The Impact of a Clinical Pharmacist on Immunosuppressive Medication Adherence in Kidney Transplant Patients

The average kidney transplant patient has a very complex medication regimen, both pre- and post-transplant, averaging between 5 and 15 medications that must be taken daily.¹ This assortment of acute and maintenance medications includes immunosuppressants, antimicrobials, and other medications to mitigate post-transplant complications, such as hypertension or diabetes.

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Due to this complex medication regimen, medication adherence can be challenging in this patient population, with a reported 20% to 60% of transplant patients reporting nonadherence; however, the consequences of nonadherence can be detrimental to the transplanted kidney.² Pharmacists can play a significant role in managing kidney transplant patients’ maintenance medications by educating patients about their specific immunosuppressive therapy, potential adverse effects (AEs), possible consequences resulting from nonadherence, and proper monitoring of medication administration and dosing parameters.

We will discuss multiple studies that have compared the outcomes of kidney transplant patients who did and did not have a pharmacist involved in their before and after transplant care. The results of our meta-analysis showed that patients who had pharmacists as part of their transplant-related care had a significant improvement in clinical outcomes.

In addition to the inherent risks associated with a major surgery, there are also risks associated with receiving a kidney transplant, including infection, thrombosis, acute rejection, diabetes, hypertension, cancer, and multiple drug-related AEs and toxicities. This is especially important to consider because the patient will be on immunosuppressants for life.³

These factors demonstrate the need for skilled medical professionals who specialize in transplant medicine. A pharmacist who participates on a transplant team acts as the lead pharmacology expert who is responsible for identifying and/or reducing the risk of medication-related complications and interactions in the transplant process.

Immunosuppressive medications are associated with a wide range of AEs and toxicities. Additionally, there are expected systemic effects, post-kidney transplant, that are directly related to each medication’s mechanism of action.⁴

Pharmacists can be considered the ideal health care professionals for managing the important pharmacological effects of immunosuppressants, such as administration, dosing, and monitoring parameters. Without careful monitoring and management of these immunosuppressive therapies, patients are susceptible to opportunistic infections, graft rejection, and multiple medication-related toxicities.⁴

Pre- and post-transplant pharmacists’ responsibilities include recognizing drug-drug and drug-disease interactions, recommending appropriate dosing and monitoring parameters for multiple immunosuppressants, and providing in-depth, thorough patient counseling that is appropriate for each patient’s health literacy level.⁵ Pharmacists who participate in a transplant team can promote an environment that enhances medication adherence and decreases the risk of complications, including graft rejection.

The medication therapy management (MTM) services offered by a transplant pharmacist are typically designed to help patients understand their disease state, as well as the new limitations that a kidney transplant can impose upon a recipient. MTM services can help to identify adverse drug events and AEs of the immunosuppressants, as well as the therapeutic efficacy of the regimen. Nonadherence can also be a major contributor to graft failure.

We conducted a meta-analysis to compare 5 studies currently published, which show the impact of pharmacist-led interventions and support groups, medication management services involving pharmacists, and pharmacist-led educational sessions for kidney transplant patients.

The goal of many of these studies was to show whether pharmacist-led intervention groups or MTM programs would improve the patients’ medication adherence, the knowledge of their disease state and medications, and the observed clinical outcomes in the study population. Each study demonstrates a unique way in which a pharmacist’s involvement in MTM has provided beneficial outcomes to kidney transplant patients.

Upon completing the meta-analysis, our results demonstrated a consistent trend that a clinical pharmacist's services have a positive impact on kidney transplant recipients' medication adherence. The results indicated that when a clinical pharmacist is part of the health care team for a transplant recipient, the patient has significantly higher quality knowledge regarding medications, better overall health and economic outcomes, and overall quality of life.

There was a consistent trend in the literature, demonstrating that the use of clinical pharmacy services is a viable and effective option for improving the post-transplant care of kidney transplant recipients. The first study compared the percent of doses taken, doses taken correctly, and adherence rates when a clinical pharmacist is involved.

