Silvia Lazzaro

Adherence in liver transplant recipients

Adherence to a medical regimen has been defined as the extent to which a patients behavior coincides with clinical prescriptions. In liver transplant patients, adherence to immunosuppressive therapy and to medical indications in general is crucial for short‐ and long‐term outcomes. Nonadherence to immunosuppression carries a risk of graft rejection and potential graft loss, whereas nonadherence to general medical indications (eg, avoiding alcohol intake and smoking after transplantation) may be associated with other complications such as de novo tumors and increasing health care costs. Among adult liver transplant patients, the rate of nonadherence to immunosuppressive drugs ranges from 15% to 40%, whereas the rate of nonadherence to clinical appointments ranges from 3% to 47%. The wide range of reported rates is due to different definitions of the term nonadherence and the variety of methods used to measure adherence in the medical literature. Nonadherence seems to be nearly 4 times higher in pediatric and adolescent patients versus adult transplant recipients. Several nonadherence risk factors, such as high medication costs, psychiatric disorders, the conviction that the medication is harmful, and side effects of immunosuppressive therapy, have been described among adult liver transplant patients. The risk factors for nonadherence in pediatric and adolescent liver transplant patients are psychological distress, the functional status of their families, and the impact of immunosuppressive side effects on their physical appearance. A single approach to promoting adherence to general medical prescriptions has been proved to be ineffectual, so a multidisciplinary strategy should be adopted to achieve significant improvements in this field. The aim of this review is to analyze the published literature on adherence in liver transplant patients with a particular focus on the reported prevalence and the identified risk factors. Patients have been split into 2 age groups (adults and children/adolescents) because the scale of the problem and the potential risk factors differ in the 2 groups. Liver Transpl 17:760‐770, 2011.

Nonadherent Behaviors After Solid Organ Transplantation

BACKGROUND AND AIM The effectiveness of any treatment depends not only on the choice of therapy, but also, to a large extent, on the patients active cooperation. Adherence to medical prescriptions and particularly to immunosuppressive therapy is crucial to prevent medical complications that negatively influence graft function and patient survival after organ transplantation. The aim of this study was to assess, among patients who underwent solid organ transplantation, nonadherent behaviors (NAB) to immunosuppressive therapy, to correct lifestyle, and to general medical prescriptions. MATERIALS AND METHODS We evaluated patients who underwent solid organ transplantation from March 2008 to June 2009. All participants completed an anonymous 15-item questionnaire to assess NAB. RESULTS We enrolled 218 organ transplant patients: 103 liver, 50 kidney, 52 heart, and 13 lung. There were 152 men and the overall age was 52.2 ± 0.8 years (mean ± standard deviation [SD]) time from transplantation, 83.6 ± 4.5 months (mean ± SD). Overall 37.9%, 38.8%, and 12.8% of patients reported nonadherence to immunosuppressive therapy, to correct lifestyle, and to general medical prescriptions, respectively. Considering nonadherence to immunosuppressive therapy and to general prescriptions, the percentage of kidney transplant patients who referred NAB was significantly lower compared with other organ transplant patients (P = .008 and P = .04, respectively). Nonadherent patients to immunosuppressive therapy and to general medical prescriptions displayed a longer interval from transplantation compared with adherent patients (P = .02 and P = .03, respectively). Among patients nonadherent to the correct lifestyle, the rates of men and of patients with disability pension were significantly higher compared to adherent patients (P = .001 and P = .002, respectively). CONCLUSIONS Poor adherence to medical prescriptions and to adequate lifestyle is common among organ transplant patients, especially those who have undergone liver transplantation. Psychoeducational interventions for transplanted patients and their families are needed to improve adherence.

Female gender in the setting of liver transplantation.

The evolution of liver diseases to end-stage liver disease or to acute hepatic failure, the evaluation process for liver transplantation, the organ allocation decision-making, as well as the post-transplant outcomes are different between female and male genders. Womens access to liver transplantation is hampered by the use of model for end-stage liver disease (MELD) score, in which creatinine values exert a systematic bias against women due to their lower values even in the presence of variable degrees of renal dysfunction. Furthermore, even when correcting MELD score for gender-appropriate creatinine determination, a quantifiable uneven access to transplant prevails, demonstrating that other factors are also involved. While some of the differences can be explained from the epidemiological point of view, hormonal status plays an important role. Moreover, the pre-menopausal and post-menopausal stages imply profound differences in a womans physiology, including not only the passage from the fertile age to the non-fertile stage, but also the loss of estrogens and their potentially protective role in delaying liver fibrosis progression, amongst others. With menopause, the tendency to gain weight may contribute to the development of or worsening of pre-existing metabolic syndrome. As an increasing number of patients are transplanted for non-alcoholic steatohepatitis, and as the average age at transplant increases, clinicians must be prepared for the management of this particular condition, especially in post-menopausal women, who are at particular risk of developing metabolic complications after menopause.

Essere genitori di un figlio diabetico: punti di incontro e differenze di genere nell’evoluzione della nuova figura paterna

Parents-child emotional attachment and a balanced educational style are associated with children’s well-being. Nevertheless, such dynamics can be modified by the presence, within a family system, of a chronic pathology afflicting one of the children. Type 1 diabetes is one of the most frequent pathology in pediatric patients. This paper presents and discusses the results of a qualitative study carried out with the involvement of a group of mothers and fathers of children and adolescents suffering with type 1 diabetes, cared for their follow-up by the Pediatric Clinic of Padua. Results stress that the new father partly is dimmed, and partly is deeply reinvented by new educational and therapeutic demands, coming from diabetes.

Educazione alla salute in giovani pazienti sottoposti a trapianto di fegato. Progetto pilota di strutturazione e implementazione di strumenti di dialogo educativo condotto presso l’Azienda Ospedaliera di Padova

Il presente progetto pilota e finalizzato alla creazione e attuazione di interventi di educazione alla salute (mediati dall’uso di strumenti dialogici originali) in un gruppo di 14 pazienti sottoposti a trapianto di fegato in eta infantile. I pazienti, in una fascia di eta compresa tra tarda adolescenza e giovane eta adulta, sono parimenti coinvolti in un processo di transizione dal servizio pediatrico al servizio per adulti. Ciascuna persona e stata coinvolta nello studio per 10 mesi; ogni paziente e stato allocato mediante randomizzazione nel gruppo sperimentale (partecipa agli incontri) o di controllo (non partecipa). Sono stati utilizzati metodi di ricerca misti: i) analisi statistica dell’efficacia degli interventi (somministrazione pre e post di una batteria di 5 questionari); ii) analisi qualitativa di interviste semi-strutturate (condotte con l’intero gruppo) e dei contenuti emersi nel corso degli incontri (con gruppo sperimentale). Lo studio, iniziato a luglio 2015, si e concluso a ottobre 2016.