Adherence is associated with a favorable outcome after lung transplantation

Participation and Progression of Hybrid Rehabilitation following Lung Transplantation

BACKGROUND

Exercise training is recommended to improve physical recovery following lung transplantation (LTx). Since the COVID-19 pandemic, hybrid rehabilitation has emerged utilizing both in-person and home-based exercise. Little is known about exercise participation, progression and intensity with this delivery model.

METHODS

A single center retrospective chart review of adult LTx recipients who undertook outpatient rehabilitation within the first 3 months after LTx between December 1, 2022 and February 29, 2024, was conducted. High participation was defined as ≥3 exercise sessions/week for at least 50% of the rehabilitation period. Progression of exercise volumes was examined and walking intensity (Borg leg fatigue scale) was compared between in-person and home rehabilitation.

RESULTS

A total of 166 LTx recipients were included (70% male, 64 [14] years, 71% interstitial lung disease). High rehabilitation participation was observed in 48% of participants over a mean of 8 ± 2 weeks. The median walking distance, biceps and quadriceps resistance training volumes increased between the first and last recorded rehabilitation sessions during both in-person (536 [538] vs. 1073 [650] m, 40 [20] vs. 60 [55] repxlbs, and 20 [10] vs. 40 [30] repxlbs) and home rehabilitation (968 [991] vs. 1556 [1019] m, 50 [70] vs. 100 [70] repxlbs, and 30 [32] vs. 40 [70] repxlbs), all p < 0.05. Leg fatigue was higher during in-person walking compared to home (3 [3-4] vs. 3 [2-3]), p < 0.001.

CONCLUSIONS

Half of LTx recipients had low participation in outpatient and home rehabilitation early after transplantation. Understanding barriers to home exercise participation and reporting will enhance hybrid rehabilitation delivery.

Assessing the Quality of Life in Adult Lung Transplant Recipients Quality of Life Post-Lung Transplant

BACKGROUND

Significant limitations in daily life characterize end-stage lung diseases (ESLD) due to symptoms such as dyspnea, recurrent infections, side effects of immunosuppressive medication, and frequent need for hospitalizations. In addition to physical symptoms, ESLD is associated with emotional and social sources of distress such as depression, anxiety, fear of dying, financial concerns, and regular need for relocation. A transplant can significantly affect the recipients' life domains, from physical and emotional well-being to social relationships and roles.

OBJECTIVE

This study aims to assess the quality of life of adult lung transplant recipients in Saudi Arabia.

METHOD

A cross-sectional quantitative design was employed using the self-administered World Health Organization Quality of Life (WHOQOL-BREF) questionnaire, a sociodemographic and clinical questionnaire, and a medical chart review. The study was conducted in a tertiary care center in Saudi Arabia. Data were collected from November 2023 to April 2024.

RESULTS

One hundred fifty-seven individuals with a mean age of 45 years had completed the questionnaire, and there was no participant refusal (Response rate = 100%). Males accounted for 61.1%, and most participants were married (63.7%). About half (44.6%) had at least one comorbidity outside ESLD. Only 26.7% were working post-transplant. Overall, the data strongly suggests that as individuals adjust and recover post-transplant, they tend to feel increasingly positive with time. Most rated their quality of life and health satisfaction as high. The lowest score was for the physical domain.

CONCLUSION

The study's findings showed that the quality was good overall across various domains, with moderate scores, with the lowest score on the physical domain. Improving rehabilitation strategies would help transplanted patients live more fulfilling lives.

Evaluation of Published Population Pharmacokinetic Models to Inform Tacrolimus Therapy in Adult Lung Transplant Recipients

BACKGROUND

The applicability of currently available tacrolimus population pharmacokinetic models in guiding dosing for lung transplant recipients is unclear. In this study, the predictive performance of relevant tacrolimus population pharmacokinetic models was evaluated for adult lung transplant recipients.

