Introduction: We carried out a survey of US transplant centers to evaluate practice patterns in the assessment of non-adherence before and after kidney transplantation.

Methods: An electronically administered, anonymous survey was sent to 181 United Network of Organ Sharing (UNOS) approved transplant centers in 2012. The survey was sent 3 times at 2 weeks intervals and only one response per center was taken into consideration.

Results: 42 centers completed the questionnaire. Sixty percent of those who responded did not have a protocol for evaluation of medication or dialysis adherence before listing patients for kidney transplant. Only 5% of responding centers used any questionnaire. Most centers used missed hemodialysis sessions (73.2%), interdialytic weight gain (56.1%) and biochemical markers [pre-hemodialysis potassium and phosphorus levels (46.3%)] as a surrogate marker for non-adherence with dialysis. Most common reasons listed by patients for non- adherence with medications were excessive number of medications (77.5%), concerned about side effects (75%) and cost of medication (70%). Most common reasons listed by patients for dialysis non-adherence were problems with transportation (74.4%) and verbalizing that missing few dialysis sessions would not adversely affect their health (56.4%). Only 2.6 % of responding centers used a formal questionnaire to evaluate adherence to medications after kidney transplant. Subjective self-reporting by patients was most commonly used for assessing adherence post-transplant (75.5%) followed by monitoring drug levels (64.9%), pill counts or prescription refill rates (37.8%) and electronic medication monitoring (24.3%). To assist patients with adherence, 80% centers used the services of a clinical pharmacist or nurse educator for patient education; half the centers used medication list with pictures or check boxes; 22% carried out pill counts and 7.5% used electronic monitoring devices.

Conclusions: There was a significant variability in the methods for screening for non-adherence while the patient was on dialysis, pre-transplant work up and post-transplant follow up period. We recommend that there should be a standardized technique to evaluate non-adherence. This will facilitate inter-center comparison and lead to focused clinical trials to improve adherence before and after kidney transplantation.

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