ESPN 50th Annual Meeting

ESPN 2017


 
Medication non-adherence is a leading modifiable cause for renal graft loss in childhood – a large centre study
Nabil Melhem Nadeesha Mudalige Stacie Bowden Grainne Walsh Helen Jones Nicos Kessaris Nizam Mamode Jelena Stojanovic

 
Introduction:

Despite continued advances in transplantation, it has been observed that the rate of renal graft failure is disproportionately high amongst the adolescent population. This study looked into why grafts fail in children.

Material and methods:

Retrospective observational study in a single paediatric transplant centre between 2003 and 2016. All patients transplanted during study period and those transplanted previously and followed up during the study period were included.

Results:

During the study period, 171 paediatric kidney transplants were performed. Median follow up was 8 years (IQR 10years). Fifteen grafts failed before adulthood. Graft loss was caused by recurrent acute rejections following medication non-adherence in four patients (27%) and chronic antibody mediated rejection (CAMR) in five patients (33%). The mean age at time of transplant was 6.4years and average age at the time of graft loss 15.7years (range 2-17.9). Living and deceased donors were evenly distributed and well matched. HLA antibodies were detected in 70%. There was no statistically significant difference in graft longevity between the CAMR group and the medication non-adherence group (p=0.07).

The medication non-adherence group were 12-17 years old at the time of graft failure. All were well matched (MM 110/111) with graft lifespan 21-120 months. All had DSA, multiple episodes of rejection (Banff 2b and 4a), with an average of five biopsy proven episodes each and low/undetectable CNI levels.

Conclusions:

Medication non-adherence was a significant contributor to poor transplant outcomes in the adolescent population. We propose a multidisciplinary staged adherence pathway to improve graft outcomes for paediatric recipients. This encompasses early identification of vulnerable patients, enrolment into a hospital passport program overseen by play specialists, MDT meetings, adherence workshops and early psychology and psychiatry referral pathways for vulnerable patients.