METHODS

Data from 43 lung transplant recipients (1021 tacrolimus concentrations) administered an immediate-release oral formulation of tacrolimus were used to evaluate the predictive performance of 17 published population pharmacokinetic models for tacrolimus. Data were collected from immediately after transplantation up to 90 days after transplantation. Model performance was evaluated using (1) prediction-based assessments (bias and imprecision) of individual predicted tacrolimus concentrations at the fourth dosing based on 1 to 3 previous dosings and (2) simulation-based assessment (prediction-corrected visual predictive check; pcVPC). Both assessments were stratified based on concomitant azole antifungal use. Model performance was clinically acceptable if the bias was within ±20%, imprecision was ≤20%, and the 95% confidence interval of bias crossed zero.

RESULTS

In the presence of concomitant antifungal therapy, no model showed acceptable performance in predicting tacrolimus concentrations at the fourth dosing (n = 33), and pcVPC plots displayed poor model fit to the data set. However, this fit slightly improved in the absence of azole antifungal use, where 4 models showed acceptable performance in predicting tacrolimus concentrations at the fourth dosing (n = 33).

CONCLUSIONS

Although none of the evaluated models were appropriate in guiding tacrolimus dosing in lung transplant recipients receiving concomitant azole antifungal therapy, 4 of these models displayed potential applicability in guiding dosing in recipients not receiving concomitant azole antifungal therapy. However, further model refinement is required before the widespread implementation of such models in clinical practice.

Feasibility study and determination of prerequisites of telecare programme to enhance patient management in lung transplantation: a qualitative study from the perspective of Iranian healthcare providers

BACKGROUND

Non-adherence to treatment plans, follow-up visits and healthcare advice is a common obstacle in the management of lung transplant patients. This study aims to investigate experts' views on the needs and main aspects of telecare programmes for lung transplantation.

DESIGN

A qualitative study incorporating an inductive thematic analysis.

SETTING

Lung transplant clinic and thoracic research centre.

PARTICIPANTS

Clinicians: four pulmonologists, two cardiothoracic surgeons, two general physicians, two pharmacotherapists, one cardiologist, one nurse and one medical informatician.

METHOD

This study adopted a focus group discussion technique to gather experts' opinions on the prerequisites and features of a telecare programme in lung transplantation. All interviews were coded and combined into main categories and themes. Thematic analysis was performed to extract the key concepts using ATLAS.Ti. Ultimately, all extracted themes were integrated to devise a conceptual model.

RESULTS

Ten focus groups with 13 participants were conducted. Forty-six themes and subthemes were extracted through the thematic analysis. The main features of the final programme were extracted from expert opinions through thematic analysis, such as continuous monitoring of symptoms, drug management, providing a specific care plan for each patient, educating patients module, creating an electronic medical record to collect patient information, equipping the system with decision support tools, smart electronic prescription and the ability to send messages to the care team. The prerequisites of the system were summarised in self-care activities, clinician's tasks and required technologies. In addition, the barriers and benefits of using a telecare system to enhance the quality of care were determined.

CONCLUSION

Our investigation recognised the main factors that must be considered to design a telecare programme to provide ideal continuous care for lung transplant patients. Users should further explore the proposed model to support the development of telecare interventions at the point of care.

The impact of postoperative cognitive impairment on mid-term survival after heart transplantation

BACKGROUND

Heart transplantation is the definitive therapy for patients with end-stage heart failure. Antecedent studies reported that a substantial proportion of heart transplant recipients developed postoperative cognitive impairment in the long term. However, no studies have explored the association between postoperative cognitive impairment and survival after heart transplantation.

METHODS

The data of 43 adult patients who underwent heart transplantation were consecutively enrolled and assessed using the MMSE and MoCA neuropsychological tests. Kaplan-Meier curves and Cox proportional hazards models were used for survival analyses. Primary component analysis was performed to integrate MoCA subtests into the "Attention factor," "Naming factor," and "Orientation factor."