The results were statistically significant across the board compared to health care teams that did not have a clinical pharmacist participating in the management of transplant patients’ treatment. There was a statistically significant difference in correct dose days (p= 0.015), percent of doses taken (p= 0.015), and adherence rates (p= 0.001) in the group, including clinical pharmacist support.⁶

The second study describes the pharmacist’s expertise and role in kidney transplantation, including outcomes such as improved medication adherence and patients’ understanding of their condition and medications.⁷ The third study compared patients’ knowledge and medication adherence before and after a pharmacist-led behavioral intervention in those who benefited from a pharmacist-led intervention and those who did not.

At the conclusion of the study, patients demonstrated a statistically significant improvement in their treatment knowledge after experiencing the pharmacist-led behavioral intervention (p= 0.001); however, there was no significant difference in medication adherence between the 2 groups.⁸ The last 2 studies in the meta-analysis focused on the importance of providing MTM services to kidney transplant patients. Both studies revealed a statistically significant improvement in medication adherence in transplant recipients who received MTM services from clinical pharmacists compared to those who did not (p= 0.02 and p< 0.001, respectively).^9,10

Including clinical pharmacists in the care of kidney transplant patients has significantly improved medication adherence. Adding pharmacist-led interventions and MTM programs positively impacted these patients’ outcomes the most significantly.

Clinical pharmacists’ pre- and post-operative care in kidney transplant patients ensures they know why, how, and when to take their newly prescribed medications. Because clinical pharmacists have the time and resources needed to care for this patient population adequately, the patients significantly benefit from the services rendered.

References

1. Anderson-Haag T. Transplant Medications: Forget me not! National Kidney Foundation. https://www.kidney.org/transplantation/transaction/TC/summer09/TCsm09_ForgetMeNot#:~:text=Most%20transplant%20patients%20a. Published August 12, 2014. Accessed February 28, 2023.
2. Kidney Disease Statistics for the United States - NIDDK. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/health-statistics/kidney-disease#:~:text=Nearly%20786%2C000%20people%20in%20the%20United%20States%20are. Published September 2021. Accessed February 28, 2023.
3. Risks: Kidney Transplant. NHS Choices. https://www.nhs.uk/conditions/kidney-transplant/risks/. Published August 19, 2022. Accessed February 28, 2023.
4. Wojciechowski D, Wiseman A. Long-Term Immunosuppression Management: Opportunities and Uncertainties. Clin J Am Soc Nephrol. 2021;16(8):1264-1271. doi:10.2215/CJN.15040920
5. Wiegel JJ, Olyaei AJ. The role of the pharmacist in the management of kidney transplant recipients. Indian J Urol. 2016;32(3):192-198. doi:10.4103/0970-1591.185108
6. Joost R, Dörje F, Schwitulla J, Eckardt KU, Hugo C. Intensified pharmaceutical care is improving immunosuppressive medication adherence in kidney transplant recipients during the first post-transplant year: a quasi-experimental study. Nephrol Dial Transplant. 2014;29(8):1597-1607. doi:10.1093/ndt/gfu207
7. Wiegel JJ, Olyaei AJ. The role of the pharmacist in the management of kidney transplant recipients. Indian J Urol. 2016;32(3):192-198. doi:10.4103/0970-1591.185108
8. Chambord J, Couzi L, Merville P, Moreau K, Xuereb F, Djabarouti S. Benefit of a pharmacist-led intervention for medication management of renal transplant patients: a controlled before-and-after study. Ther Adv Chronic Dis. 2021;12:20406223211005275. Published 2021 Apr 5. doi:10.1177/20406223211005275
9. Chisholm-Burns MA, Spivey CA, Tolley EA, Kaplan EK. Medication therapy management and adherence among US renal transplant recipients. Patient Prefer Adherence. 2016;10:703-709. Published 2016 Apr 28. doi:10.2147/PPA.S104646
10. Chisholm-Burns MA, Spivey CA, Garrett C, McGinty H, Mulloy LL. Impact of clinical pharmacy services on renal transplant recipients' adherence and outcomes. Patient Prefer Adherence. 2008;2:287-292. Published 2008 Feb 2. doi:10.2147/ppa.s4174