Individual and environmental correlates and predictors of early adherence and outcomes after liver transplantation

Posttransplant adherence for liver recipients involves taking medications on a regular basis, keeping appointments, and making and sustaining recommended lifestyle changes related to smoking, drinking, drug use, and other high-risk behaviors. Much of the research to date has been focused primarily on 1 facet of adherence in a subgroup of liver transplant recipients, namely, return to drinking among recipients who received a transplant because of alcoholic liver disease. Little is known about the contribution of patient and environmental factors to adherence or health outcomes in the general population of liver transplant recipients. Yet nonadherence affects physical and mental health in other transplant recipients.1,2 Not taking medications, failure to keep appointments, and relapse to drug or alcohol use and/or smoking are directly related (among other transplant recipients) to the leading causes of late mortality (chronic rejection, de novo malignant neoplasms)3,4 among liver transplant recipients. Liver transplant patients vary widely in terms of psychiatric, behavioral, and medical history. Approximately half of the population receives a transplant because of hepatitis C and/or alcoholic cirrhosis, contracted through substance abuse and/or other risky activities; most other causes of end-stage liver disease are unrelated to behavior. The range of psychopathology and behavioral history unique to this population5,6 suggests that liver transplant recipients may differ from other transplant groups with respect to patterns of behavior that affect adherence and health outcomes. Rates and risk factors for nonadherence to the posttransplant medical regimen in the general population of liver transplant recipients were reported in a recent meta-analysis.7 However, empirical evidence about adherence to medication taking, appointment keeping, lifestyle changes, and clinical outcomes among liver transplant recipients is scarce, and the methods of collecting such evidence are generally limited. No published studies have involved comprehensive assessment of psychosocial and environmental factors in relation to the full range of adherence and health outcomes. Findings about the impact of specific behaviors (eg, medication adherence) on specific health outcomes in this population are mixed.8,9 Although relapse to drug and/or alcohol use does not appear to directly affect short-term outcome, rates are significant and little is known about the longer-term effects of recidivism to alcohol or other drugs of abuse on adherence to the rest of the treatment regimen or on health outcomes.10,11 Some research on patients with alcoholic liver disease suggests that nonadherence with other aspects of the treatment regimen, particularly relapse to smoking, is concomitant with relapse to drinking and affects morbidity and mortality.12,13 This study is the first to prospectively focus on adherence to the entire treatment regimen by the general population of liver transplant recipients with a comprehensive assessment approach. We know that nonadherence affects health outcomes in other transplant populations1,2 but, given the wide range of psychiatric disease (which underlies patterns of behavior), we hypothesized that behavior relevant to adherence would differ in liver transplant recipients. Specific aims of the study pertinent to this article are as follows: (1) To characterize adherence to medication taking, appointment keeping, and lifestyle changes during the first year after liver transplantation. (2) To determine the individual and environmental factors that underlie adherence and health outcomes during the first year after liver transplantation. We examined sociodemographic, clinical (factors related to medical history, psychiatric history, and transplant), individual, and environmental characteristics known to affect adherence and health outcomes in general medicine and other transplant populations14,15 shortly after transplantation. Multiple methods are being used to track aspects of posttransplant adherence (appointment keeping, medication taking, lifestyle changes) and health outcomes (physical and mental function) for the remainder of the study.