Self-regulation predictors of medication adherence among ethnically different pediatric patients with renal transplants.

OBJECTIVE: To predict medication adherence among ethnically different pediatric patients with renal transplants between the ages of 6 and 20 years old, using self-regulation variables including motivation, perceived control and responsibility, and perceived support. METHODS: Twenty-six African American children and 42 Caucasian children were verbally administered the Self-Regulation of Medication Adherence Battery to assess their (1) motivation to be medication adherent, (2) perceived control of and responsibility for medication adherence, and (3) perceived support of medication adherence from their primary caregiver. Four measures were used to assess medication adherence: self-ratings, nephrologists' ratings, cyclosporine levels, and pill count/refill histories. RESULTS: For the African American patients, regression analyses revealed that responses to motivation and perceived control questions that focused on self-efficacy were unique predictors of medication adherence as rated by their primary nephrologist. For the Caucasian patients, one motivation question regarding how often they forget to take their medication predicted their self-reported adherence. CONCLUSIONS: Facilitating their beliefs that they can regularly take their medications may help promote medication adherence among African American children with renal transplants, whereas for Caucasian children, providing cues and reminders to take their medications may help. We discuss implications of the results for multimodal assessment of medication adherence and for ethnic group-specific medication adherence research and interventions.

Demographic and medical predictors of medication compliance among ethnically different pediatric renal transplant patients.

Medication adherence in African-American and European-American pediatric renal transplant recipients was evaluated by four separate measures. Demographic and medical factors were analyzed. Based on pill count/refill history, European-American females were more compliant than their male counterparts. Based on self-ratings of compliance, African-American recipients were more compliant if they had vs. had not had dialysis experience prior to their transplant. These recipients also had higher self-ratings of compliance if their donors were cadaveric rather than living related.

Transplantation in children. A longitudinal assessment of mothers' stress, coping, and perceptions of family functioning.

This study examined the parenting stress, coping resources, and family functioning among 27 mothers of children undergoing bone marrow, liver, kidney, and heart transplantation. The mothers completed a comprehensive battery of psychological instruments at the pretransplant stage and at 1- and 6-month posttransplant stages. Increased parenting stress, financial strain, caregiver burden, and family stress were reported following transplantation and persisted for several months. The mothers reported using coping strategies characterized by attempts to maintain family integration and to understand the child's medical situation. Development and evaluation of intervention programs to enhance parents' ability to cope with stress and maintain family stability are warranted.

Perceptions of parenting stress and family relations by fathers of children evaluated for organ transplantation.

18 fathers of children evaluated for solid organ or bone marrow transplantation completed measures of parenting stress and family functioning. Comparisons with normative data indicated that these fathers reported less parenting stress, less family conflict, more concern about family finances, and more limitations in family activities. These data highlight the need for family-based assessments in pediatric transplantation.

Factors affecting cyclosporine-induced gingival overgrowth in pediatric renal transplant recipients.

The purpose of this research was to study the occurrence of gingival overgrowth (GO) in children after kidney transplantation and to investigate the relationship of GO to medical and dental parameters. Forty-nine kidney transplant patients taking the immunosuppressive drug cyclosporine A (CsA) were evaluated for plaque (PI), calculus (CI), gingival inflammation (GI), probing depth (PD), width of keratinized gingiva (GW), and gingival overgrowth (GO). Blood trough levels and oral dosages of CsA were obtained from medical charts on the day of examination. Most (77.5%) subjects exhibited GO, suggesting that GO is a frequent problem in children and adolescents ingesting CsA. GI, PD, and GW were found to be statistically significantly greater in subjects with GO than in those without GO. CsA dose/day was not significantly different between subjects with GO and those without GO. CsA dose/kg body weight and blood trough levels of CsA were significantly higher in subjects without GO, but the average length of time subjects without GO had been ingesting CsA was only 1.3 months, compared with an average 3.5 years for subjects with GO. The results indicate that in young subjects, duration of CsA ingestion may be the most critical factor related to eventual GO development.

Mothers of children evaluated for transplantation: stress, coping resources, and perceptions of family functioning.

The stress, coping resources, and family functioning of 36 mothers of children awaiting transplantation were evaluated. Using standardized assessment techniques, we found that, overall, 20% of mothers reported clinically elevated stress responses and that parenting stress was higher for mothers of children evaluated for solid organ transplantation (vs. bone marrow transplantation). Coping strategies characterized by maintenance of personal and family stability were strongly associated with lower levels of parenting stress. Findings also showed significant disruption in family planning and activities, as well as a strong association between lower socioeconomic status and higher parenting stress. There is a need for the longitudinal assessment of parental and family functioning throughout the transplantation process as well as for interventions designed to reduce parenting distress.

Family behavior, adaptation, and treatment adherence of pediatric nephrology patients.

In this exploratory study we investigated the relationships among family behavior variables (e.g., family expressiveness), adaptive functioning skills, maladaptive behavior, and adherence to treatment in pediatric renal failure patients. The study included 22 pediatric outpatients with renal failure who had not yet received dialysis or transplantation (RF) and their parents, and 12 pediatric outpatients with kidney transplants (TX) and their parents. For the RF patients, significant correlations were found between some of their adaptive functioning skills and measures of their medication adherence, diet adherence, and clinic appointment adherence; however, for the TX patients significant correlations were found only between some of their adaptive functioning skills and measures of their medication adherence. For the RF patients only, some measures of their family behavior were significantly correlated with measures of their medication adherence and diet adherence. Additionally, some measures of the RF patients' family behavior were significantly related to their communication skills, socialization skills, overall adaptive functioning skills, and maladaptive behavior. For the TX patients, only their socialization skill level was significantly correlated with one measure of their family behavior. It is concluded that facilitation of adaptive and physical functioning among renal pediatric patients likely requires multidimensional training and/or counselling interventions with the children and their families, and that some of the content and/or emphasis of this training likely needs to differ for RF patients versus TX patients.