RESULTS

About 30% of the patients were diagnosed with short-term postoperative cognitive impairment. The impairment group was older and had lower baseline cognitive performances, larger LV diameter, worse MMSE decline and higher ratio of significant MoCA decline. Postoperative cognitive impairment was significantly associated with worse survival (P = .028). Multivariate Cox analyses showed that higher postoperative MoCA score was significantly associated with lower mid-term post-transplant mortality (HR = .744 [.584, .949], P = .017), in which "Attention factor" contributed to this association most (HR = .345 [.123, .970], P = .044) rather than "Naming factor" or "Orientation factor." Notably, preoperative cognitive impairment was closely related with postoperative cognitive impairment and also indicated the worse post-transplant survival (P = .015).

CONCLUSION

Postoperative as well as preoperative cognitive impairments were associated with a worse mid-term survival after heart transplantation, indicating that neuropsychological assessments before and after heart transplantation should be routinely performed for heart transplant recipients for better risk stratification.

Place-based heterogeneity in lung transplant recipient outcomes

Place is defined as a social or environmental area of residence with meaning to a patient. We hypothesize there is an association between place and the clinical outcomes of lung transplant recipients in the United States. In a retrospective cohort study of transplants between January 1, 2010, and December 31, 2019, in the Scientific Registry of Transplant Recipients, multivariable Cox regression models were used to test the association between place (through social and environmental factors) with readmission, lung rejection, and survival. Among 18,465 recipients, only 20% resided in the same county as the transplant center. Recipients from the most socially vulnerable counties when compared to the least vulnerable were more likely to have COPD as a native disease, Black or African American race, and travel long distances to reach a transplant center. Higher local life expectancy was associated with lower likelihood for readmission (odds ratio [OR] = 0.90, 95% confidence interval [CI]: 0.84, 0.98, p = .01). Higher social vulnerability was associated with a higher likelihood of lung rejection (OR = 1.37, [CI]: 1.07, 1.76, p = .01). There was no association of residence with posttransplant survival. Recipient place-based factors were associated with complications and processes of care after transplant and warrant further investigation.

Application of Place-Based Methods to Lung Transplant Medicine

Lung transplantation is an increasingly common lifesaving therapy for patients with fatal lung diseases, but this intervention has a critical limitation as median survival after LT is merely 5.5 years. Despite the profound impact of place-based factors on lung health, this has not been rigorously investigated in LT recipients-a vulnerable population due to the lifelong need for daily life-sustaining immunosuppression medications. There have also been longstanding methodological gaps in transplant medicine where both time and place have not been measured; gaps which could be filled by the geospatial sciences. As part of an exploratory analysis, we studied recipients transplanted at our center over a two-year period. The main outcome was at least one episode of rejection within the first year after transplant. We found recipients averaged 1.7 unique residential addresses, a modest relocation rate. Lung rejection was associated with census tracts of predominantly underrepresented minorities or where English was not the primary language as measured by the social vulnerability index. Census tracts likely play an important role in measuring and addressing geographic disparities in transplantation. In a future paradigm, patient spatial data could become an integrated part of real time clinical care to aid in personalized risk stratification and personalized delivery of healthcare.

Care Technologies to Improve Treatment Adherence in Patients Undergoing Organ Transplant: A Scoping Review

BACKGROUND

The objective of this study was to map care technologies being developed to improve treatment adherence in patients undergoing organ transplant.

METHODS

A scoping review was developed according to the Joanna Briggs Institute manual. The research question was developed according to the population, concept, and context strategy. Searches were conducted independently in 6 databases between June and August 2021. The data were evaluated and organized together. The review protocol was published.

RESULTS

Fifteen articles were part of the study, mostly published in the United States (33.3%) and in 2016 (33.3%). The main research method identified was clinical studies (80%). Most of the care technologies identified are in relation to medication adherence in the post-transplant setting. Another intervention identified was health education action with the support of mobile apps, electronic monitoring systems, and a card game.

