10 practical tips for improving adherence to immunosuppressive meds after kidney transplantation

Nonadherence is a significant problem affecting up to 30% of patients following a kidney transplant. Not taking immunosuppressive medications as directed is strongly correlated with late acute rejection, allograft dysfunction and graft loss. Nonadherence after transplantation can be unintentional or intentional, but is usually amenable to intervention. A multidisciplinary approach is required for most patients, including education, counselling, simplification of dosing regimens and the use of technology.To address nonadherence after kidney transplantation, researchers have outlined 10 practical tips based on available data and their personal experiences in improving adherence in patients following kidney transplantation. 1. Consider the causes of and risk factors for nonadherence and identify factors that are amenable to intervention. The root causes of nonadherence include social and economic factors, the healthcare team or system, the characteristics of the disease, disease therapies and patient-related factors with psychological and behavioural elements. Psychological factors can include a lack of understanding of the medication, distress due to symptom burden and comorbid conditions, the presence of cognitive impairment and psychiatric disorders. The article includes a table summarizing the causes of and risk factors for nonadherence; this resource can be used to help identify patients at risk and pinpoint which factors are amenable to intervention.2. Document nonadherence, but avoid labelling patients as nonadherent. Labelling patients as nonadherent can be seen as projecting blame onto an individual without an understanding of the cause(s). It fails to capture the social and behavioural determinants of health, such as receiving insufficient medical information, an overwhelming number of medications, a lack of social support and financial constraints. It may also give the impression that the situation is permanent and that the patient is expected to remain nonadherent; this can lead to a vicious circle of stigma, nonengagement by patients and poor outcomes. Instead of using labels, healthcare teams should remain aware of patients with a history of nonadherence and signify the need for additional support and individualized help for these patients.3. Recognize the phases of medication adherence and identify opportunities for education and intervention. Medication adherence involves three key phases: initiation, implementation and long-term persistence. The initiation phase begins when treatment is first prescribed, often in-hospital during the perioperative phase. Patients are introduced to complex immunosuppressive regimens and must absorb a large volume of new information. Practical strategies might include structured medication education sessions before discharge, using visual aids, simplified medication schedules and involving family members or caregivers early in the process. Help patients establish medication-taking habits by linking medication-taking to daily activities, such as mealtimes or other regular habits. The implementation phase occurs when the patient returns home and is expected to follow the prescribed regimen independently. This phase is particularly vulnerable to errors due to polypharmacy and complex dosing schedules. Patients can be supported during this phase by conducting early and frequent follow-up visits (in-person or virtual), using tools like dosette boxes or digital tools, and simplify medication regimens where possible. Routine medication reviews can help identify early signs of nonadherence or regimen confusion. The persistence phase involves the patient’s long-term continuation of treatment, often for life. Over time, patients may experience “treatment fatigue,” lose motivation or face life events that disrupt routines. Care providers should maintain an open dialogue about the patient’s evolving challenges and offer support. Support groups, peer mentoring programs and periodic re-education sessions can help reinforce the importance of sustained adherence.4. Measure adherence to immunosuppressive medication and treat adherence as an additional vital sign in all clinical encounters. Several approaches can be taken to monitor adherence to immunosuppressive drugs:Self-reported medication prescription or refill dataTacrolimus levels and variabilityElectronic monitoringUsing a combination of these methods gives a more comprehensive view of adherence, allowing for timely interventions and personalized care adjustments.Treating adherence as an additional vital sign involves talking to transplant patients about adherence during all clinical encounters and asking them about any problems with taking or remembering their medications.5. Consider dose simplification and avoid unnecessary polypharmacy.Three different strategies can be used to reduce the complexity of medication regimens: fixed-dose combinations, once-daily dosing and a combined approach. Unfortunately, fixed-dose combinations are not currently available to transplant recipients. Switching to once-daily immunosuppressive regimens, where possible, significantly improves adherence, with no additional risks of efficacy failure or adverse outcomes.Review all medications at each encounter, particularly in the early months after transplantation. Consider reducing or stopping unnecessary medications, such as bicarbonate supplements, vitamin D analogues and others, where appropriate.6. Consider the use of technology and artificial intelligence (AI).Simple technologies such as dosettes can be used to prepare medications for a week ahead and placed according to daily habits (e.g., morning medicines next to the toothbrush or in a designated spot in the kitchen to be visible when preparing breakfast). More sophisticated digital containers feature reminders and dispense the dose at the required time; however, they can be complicated to use and may not be suitable for all patients. Community pharmacies can issue blister packs to patients, send electronic reminders when prescriptions are due for refill, and talk to patients to help assess adherence. Smartphones or watches can send reminders to help patients to remember their medicines. More advanced apps are also available, although few have been tested in trials. Most alert the patient when medicine doses are due, some allow friends or family to be notified if doses are missed and others link with care providers. AI will likely play a major role in this area, but it will be crucial that patients and healthcare professionals are involved in their development.7. Offer peer support.Peer support groups (in-person, via telephone, online) allow patients to learn from others who truly understand the journey, as they have navigated similar challenges firsthand.Encourage patients to engage with these support groups, as they provide a supportive community where individuals can share experiences, challenges and strategies related to managing complex medication regimens. Peer support can provide emotional reassurance and practical tips, enhance confidence, and boost motivation to manage medication regimens.8. Develop a portfolio of patient information.It is essential to provide educational materials tailored to kidney transplant patients, to break down complex information into easy-to-follow formats. These resources need to be accessible to all levels of literacy as well as available in multiple languages. They should also be provided in a variety of formats (videos, leaflets, websites, mobile apps) so patients can choose resources that suit them. Trusted websites from transplant organizations can give patients access to a wide range of resources in one place and often offer downloadable guides, educational videos and medication tracking tools. Materials should be reviewed periodically to ensure clarity and relevance.9. Consider your approach to patients who lost a previous transplant due to nonadherence.Some guidelines view nonadherence as a contraindication to future transplantation, but the authors suggest trying to identify causes of nonadherence and focus on those who are amenable to intervention. Set clear, transparent and achievable criteria before considering the relisting of a patient for transplant. All decisions for or against relisting should be made by a multiprofessional panel, documented in writing and shared with the patient.10. Promote a multidisciplinary approach to nonadherence and consider novel models of post-transplant care.A multiprofessional team, including transplant pharmacists, nurses, psychologists and social workers is required to tackle nonadherence. This is particularly important for adolescent transplant patients who are transitioning from pediatric to adult renal care.New technologies such as point-of care blood tests for use at home, methods to measure serum creatinine and tacrolimus levels in capillary blood samples obtained by the patient at home and urinalysis with a smartphone kit may also enhance adherence with treatment regimens.Summary These 10 tips emphasize the importance of identifying causes and risk factors for nonadherence and understanding its complexity. Even in a busy clinic, there is usually some opportunity for identifying patients at risk of nonadherence and factors that can be improved to manage the situation.ReferenceMahmood K, Allen J, Varley R, et al. 10 tips to improve adherence to immunosuppressive medication after kidney transplantation. Clin Kidney J 2025;18(6):sfaf164. https://pmc.ncbi.nlm.nih.gov/articles/PMC12164751/pdf/sfaf164.pdf (accessed June 19, 2025).

10 practical tips for improving adherence to immunosuppressive meds after kidney transplantation

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