Increased antibody responsiveness to blood transfusions in pediatric patients.

Heightened immune responsiveness has been proposed as one of the reasons underlying suboptimal renal transplant results in very young children or African American recipients. Because multiple factors influence graft outcome, it has been difficult to provide experimental evidence to confirm or refute this suggestion. In the present study we measured IgG antibodies with confirmed HLA specificity produced in response to blood transfusions. The patients evaluated were renal transplant candidates who had not had previous pregnancies or transplants. The overall incidence of HLA sensitization was 12%. Age was the most influential factor in sensitization: patients < 20 years old were 4-5 times as likely to produce anti-HLA antibodies than patients > 20 (P = 0.0018). Female patients were also high responders. However, this was explained by the higher proportion of children among nulliparous female patients rather than by differences in gender. In contrast, the antibody response of black and white recipients was similar. The antibody levels in most patients were low and decreased significantly with time. We conclude that the immunoregulatory influences in patients < 20 years old favor the production of anti-HLA antibodies in response to blood transfusions, a fact that may explain some clinical observations in pediatric transplant recipients.

Increased incidence of rejection in patients with delayed graft function.

Because of the difficulties in diagnosing rejection in patients with delayed graft function, such patients were routinely biopsied 7-10 days after kidney transplantation. We found histologic evidence of rejection in 48% of the cases during the lst month posttransplant, a proportion that was significantly higher than in patients with immediate graft function. Furthermore, the 2-year graft survival in patients with delayed graft function and rejection, but not in those without rejection, was significantly lower than in patients with immediate function. The results suggest that there is an association between delayed graft function and rejection and that rejection is the component responsible for the decreased graft survival previously reported for patients with delayed graft function.

Captopril renography and the hypertensive renal transplantation patient: a predictive test of therapeutic outcome.

PURPOSE: To detect predictive accuracy of captopril renography in transplant recipients with hypertension. MATERIALS AND METHODS: This prospective study was performed to evaluate findings on 18 renal scans acquired after administration of captopril (captopril renograms) in 14 transplantation patients with new-onset or poorly controlled hypertension. Captopril renography was not used to affect case management but to predict response to angioplasty. RESULTS: Arteriograms were abnormal in 12 of 18 studies. In the six cases in which angiograms were normal, captopril renograms also were normal. In the 12 cases in which angiograms were abnormal, captopril renograms were normal in five and abnormal in seven. In the five cases in which renograms were normal, hypertension did not improve, although angioplasty was technically successful. In the seven with abnormal renograms, four patients underwent angioplasty with excellent results. These patients had a significant (P < .05) decrease in diastolic blood pressure (-15 mm Hg) and in creatinine concentration (-0.4 mg/dL) compared with patients with normal renograms and abnormal angiograms. CONCLUSION: In this small population, captopril renography appeared to be predictive of physiologically meaningful renal artery stenosis.

Social support, family variables, and compliance in renal transplant children.

The relationship between family functioning, social support, and medication compliance in 32 renal transplant children and their parents was examined. Results indicated that children whose fathers gave more emotional support or were more informative were less compliant with azathioprine and cyclosporine (P < 0.05 for both). Children from families experiencing numerous stresses were also found to be less compliant with azathioprine (P < 0.05). Finally, compared with older children, younger children were found to be less compliant with cyclosporine (P < 0.005). Implications for predicting child adherence and for future research relating to compliance with multidrug regimens are discussed.

Technetium-99m sulfur colloid accumulation as a predictor of acute renal transplant rejection.

Renal transplantation is the preferred treatment for end-stage renal disease in children. Most transplant failures are due to allograft rejection. To date, only histopathological findings on renal biopsy can establish this diagnosis. Prior to the availability of cyclosporine, technetium-99m sulfur colloid nuclear scans (TSC) were used in a limited number of institutions to detect rejection episodes. The purpose of this study was to determine whether TSC could predict acute rejection in the cyclosporine era. A prospective study involving 41 pediatric renal transplant patients (M = 25, F = 16) was conducted from 6/1/89 to 10/31/91. Patients who received a TSC and biopsy (41 patients, 62 studies) within one week of clinical and laboratory evidence of acute rejection were included in the study. A qualitative method of determining sulfur colloid uptake was used by comparing allograft uptake with that of the fifth lumbar vertebrae (L5) marrow uptake: 3(+)--allograft with greater than L5 marrow uptake, 2(+)--same as, 1(+)--less than, and 0--no allograft uptake. Transplant accumulation of > or = 2+ was considered consistent with acute rejection (P < 0.001). Acute rejection was noted in 53 of 62 renal biopsies. Of those with biopsy-proved acute rejection, SC was positive (> or = 2+) in 46 of 53. SC of > or = 2+ has proved to be a good predictor of acute rejection. This technique has a sensitivity of 98%, specificity of 53%, positive predictive value of 87%, and negative predictive value of 89%.