CONCLUSIONS

The results present technologies directed at the importance of post-transplant drug adherence; however, it is important to adapt the technologies to the reality experienced by the patient, as well as to train patients so that they can introduce these technologies in their daily lives. Furthermore, it is important that technologies are developed that include other aspects of adherence to post-transplant treatment.

Remote intervention engagement and outcomes in the Clinical Trials in Organ Transplantation in Children consortium multisite trial

Remote interventions are increasingly used in transplant medicine but have rarely been rigorously evaluated. We investigated a remote intervention targeting immunosuppressant management in pediatric lung transplant recipients. Patients were recruited from a larger multisite trial if they had a Medication Level Variability Index (MLVI) ≥2.0, indicating worrisome tacrolimus level fluctuation. The manualized intervention included three weekly phone calls and regular follow-up calls. A comparison group included patients who met enrollment criteria after the subprotocol ended. Outcomes were defined before the intent-to-treat analysis. Feasibility was defined as ≥50% of participants completing the weekly calls. MLVI was compared pre- and 180 days postenrollment and between intervention and comparison groups. Of 18 eligible patients, 15 enrolled. Seven additional patients served as the comparison. Seventy-five percent of participants completed ≥3 weekly calls; average time on protocol was 257.7 days. Average intervention group MLVI was significantly lower (indicating improved blood level stability) at 180 days postenrollment (2.9 ± 1.29) compared with pre-enrollment (4.6 ± 2.10), p = .02. At 180 days, MLVI decreased by 1.6 points in the intervention group but increased by 0.6 in the comparison group (p = .054). Participants successfully engaged in a long-term remote intervention, and their medication blood levels stabilized. NCT02266888.

The Transplant Evaluation Rating Scale Predicts Clinical Outcomes 1 Year After Lung Transplantation: A Prospective Longitudinal Study

Objectives: It has been recommended that all candidates for lung transplantation undergo pre-transplant psychosocial evaluation for risk assessment. However, psychosocial issues are only important if they correlate with outcomes after transplantation. Methods: In this prospective study patients who were referred for lung transplantation from 2016 to 2018 (n = 352) at Hannover Medical School were evaluated using the Transplant Evaluation Rating Scale (TERS). Clinical outcomes included listing, and post-transplant outcomes including mortality, medical aspects such as lung allograft dysfunction, hospitalizations, and renal function, behavioral aspects such as BMI and adherence, and mental issues such as levels of depression, anxiety, and quality of life. TERS scores were divided into tertiles and, in addition, the impact of the two subscale scores-"defiance" and "emotional sensitivity"-was investigated. Results: Of the patients who were transplanted (n = 271) and were still alive (n = 251), 240 had already reached their 1-year assessment at the end of 2020 and were evaluated 1 year after the operation. A subgroup of 143 received an extended mental assessment. BMI, adherence scores, levels of anxiety, depression, and quality of life 1 year post-transplantation differed significantly between TERS tertiles with higher TERS scores predicting less favorable outcomes. The TERS subscale "defiance" was predictive of BMI and adherence whereas the TERS subscale "emotional sensitivity" was predictive of symptoms of anxiety and depression, and quality of life 1 year after transplantation. Patients in the lowest TERS tertile were more likely to having been listed and-as a trend-to having survived the first year after transplantation Conclusions: Our findings show that psychosocial factors as measured by TERS score are predictors of behavioral and mental outcomes 1 year after lung transplantation. The TERS allows us to focus on psychosocial risk factors that can be treated or minimized before or after transplantation.

The relation between psychological distress and medication adherence in lung transplant candidates and recipients: A cross-sectional study

AIMS AND OBJECTIVES

To explore the prevalence of psychological distress such as anxiety, depression and post-traumatic stress disorder and its associations with medication adherence in lung transplant patients.

