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Medication Adherence and Immunologic Activity in Upper Extremity Transplantation
Vincent A. Chavanon, BA; Joseph E. Losee, MD; Daniel E. Foust, RN, BSN; Vijay S. Gorantla, MD, PhD; Alexander M. Spiess, MD; University of Pittsburgh
University of Pittsburgh, Pittsburgh, PA, USA

Background: Upper extremity transplantation (UET) is an emerging field with the potential to restore form and function to patients after significant injury or amputation. Medication adherence is vital for favorable immunologic and functional outcomes. We evaluated variability of tacrolimus trough levels, number of tacrolimus serum draws, and biopsy grades as surrogates in conjunction with the Morisky Medication Adherence Questionnaire (MMAQ 8) to infer medication adherence in our UET recipients.

Methods: Patients completed the MMAQ 8, a validated instrument to assess patient-reported medication adherence. Patient records were reviewed retrospectively to assess the variability of tacrolimus trough levels, number of serum levels obtained, and biopsy results. Tacrolimus troughs were analyzed in sequential 6-month blocks after transplantation to assess trough lability and number of draws over time, both as an indirect marker of medication adherence. Biopsy results were reported as Banff scores: 0-no rejection, 1-mild, 2-moderate, 3-severe.

Results: Between March 2009 and September 2010, 5 patients received 8 UETs with a mean follow-up of 2.3 years. Patients 2 and 3 reported high adherence, while patients 1, 4 and 5 were moderately adherent, by self-reported MMAQ8 standards. All patients experienced relatively wide variations in tacrolimus troughs during the first six months, but patients 2-5 achieved relative stability of levels. Patient 1 demonstrated tacrolimus level lability, and required more frequent monitoring (blood draws) during the last 18 months of follow-up, suggesting a trend towards non-adherence. All patients experienced acute rejection (AR) during the first three months after transplant. Patients 2, 3, 4 and 5 had additional episodes of biopsy proven AR beyond 3 months that resolved with topical and/or IV steroids. Patient 1 had multiple episodes of AR requiring IV steroids, thymoglobulin, and IVIG rescue therapy. He has since required the addition of mycophenolate mofetil and daily oral steroids to his regimen.

Conclusions: Medication adherence in transplant recipients is vital to preventing graft rejection. Surrogate trends of fluctuating tacrolimus troughs, more frequent monitoring, and repetitive AR mandating increased immunosuppression indicate non-adherence in Patient 1. He had a greater cumulative AR incidence and a trend toward higher Banff grades as compared to the other recipients. Patients 2, 3, 4 and 5 have demonstrated reasonable adherence to medication as evidenced by relatively stable tacrolimus troughs, less frequent monitoring, and a fewer number AR episodes. Tracking medication adherence after UET is an important aspect of post operative management.

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