- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT03892317
Improving Adherence in Nonadherent Kidney Transplant Patients
A Pharmacist Led, Patient Tailored Intervention to Improve Immunosuppressant Medication Adherence in Nonadherent Kidney Transplant Patients
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
This study will be undertaken using a prospective, multidimensional design. 42 nonadherent kidney transplant patients will be included in the intervention group. The nonadherent patients will be identified through Imperial College Renal and Transplant Centre (ICRTC) Outpatient Clinic based at Hammersmith Hospital. Standard and transplant specific demographics will be collected for all patients. All kidney transplant patients have their tacrolimus levels measured at each clinic visit. The variability of these levels can be used as a marker of their adherence. Patients with a high intrapatient variability (IPV) of their levels are said to be nonadherent. The Chief Investigator or another member of the research team will approach individual patients directly in the transplant out-patient clinic where they are members of the multidisciplinary clinical care team. The Chief Investigator or another member of the research team may also telephone patients to invite them to clinic to discuss participation in the trial. The Chief Investigator or another member of the research team will describe the study to the patient, answer any questions they have and provide them with a participant information sheet (PIS). Patients will be given the opportunity to take the PIS away and think about whether they would like to participate. A follow up discussion either in clinic or on the phone will be arranged with the patient to answer any queries they have within two weeks of providing them with the PIS; during that discussion, the Chief Investigator or other member of the research team will arrange an appointment in the transplant clinic with the patient to sign the consent form if they do decide to participate. Patients recruited into the study will receive pharmacist led, patient tailored interventions to improve immunosuppressant medication adherence. Patients will be included in the study for one year from recruitment.
The pharmacist led, patient tailored intervention will involve regular, intensive, personalised support from a pharmacist to improve adherence to immunosuppressive medications. The pharmacist will meet with the patient on a regular basis in the transplant clinic to identify their perceptual and practical barriers to adherence and agree a support plan that is tailored to them.
Within the first two weeks of recruitment, the study pharmacist will meet with the patient in transplant clinic to:
- Undertake a full medication history
- Discuss self-reported medication nonadherence
- Undertake the BAASIS questionnaire
- Ask the patient to complete a Beliefs about Medicines Questionnaire (BMQ)
- Undertake a socioeconomic and educational assessment
- Undertake to gain collateral reporting of nonadherence by clinicians, relatives, friends or carers
- Perform a tacrolimus pill count
- Check in-house dispensing records of tacrolimus
- Identify barriers to adherence
- Tailor interventions and support to the needs of the patient
- Complete a motivational interview
- Agree to meet again during an outpatient clinic visit within an agreed time which is appropriate for the patient needs and within 3 months.
This first visit will provide a baseline assessment of the patient's medication adherence.
Tailored support may include:
- Setting alarms
- Medication diary card or calendar
- Medication compliance aid filled by the patient, family/carers or by a pharmacy professional
- Adherence app
- Reducing the complexity of the medication regime
- Positioning medication within their daily routine eg. by toothbrush
- Changing formulations
- Additional education regarding need for medication / timing of doses
- Referral to a social worker to assist with affordability of medicines
- Referral to a psychologist to explore deeper psychological issues regarding medicines taking
The structure of each follow up adherence review will be the same as the first formal adherence review with the exception that the BMQ will only be repeated at the end of the one year follow-up and the socioeconomic and educational assessment will only be undertaken at the first assessment review. Every patient will have a formal adherence assessment at recruitment and then at 3, 6, 9 and 12 months. At the end of one year of follow-up, the specific benefits perceived by the patient of intensive adherence support from a pharmacist will be determined through a questionnaire.
Baseline nonadherence will be measured at the first visit with the study pharmacist within two weeks of recruitment and then at 3, 6, 9 and 12 months. The IPV of their tacrolimus levels and their outpatient clinic nonattendance rate will be measured retrospectively in the 12 months prior to recruitment to the study and then prospectively at the end of the intervention year. The IPV is calculated from the tacrolimus levels measured for an individual patient using the coefficient of variance mathematical formula - Coefficient of variance (COV) defined as: SD x 100 / Mean. The outpatient clinic nonattendance for each participant will be taken from the hospital integrated computer system.