BACKGROUND

Psychological distress after lung transplantation may impact clinical outcomes by associated behaviours such as non-adherence to medication. Evidence about the relation between psychological distress and medication adherence in lung transplant patients is limited and not well explained.

DESIGN AND METHODS

We conducted a single-centre study with a cross-sectional design in 73 lung transplant candidates and 116 recipients. Questionnaires were the Brief Symptom Inventory, Impact of Event Scale and Basel Assessment of Adherence to Immunosuppressive Medications Scale. The STROBE checklist was monitored.

RESULTS

In candidates, 39.7% reported (sub)clinical symptoms of depression, in recipients this was 21.6%. We observed suicidal ideation in recipients (8.6%), and candidates (5.5%). The prevalence of (sub)clinical symptoms of anxiety was 38.3% in candidates and 33.7% in recipients. After lung transplantation, 12% of the recipients reported clinical symptoms of PTSD related to the transplantation. Symptoms of anxiety and medication adherence were significantly and positively related in transplant recipients. We found no association between depressive or post-traumatic stress symptoms, and medication adherence.

CONCLUSIONS

In lung transplant patients, we found a high prevalence of symptoms of depression and anxiety. Recipients had high levels of post-traumatic stress symptoms related to the transplantation. The prevalence of suicidal ideation was unexpectedly high in recipients. After lung transplantation, higher levels of anxiety were related to better medication adherence. We propose that LTX recipients are very anxious to develop dyspnoea and therefore take their medication more conscientiously.

RELEVANCE TO CLINICAL PRACTICE

The clinical nurse specialist can play a key role in identifying and addressing psychological and behavioural problems. More prospective research on the role of anxiety and dyspnoea in lung transplant recipients is recommended.

Evaluation of a Home Monitoring Application for Follow Up after Lung Transplantation-A Pilot Study

Home spirometry after lung transplantation is common practice, to monitor graft function. However, there is little experience with online home monitoring applications with direct data transfer to the hospital. We evaluated the feasibility and patient experiences with a new online home monitoring application, integrated with a Bluetooth-enabled spirometer and real-time data transfer. Consecutive lung transplant recipients were asked to evaluate this home monitoring application for three months in a pilot study. Home spirometry measurements were compared with in-hospital lung function tests (the forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC)) at the end of the study. Ten patients participated. The home and hospital spirometry measurements showed a high correlation, for both the FEV1 (r = 0.99, p < 0.01) and FVC (r = 0.99, p < 0.01). The adherence and patient satisfaction were high, and the patients preferred the home monitoring application over the current home spirometer, with a difference of 1.4 ± 1.5 points on a scale from 0 to 10 (p = 0.02). Online home monitoring with direct data transfer is feasible and reliable after lung transplantation and results in high patient satisfaction. Whether the implementation of online home monitoring enables the earlier detection of lung function decline and improves patient and graft outcomes will be the subject of future research.

An E-Learning Program Improves Patients' Knowledge After Lung Transplantation

Background: Adherence to immunosuppressive medicine in lung transplant recipients is associated with improved long-term survival. Patient education and support from health care providers are key components. We investigated e-learning as a tool to improve lung transplant recipients' knowledge of post-transplant care such as hygiene, self-monitoring, travel precautions, vaccinations, and the importance of adherence to medication. Objective: To compare the effect of e-learning and conventional patient education with respect to level of knowledge and drug adherence. A single-center open randomized controlled trial design was used. Methods: Lung transplant recipients were randomized to an e-learning program or standard care. One month before a scheduled follow-up visit, the intervention group received a link by e-mail to a 15-min e-learning program. At the follow-up visit, all lung transplant recipients completed two drug adherence questionnaires (Basel Assessment of Adherence with Immunosuppressive medication Scales [BAASIS] and Transplant Adherence Questionnaire [TAQ]) and a questionnaire testing their knowledge of post-transplant care. Results: Fifty lung transplant recipients were randomized with 24 recipients in each group completing the study. Recipient adherence measured by BAASIS showed a tendency toward improved drug adherence in the intervention group compared with the control group (71% vs. 55%, p = 0.23). TAQ showed no difference between the two groups (p = 1.0). Recipients in the intervention group had a significantly higher number of correct answers to questions about transplant-friendly lifestyle (median 11 vs. 10, p = 0.02). Conclusion: A 15-min e-learning program is a simple and effective tool to improve lung transplant recipients' knowledge of post-transplant care.

