Kidney Week

Abstract: TH-PO1223

Medication Adherence Barriers and Tacrolimus Variability Predict Acute Rejection in Kidney Transplant Recipients

Session Information

• Pediatric Nephrology: CV Health, CKD, AKI, Dialysis, Transplantation, and Health Services Research
  October 22, 2026 | Location: Exhibit Hall A, Convention Center
  Abstract Time: 10:00 AM - 12:00 PM

Category: Pediatric Nephrology

• 1800 Pediatric Nephrology

Authors

• Hite, Corinne M., Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States

Corinne M. Hite, MD, MS

• Mara, Constance A., Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States

Constance A. Mara, PhD

• Belsha, Craig W., SSM Health Cardinal Glennon Children's Hospital, St. Louis, Missouri, United States

Craig W. Belsha, MD

• Chaudhuri, Abanti, Stanford University, Stanford, California, United States

Abanti Chaudhuri, MD

• Harshman, Lyndsay, The University of Iowa Stead Family Children's Hospital, Iowa City, Iowa, United States

Lyndsay Harshman, MD, MS

• Parsons, Jessica L.S., Primary Children's Hospital, Salt Lake City, Utah, United States

Jessica L.S. Parsons, MD, MS

• Modi, Avani, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States

Avani Modi, PhD

• Ranabothu, Saritha, Arkansas Children's Hospital, Little Rock, Arkansas, United States

Saritha Ranabothu, MD, MBBS

• Seifert, Michael E., Children's of Alabama, Birmingham, Alabama, United States

Michael E. Seifert, MD, MS

• Singer, Pamela, Cohen Children's Medical Center, New York, New York, United States

Pamela Singer, MD, MS

• VanSickle, Judith Sebestyen, Children's Mercy Kansas City, Kansas City, Missouri, United States

Judith Sebestyen VanSickle, MD, MEHP, FASN

• Yanik, Megan V., Levine Children's Hospital, Charlotte, North Carolina, United States

Megan V. Yanik, MD

• Varnell, Charles D., Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States

Charles D. Varnell, MD, MS

• Hooper, David K., Primary Children's Hospital, Salt Lake City, Utah, United States

David K. Hooper, MD, MS

Group or Team Name

• Improving Renal Outcome Collaborative

Background

Adolescent and young adult kidney transplant recipients have the highest risk of allograft loss with half related to poor medication adherence. Medication adherence barriers (MAB) and elevated tacrolimus variability may help identify patients at risk for rejection.

Methods

This retrospective study using the Improving Renal Outcomes Collaborative (IROC) registry identified kidney transplant recipients and/or caregivers who completed a medication adherence barriers assessment tool (BAT). Data from nine participating sites were analyzed to examine relationships between MAB, tacrolimus coefficient of variation (CV%) and T-cell mediated rejection (TCMR) Banff grade IA or higher in the 12 months after BAT. Patients were defined as having 0, 1 or ≥2 MAB. Nested multivariable logistic regression models examined rejection risk of MAB and CV% controlling for other risk factors.

Results

In 892 patients aged 1 to 23 years (median 13.6, IQR 8.3-17.2), 22.4% of BAT respondents reported 1 MAB and 18.7% reported ≥2 MAB. Patients were more likely than caregivers to report barriers (p<0.001). Among 794 patients with CV% data, 49.5% had a CV%≥30. There was no difference in mean CV% by MAB status (32.5, 34.1 & 33.9%, p=0.1). CV%≥30 was associated with higher MAB status only in patient respondents (p=0.03), not caregivers (p=0.7). TCMR ≥1A was seen in 9.5% of patients and occurred more frequently in those with ≥2 MAB (15.5 v 8.2 & 8.0%, p=0.01) and in those with CV%≥30 (12.2 v 6.9%, p=0.01) with the highest observed prevalence in those with both risk factors (21.5%, p<0.001). In the full model, the presence of ≥2 MAB (OR=2.28,95%CI=1.21-4.28), higher CV% (OR=1.12,95%CI=1.04-1.21), prior history of TCMR (OR=2.15,95%CI=1.39-3.31), deceased donor type (OR=0.5,95%CI=0.3-0.82) and shorter time since transplant (OR=0.9996,95%CI=0.9994-0.9999) were significantly associated with higher odds of TCMR. Model performance with immunologic and demographic risk factors was maximally improved when incorporating both MAB status and CV%, rather than either factor alone (p<0.001).

Conclusion

In pediatric kidney transplant recipients, the presence of 2 or more MAB and a higher CV% are independent and significant risk factors for acute TCMR in the following 12 months. The two risk markers are better used in conjunction than separately to identify patients who might benefit from intervention.