Study Type
Enrollment (Actual)
Phase
- Not Applicable
Contacts and Locations
Study Locations
-
-
-
London, United Kingdom, W12 0HS
- Imperial College Renal and Transplant Centre
-
-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- Adult kidney transplant patients (18 years of age and above)
- Kidney transplant patients with an IPV of tacrolimus levels of greater than 18.15% in the previous 12 months
Exclusion Criteria:
- Antibody incompatible transplants including patients with preformed HLA and blood group incompatible
- Previous rejection
- Donor specific antibody positive
- HIV positive patients
- Simultaneous pancreas and kidney patients
- Paediatric patients (less than 18 years of age)
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Prevention
- Allocation: N/A
- Interventional Model: Single Group Assignment
- Masking: None (Open Label)
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Other: Medication adherence interventions
Pharmacist led medication adherence interventions which will be tailored to individual patient need
|
Medication adherence interventions which will be tailored to individual patient need
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Change in immunosuppression medication adherence before and after the intervention
Time Frame: One year
|
Medication adherence will be assessed and compared using the BAASIS questionnaire at recruitment and at the end of the study.
The BAASIS questionnaire is validated for assessing immunosuppression nonadherence in transplant patients.
Any patient answering yes to any of the questions is assessed to be nonadherent
|
One year
|
Change in the median IPV before and after the intervention
Time Frame: One year
|
Intrapatient variability of tacrolimus levels will be measured and compared
|
One year
|
Change in outpatient clinic nonattendance rate before and after the intervention
Time Frame: One year
|
Outpatient clinic nonattendance rate will be assessed and compared during the 12 months prior to recruitment to the study and during the study
|
One year
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Biopsy proven ACR / AMR
Time Frame: One year
|
Number of patients who develop biopsy proven ACR/AMR
|
One year
|
The number of readmissions
Time Frame: One year
|
The number of readmissions and their reasons why during the study will be recorded
|
One year
|
Donor specific antibody (DSA) or transplant glomerulopathy
Time Frame: One year
|
Number of patients who develop a DSA or transplant glomerulopathy (CNI) toxicity or diabetic change on biopsy
|
One year
|
Fibrosis, hyalinosis, calcineurin inhibitor (CNI) toxicity or diabetic change on toxicity
Time Frame: One year
|
Number of patients who develop fibrosis, hyalinosis, calcineurin inhibitor
|
One year
|
Graft loss
Time Frame: One year
|
Number of patients who lose their graft
|
One year
|
Death
Time Frame: One year
|
Number of patients who die
|
One year
|
Serum creatinine
Time Frame: One year
|
Change in serum creatinine at the end of the study
|
One year
|
eGFR
Time Frame: One year
|
Change in eGFR at the end of the study
|
One year
|
Proteinuria
Time Frame: One year
|
Change in proteinuria at the end of the study
|
One year
|
Haematocrit
Time Frame: One year
|
Change in haematocrit at the end of the study
|
One year
|
Haemoglobin
Time Frame: One year
|
Change in haemoglobin at the end of the study
|
One year
|
Albumin
Time Frame: One year
|
Change in albumin at the end of the study
|
One year
|
Tacrolimus levels
Time Frame: One year
|
Change in tacrolimus levels at the end of the study
|
One year
|
Collaborators and Investigators
Sponsor
Investigators
- Principal Investigator: Dawn Goodall, Imperial College Healthcare NHS Trust
Publications and helpful links
General Publications
- Schafer-Keller P, Steiger J, Bock A, Denhaerynck K, De Geest S. Diagnostic accuracy of measurement methods to assess non-adherence to immunosuppressive drugs in kidney transplant recipients. Am J Transplant. 2008 Mar;8(3):616-26. doi: 10.1111/j.1600-6143.2007.02127.x.
- De Bleser L, Matteson M, Dobbels F, Russell C, De Geest S. Interventions to improve medication-adherence after transplantation: a systematic review. Transpl Int. 2009 Aug;22(8):780-97. doi: 10.1111/j.1432-2277.2009.00881.x. Epub 2009 Apr 6.
- Kidney Disease: Improving Global Outcomes (KDIGO) Transplant Work Group. KDIGO clinical practice guideline for the care of kidney transplant recipients. Am J Transplant. 2009 Nov;9 Suppl 3:S1-155. doi: 10.1111/j.1600-6143.2009.02834.x.
- Denhaerynck K, Steiger J, Bock A, Schafer-Keller P, Kofer S, Thannberger N, De Geest S. Prevalence and risk factors of non-adherence with immunosuppressive medication in kidney transplant patients. Am J Transplant. 2007 Jan;7(1):108-16. doi: 10.1111/j.1600-6143.2006.01611.x. Epub 2006 Nov 15.
- Fine RN, Becker Y, De Geest S, Eisen H, Ettenger R, Evans R, Rudow DL, McKay D, Neu A, Nevins T, Reyes J, Wray J, Dobbels F. Nonadherence consensus conference summary report. Am J Transplant. 2009 Jan;9(1):35-41. doi: 10.1111/j.1600-6143.2008.02495.x.
