10 tips to improve adherence to immunosuppressive medication after kidney transplantation.

Non-adherence is an issue in all chronic health conditions and the World Health Organization estimates that up to 50% of patients do not take all of their medications. The situation in kidney transplant patients is probably better, as these patients are preselected for good adherence and proactive behaviour. Nonetheless, non-adherence remains a common, significant and likely underdiagnosed problem in transplant nephrology. Not taking immunosuppressive medication as directed is strongly correlated with late acute rejection, which is often severe, leading to progressive loss of transplant function and poor outcomes overall. It is important to acknowledge that non-adherence is multifactorial and that interventions work best if clinicians understand risk factors and the causes of non-adherence in their patients. Reflex labelling of patients as non-adherent in documentation and clinic letters is unlikely to be helpful but good documentation is also important. It is also important to be aware of the phases of adherence and to have some knowledge of how to measure non-adherence. Dose simplification may help in some patients and technology can be employed to improve adherence, particularly in younger and information technology-literate patients. Peer support and patient information are also important. Individual assessment is important in patients who have lost a previous transplant due to non-adherence. We also emphasize the importance of a multidisciplinary approach and the relative paucity of robust data in this area. Based on the limited evidence and our individual and departmental experience, our 10 tips aim to provide clinicians with a toolbox of evidence-based interventions to address this important issue in daily clinical practice. We also provide a list of suggestions for institutions to address this important issue at departmental and institutional levels and suggest future research.