Unfortunately, those are frequently not available at the point of decision (patient listing, organ acceptance, posttransplant clinic), limiting utilization. Incorporation of these tools into the EMR, the Donor Net® organ offer system, and mobile devices is vital to ensure widespread adoption.

Perceived Adequacy of Tangible Support during Stay-at-Home Orders in Chicago and New York

Objectives:

Physical distancing precautions during the COVID-19 pandemic may challenge the provision of tangible support many middle age and older adults receive in managing their health. We examined the association between unmet tangible support needs and self-management behaviors and mental health status during the stay-at-home orders in Chicago and New York.

Methods:

We used data from the COVID-19 & Chronic Conditions study collected between May 1st and May 22nd, 2020. A total of 801 middle age and older adults with ≥1 chronic condition in Chicago and New York City completed the telephone interview. Adequacy of tangible social support was measured using a brief, validated scale that determined whether an individual needed assistance managing his or her health, and if yes, whether this need was met. Participants reported their level of difficulty engaging in self-management behaviors using 2 discrete items; they also self-reported medication adherence using the ASK-12 medication adherence scale. Mental health status was measured using the depression and anxiety PROMIS short-form instruments.

Results:

Participants’ mean age was 63 years; 30% identified as Black, 26% identified as Latino, and 12% identified unmet support needs. Inadequacy of tangible support was associated with greater difficulty managing one’s health and accessing medications due to COVID-19, as well as poorer medication adherence, increased anxiety and depressive symptoms, and poorer overall well-being (P’s < .05).

Conclusions:

Perceived unmet support needs during stay-at-home orders were associated with greater difficulty engaging in self-management behaviors and poorer overall well-being. Two brief items quickly identified individuals with unmet support needs.