- Gaston RS, Hudson SL, Ward M, Jones P, Macon R. Late renal allograft loss: noncompliance masquerading as chronic rejection. Transplant Proc. 1999 Jun;31(4A):21S-23S. doi: 10.1016/s0041-1345(99)00118-9. No abstract available.
- Morrissey PE, Flynn ML, Lin S. Medication noncompliance and its implications in transplant recipients. Drugs. 2007;67(10):1463-81. doi: 10.2165/00003495-200767100-00007.
- Morrissey PE, Reinert S, Yango A, Gautam A, Monaco A, Gohh R. Factors contributing to acute rejection in renal transplantation: the role of noncompliance. Transplant Proc. 2005 Jun;37(5):2044-7. doi: 10.1016/j.transproceed.2005.03.017.
- Prendergast MB, Gaston RS. Optimizing medication adherence: an ongoing opportunity to improve outcomes after kidney transplantation. Clin J Am Soc Nephrol. 2010 Jul;5(7):1305-11. doi: 10.2215/CJN.07241009. Epub 2010 May 6.
- Wiebe C, Nevins TE, Robiner WN, Thomas W, Matas AJ, Nickerson PW. The Synergistic Effect of Class II HLA Epitope-Mismatch and Nonadherence on Acute Rejection and Graft Survival. Am J Transplant. 2015 Aug;15(8):2197-202. doi: 10.1111/ajt.13341. Epub 2015 Jun 11.
- Sellares J, de Freitas DG, Mengel M, Reeve J, Einecke G, Sis B, Hidalgo LG, Famulski K, Matas A, Halloran PF. Understanding the causes of kidney transplant failure: the dominant role of antibody-mediated rejection and nonadherence. Am J Transplant. 2012 Feb;12(2):388-99. doi: 10.1111/j.1600-6143.2011.03840.x. Epub 2011 Nov 14.
- Roberts DM, Jiang SH, Chadban SJ. The treatment of acute antibody-mediated rejection in kidney transplant recipients-a systematic review. Transplantation. 2012 Oct 27;94(8):775-83. doi: 10.1097/TP.0b013e31825d1587.
- Wiebe C, Gibson IW, Blydt-Hansen TD, Karpinski M, Ho J, Storsley LJ, Goldberg A, Birk PE, Rush DN, Nickerson PW. Evolution and clinical pathologic correlations of de novo donor-specific HLA antibody post kidney transplant. Am J Transplant. 2012 May;12(5):1157-67. doi: 10.1111/j.1600-6143.2012.04013.x. Epub 2012 Mar 19.
- Pinsky BW, Takemoto SK, Lentine KL, Burroughs TE, Schnitzler MA, Salvalaggio PR. Transplant outcomes and economic costs associated with patient noncompliance to immunosuppression. Am J Transplant. 2009 Nov;9(11):2597-606. doi: 10.1111/j.1600-6143.2009.02798.x.
- Butler JA, Roderick P, Mullee M, Mason JC, Peveler RC. Frequency and impact of nonadherence to immunosuppressants after renal transplantation: a systematic review. Transplantation. 2004 Mar 15;77(5):769-76. doi: 10.1097/01.tp.0000110408.83054.88.
- Massey EK, Tielen M, Laging M, Timman R, Beck DK, Khemai R, van Gelder T, Weimar W. Discrepancies between beliefs and behavior: a prospective study into immunosuppressive medication adherence after kidney transplantation. Transplantation. 2015 Feb;99(2):375-80. doi: 10.1097/TP.0000000000000608.
- Massey EK, Tielen M, Laging M, Beck DK, Khemai R, van Gelder T, Weimar W. The role of goal cognitions, illness perceptions and treatment beliefs in self-reported adherence after kidney transplantation: a cohort study. J Psychosom Res. 2013 Sep;75(3):229-34. doi: 10.1016/j.jpsychores.2013.07.006. Epub 2013 Aug 3.
- Dew MA, DiMartini AF, De Vito Dabbs A, Myaskovsky L, Steel J, Unruh M, Switzer GE, Zomak R, Kormos RL, Greenhouse JB. Rates and risk factors for nonadherence to the medical regimen after adult solid organ transplantation. Transplantation. 2007 Apr 15;83(7):858-73. doi: 10.1097/01.tp.0000258599.65257.a6.
Study record dates
Study Major Dates
Study Start (Actual)
Primary Completion (Actual)
Study Completion (Actual)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Actual)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Other Study ID Numbers
- 17HH4287
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
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