Is noncompliance among adolescent renal transplant recipients inevitable?

OBJECTIVE: To evaluate the prevalence of noncompliance and factors that influence poor adherence to immunosuppressive drug regimens among kidney transplant recipients. METHODS: We reviewed immunosuppressive drug compliance in 79 posttransplant patients. Patient self-report and low plasma calcineurin inhibitor levels served as indicators of noncompliance. RESULTS: The prevalence of noncompliance was found to be highest in adolescents who were responsible for their own medications and who underwent cadaveric kidney transplantation (CTx; 45.5%) and lower after living related transplantation (28.6%). There were no documented cases of noncompliance among any recipient of living unrelated (commercial) transplantation. Among 13 noncompliant patients, the first indication of "drug holiday" was low plasma calcineurin inhibitor levels in 11 children. Two additional children presented with acute rejection. In 7 patients, repeated episodes of "drug holidays" led to acute rejection later: 21.4 +/- 13.2 months after the first decrease in plasma calcineurin inhibitor level had been recorded. All 9 patients who experienced acute rejection subsequently developed chronic rejection. In 4 patients, noncompliance did not influence graft function. Psychosocial factors that were associated with noncompliance included insufficient family support, low self-awareness caused by poor cognitive abilities, and denial. CONCLUSIONS: The absence of cases of noncompliance in adolescents who underwent commercial living unrelated kidney transplantation suggests that although noncompliance is prevalent, it is not inevitable. Strategies to decrease noncompliance in young patients with chronic illnesses can be learned from the experience with transplant recipients. The general pediatrician has a central role in identifying and addressing the problem of noncompliance in adolescents with chronic disease.