Journal de néphrologie et thérapeutique

Association entre l'adhésion au traitement évaluée par le questionnaire simplifié d'adhésion au traitement et les antécédents de rejet dans la transplantation rénale pédiatrique - Hernandez-Martinez Efren, Université nationale autonome

Abstract

Hernandez-Martinez Efren

Résumé : L'absence d'adhésion au traitement chez les patients atteints d'une insuffisance rénale est un facteur immédiat lié à la perte de fonction rénale et même au décès. Parmi les instruments permettant d'évaluer l'adhésion au traitement, on trouve le Questionnaire simplifié d'adhésion au traitement (SMAQ). Le SMAQ est un instrument bref et simple, basé sur des questions posées au patient sur sa propension à prendre des médicaments, approuvé pour quantifier l'adhésion chez les patients atteints d'une insuffisance rénale. De nombreuses études ont été menées pour évaluer l'adhésion au traitement et les répercussions sur l'abandon chez les patients présentant une mauvaise adhésion, mais jusqu'à présent, nous n'avons aucune étude de ce type au Mexique. Le Centre médical national de l'Ouest (CMNO) a le plus grand nombre de cas de transferts rénaux chez les patients pédiatriques au Mexique, par conséquent, nous avons pensé qu'il était approprié de réaliser cette étude dans le nombre d'habitants du CMNO. Le but de cette étude était de déterminer la relation de relation au traitement estimée par le SAMQ chez les patients pédiatriques ayant des antécédents marqués par un refus de transplantation rénale dans notre clinique. Français Nous avons effectué une enquête croisée chez des patients pédiatriques atteints d'une relocalisation rénale de l'hôpital pédiatrique du CMNO. Nous avons vérifié les dossiers cliniques des patients qui sont venus se rattraper en janvier 2017 et avons appliqué le SMAQ à ces patients. Un total de 89 enquêtes ont été appliquées au cours de la période. Le SMAQ a montré que les patients avec une jointure fonctionnelle étaient fidèles au traitement à 96,7 %, tandis que les patients avec une jointure inutile avaient une adhésion au traitement de moitié. Les patients sans adhésion au traitement ont un risque plus élevé de rupture de la relocalisation (p < 0,001). Lorsque l'adhésion au traitement est inférieure à 95 %, le risque de rupture de l'articulation est de 39 % (p = 0,006), par rapport aux personnes qui affichent une adhésion au traitement de 95 % ou plus. Selon le SMAQ, les patients qui ne sont pas fidèles au traitement et les personnes qui ont une adhésion au traitement immunosuppresseur inférieure à 95 %, ont un risque plus élevé de rupture de l'articulation.

Introduction : La non-observance du traitement chez les patients en réanimation est, en quelque sorte, une cause immédiate ou peut-être un facteur associé à la perte d'unités et au décès. La non-observance a également des répercussions sur la satisfaction personnelle des patients en réanimation, ainsi que sur les coûts de santé liés à la maladie sous-jacente, généralement en nécessitant un transfert ultérieur et une dialyse. Le taux évalué de patients en réanimation résistants aux schémas thérapeutiques varie entre 20 % et 54 %. Dans les réanimations rénales, le manque de cohérence est estimé à 20 % des rejets graves et à 16 % des pertes d'unités. Parmi les facteurs associés à une non-observance du traitement immunosuppresseur figurent l'âge, la tristesse, le stress, le nombre de doses quotidiennes, les effets secondaires du traitement immunosuppresseur, le manque de confiance dans la prescription approuvée, la faible indépendance du patient, le fait d'avoir reçu l'unité d'un donneur vivant et un manque de perception sociale des services à la personne. En raison de l'importance clinique de l'adhésion, elle doit être rigoureusement vérifiée dans les conventions cliniques de routine pour les bénéficiaires d'organes forts. Le degré d'adhésion est particulièrement important chez les bénéficiaires de transferts rénaux, car le taux de patients qui n'acceptent pas les conventions de traitement immunosuppresseur est plus élevé dans ce groupe chez ceux qui reçoivent différents types de transferts. L'adhésion peut être estimée à l'aide d'une estimation objective (perception directe des prescriptions utilisées) ou par des techniques indirectes, par exemple, l'estimation de la quantité de médicament dans les analyses de sang ou de sérum, les marqueurs naturels ou la vérification électronique. Il existe également des estimations émotionnelles, par exemple, l'émotion clinique ou la déclaration du patient. Il n'y a pas de consensus sur une méthode idéale pour estimer l'adhésion dans la pratique clinique. Cependant, il a été indiqué que l'utilisation combinée de techniques abstraites et aberrantes donne une mesure extrêmement sensible pour évaluer la cohérence. Le questionnaire simplifié d'adhésion aux médicaments est un instrument court et simple basé sur des questions posées directement au patient concernant ses habitudes de prise de médicaments, qui a été initialement approuvé pour l'estimation de l'adhésion chez les patients sous traitement antirétroviral. Dans le domaine de la néphrologie, cet appareil a été utilisé pour évaluer la conformité au traitement de restriction du phosphate chez les patients hémodialysés, bien qu'il n'ait pas été approuvé pour ce groupe de patients. Dans cette étude, nous présentons l'approbation d'un questionnaire SMAQ qui a été adapté pour être utilisé chez les patients transférés. Notre objectif était de fournir un appareil adapté à la pratique clinique de routine, à la fois seul et en combinaison avec des stratégies aberrantes, pour identifier les patients transférés qui risquent de devenir réfractaires au médicament immunosuppresseur approuvé, afin de renforcer le contrôle et de limiter les effets indésirables possibles.