Prospective single-centre clinical observational study on electronically monitored medication non-adherence, its psychosocial risk factors and lifestyle behaviours after heart transplantation: a study protocol

INTRODUCTION

In heart transplant recipients (HTRs), non-adherence (NA) to immunosuppressive (IS) medication and to recommended lifestyle behaviours are a common phenomenon and associated with higher risk of allograft rejection, organ loss and mortality. Risk factors for NA are highly diverse and still insufficiently researched. Precise measures of NA and an accurate understanding of its aetiology are of undisputable importance to detect patients at risk and intervene accordingly. The aim of this study is to assess the accuracy and concordance of different measures for NA as well as to determine potential risk factors.

METHODS AND ANALYSIS

This is a single-centre prospective observational trial. HTRs who are at least aged 18 are no less than 6 months post-transplant and receive tacrolimus (Prograf or Advagraf), cyclosporine (Sandimmun) or everolimus (Certican) as their prescribed IS medication are eligible for participation. We only include patients during the phase of medication implementation. At study enrolment, we assess depression, health-related quality of life, self-efficacy, social support, attachment, experiences and attitudes towards IS medication, emotional responses after transplantation, satisfaction with information about IS medication and perceptions and beliefs about medications. We further ask patients to rate their lifestyle behaviours concerning alcohol, smoking, diet, physical activity, sun protection and appointment keeping via questionnaires. Three different measurement methods for NA are applied at T0: self-reports, physician's estimates and IS trough levels. NA is monitored prospectively using an electronic multicompartment pillbox (MEMS, VAICA) over a 3-month period. Meanwhile, participants receive phone calls every second week to obtain additional self-reports, resulting in a total of seven measurement points.

ETHICS AND DISSEMINATION

The study was approved by the Clinical Ethics Committee of the University Hospital Erlangen (Friedrich-Alexander-University, Erlangen-Nürnberg). Written informed consent is attained from all participants. The results of this study will be published in peer-reviewed journals and presented at conferences.

TRIAL REGISTRATION NUMBER

DRKS00020496.

Chronic Obstructive Pulmonary Disease and Lung Transplantation

Lung transplantation (LTx) has been a viable option for patients with end-stage chronic obstructive pulmonary disease (COPD), with more than 20,000 procedures performed worldwide. Survival after LTx lags behind most other forms of solid-organ transplantation, with median survival for COPD recipients being a sobering 6.0 years. Given the limited supply of suitable donor organs, not all patients with end-stage COPD are candidates for LTx. We discuss appropriate criteria for accepting patients for LTx, as well as contraindications and exclusionary criteria. In the first year post-LTx, infection and graft failure are the leading causes of death. Beyond this chronic graft rejection-currently referred to as chronic lung allograft dysfunction-represents the leading cause of death at all time points, with infection and over time malignancy also limiting survival. Referral of COPD patients to a lung transplant center should be considered in the presence of progressing disease despite maximal medical therapy. As a rule of thumb, a forced expiratory volume in 1 second < 25% predicted in the absence of exacerbation, hypoxia (PaO₂ < 60 mm Hg/8 kPa), and/or hypercapnia (PaCO₂ > 50 mm Hg/6.6 kPa) and satisfactory general clinical condition should be considered the basic prerequisites for timely referral. We also discuss salient issues post-LTx and factors that impact posttransplant survival and morbidity such as infections, malignancy, renal insufficiency, and complications associated with long-term immunosuppression.