Methods: Our own was an observational epidemiological examination assessing the psychometric properties of the Simplified Medication Adherence Questionnaire in renal transfer recipients.We intended to select a sum of 150 renal join beneficiaries that had experienced kidney relocate in any event one year before their consideration in the investigation. With the goal of expanding the homogeneity of the example and keeping away from the over the top fluctuation related with the immunosuppressive regimens typically utilized in strong organ relocate beneficiaries, we constrained our examination to patients getting tacrolimus, therefore diminishing the potential solutions to those including mixes of this medication with different immunosuppressants usually connected with it. The choice rules utilized were the accompanying: patients 18 years old or more seasoned, with a renal transfer of at any rate 11 months development, and on immunosuppressive treatment with tacrolimus. We additionally believed it to be an essential necessity for investment in the investigation and information assortment that the patient be educated regarding the objectives and strategies for the examination and willful sign the composed educated assent form.The fundamental socio-segment and clinical information were gathered from every patient by the pro specialist. Every patient finished the Morisky-Green scale 16 and the SMAQ, the last including two free meetings did around the same time, one by the master specialist and one by the nursing staff.The Morisky-Green scale is a straightforward scale including just 4 things that ask the patient how he/she agrees to the drug routine endorsed by the specialist. This scale permits us to group patients as agreeable or rebellious. It has been appropriately approved in Spain. The SMAQ survey was created as an alteration of the Morisky-Green poll to gauge adherence to antiretroviral treatment in patients with (AIDS). This survey comprises of six inquiries that assess various parts of patient consistence with treatment: neglect, normal, unfriendly impacts, and a measurement of exclusions. A patient is named rebellious on the off chance that he/she reacts to any of the inquiries with a non-adherence answer, and as far as measurement, if the patient has lost multiple portions during the most recent week or has not taken medicine during in excess of two complete days during the most recent three months. This poll was approved in an example of Spanish patients under treatment with unboosted nelfinavir somewhere in the range of 1998 and 1999. The SMAQ survey subject to approval was a Spanish rendition adjusted for use in relocate patients. The adjustment procedure occurred through master discussions, alongside a patient/master board.

Statistical analysis: The information were gone into a database made explicitly for this reason utilizing STATA factual programming, adaptation 10, which was submitted to ranges and inside intelligibility rules so as to control confusion and/or redresses in the assortment and classification of the information. The starter database included 146 cases got by the end date. Afterward, we performed quality control keeps an eye on the information, investigating and revising any fragmented or inaccurate information. Furthermore, we played out an examination of consistence with the incorporation measures "understanding with a kidney relocate of in any event a year post-relocate development," in light of the period of time between the transfer date and the principal visit for the investigation. This examination prompted the evacuation of two cases that had short of what one year with their transplants. With regard to the investigation, we utilized measurable noteworthiness esteem (α) of 0.05 in all exploratory and logical factual tests. We likewise depicted the example as far as the diverse socio-segment and clinical factors gathered during the investigation. In the examination of the psychometric properties of the SMAQ survey, we considered the between onlooker reproducibility utilizing Cohen's kappa coefficient as a proportion of unwavering quality. In the legitimacy examination, we dissected the relationship between the aftereffects of the survey and the diverse clinical factors identified with adherence. We additionally analyzed the affectability and particularity of the survey (when contrasted with the Morisky-Green scale) in recognizing resistant patients, utilizing the degree of tacrolimus in blood tests as our highest quality level, with sub-target focuses being those under 5ng/ml. At long last, the focalized legitimacy of the review was assessed utilizing an investigation of the relationship between poll scores and those from the Morisky-Green scale. We played out all measurable investigates utilizing STATA factual programming, rendition 10. The breaks down depended on the quantity of sections given for every particular thing, to such an extent that we never doled out qualities â??â??to things with lost qualities. The scores from the surveys, and accordingly the breaks down that included the administration of these scores, were determined uniquely for those patients that had reacted to the entirety of the things for the poll considered.

Result: As we referenced beforehand, the database that we investigated included 144 grown-up patients that had gotten a kidney relocate in any event one year before their incorporation in the examination, and who were experiencing immunosuppressive treatment with tacrolimus. The mean patient age in our example was 50.63 years, and the example was made essentially out of guys. The interim slipped by between the transfer and the primary visit for consideration in our examination was 5.30 years. The base time enrolled was 0.99 years, since one patient was viewed as legitimate as just a couple of days were required so as to follow the 1-year consideration rules. The patients experienced a second transfer in 12.5% â??â??of cases. Tacrolimus was endorsed as an underlying post-relocates immunosuppressive treatment in 84.72% of cases, and 99.31% got steroids. The mean every day portion of tacrolimus endorsed upon incorporation in the investigation was 3.95mg, and mean levels were 6.83ng/ml. In light of as far as possible incentive for tacrolimus of 5ng/ml, 20.14% of patients had sub-target levels. As per the going to doctors shows how patients were ordered by their reactions to the two surveys. As per the SMAQ poll, 39.01% of patients were named rebellious when the study was managed by the specialist, and 41.84% when controlled by the nursing staff. The Morisky-Green scale confirmed that 22.38% of patients were rebellious. For the examination of the psychometric properties of the SMAQ poll, we originally contemplated the degree of concordance between the SMAQ scores for the two unique meetings regulated. As appeared in, the degree of concordance between the outcomes from the meeting with the specialist and the meeting with the medical caretaker was very high, proposing a generally excellent between spectator reproducibility. We inspected the united legitimacy utilizing the relationship between the arrangement created by the SMAQ poll for the two meetings and the score from the Morisky-Green scale. As appeared in, a moderate degree of relationship exists between the two scales. With respect to models legitimacy, this equivalent table shows the negative relationship between adherence as estimated by the SMAQ poll and the ridiculous varieties in immunosuppressive medication levels. There was additionally a practically noteworthy connection between the characterization gave by the SMAQ survey and the going to doctor's impression of the correct consistence with respect to the patient with the immunosuppressive convention. We additionally analyzed the affectability and particularity of the survey in recognizing rebellious patients utilizing the best quality level of the tacrolimus fixation in blood tests. On the off chance that we contrast it with the Morisky-Green scale, the SMAQ survey gives a more prominent affectability and lower particularity, just as a higher level of effectively characterized patients.

Conclusions: In this examination, we endeavored to approve a form of the SMAQ poll so as to acquire a basic instrument for identifying transfer patients that are not consenting to immunosuppressive treatment in typical clinical practice.The survey has satisfactory qualities â??â??of legitimacy and between eyewitness reproducibility. Past investigations demonstrated that the mean resistance with immunosuppressive treatment is 28% in kidney relocate patients, as indicated by understanding declaration. As indicated by the outcomes from our investigation, the adjusted SMAQ has arranged a higher level of rebellious patients than the built up mean, while the Morisky-Green scale ordered a lower number as resistant. The level of resistant patients as per the SMAQ in this examination was likewise higher than the rate from the first approval concentrate for consistence with against retroviral treatment in patients with AIDS, despite the fact that our rate was like distributed qualities â??â??for adherence to phosphate - restricting drug in haemodialysis patients. Utilizing tacrolimus levels in blood tests as our best quality level, the SMAQ poll gives a higher affectability and lower explicitness than the Morisky-Green scale. A higher affectability is profitable in a device, for example, this, since it gives a more prominent intensity of identification of resistant subjects and consequently prompts better clinical development. As a constraint to the examination, we should call attention to that, in spite of the fact that we got a great inclination, the qualities â??â??obtained for affectability and explicitness when contrasted with the characterization utilizing objective/sub-target tacrolimus focuses is far underneath the ideal range for a device of this sort, and beneath the outcomes acquired in the first approval utilizing the outcomes from a prescription observing framework as a best quality level. This is most likely because of the idea of the highest quality level utilized in our examination, since the qualities â??â??obtained utilizing the Morisky-Green scale were likewise far beneath the normal range. We ought to likewise bring up that, in spite of the fact that the outcomes from the SMAQ survey were related with clinical assessment on tolerant adherence, the pace of rebellious patients as indicated by the clinical reports didn't reach 6%, though the rate dependent on the poll surpassed 39 % (22%, as per the Morisky-Green scale). Then again, over 20% of patients had sub-target tacrolimus values â??â??in blood tests. The contrasts between proficient discernment and the outcomes from the tests and dissects are as per the basic under-location paces of helpless adherence in this sort of patient, 18 which shows the requirement for a consistence estimation device that is material in day by day practice for a superior discovery and follow-up of resistant patients. As respects the investigation of the psychometric properties of the survey, the degree of between spectator concordances was higher than that gotten in the first approval of the poll. The survey likewise shows satisfactory joined and standards legitimacy, by being connected with the Morisky-Green scale and the clinical boundaries investigated, which drives us to presume that the adjusted SMAQ poll had sufficient psychometric properties – unwavering quality and legitimacy for recognizing transfer patients that are resistant with immunosuppressant drug in typical clinical practice.