Revista de nefrología y terapéutica

Asociación de la adherencia al tratamiento evaluado mediante el cuestionario simplificado de adherencia a la medicación con el antecedente de rechazo en el trasplante renal pediátrico- Hernández-Martínez Efrén, Universidad Nacional Autónoma

Abstract

Hernández-Martínez Efrén

Resumen: La falta de adherencia al tratamiento en pacientes con enfermedad renal crónica es un factor inmediato relacionado con la pérdida de adherencia e incluso la muerte. Entre los instrumentos para medir la adherencia al tratamiento se encuentra el Cuestionario Simplificado de Adherencia a la Medicación (SMAQ). El SMAQ es un instrumento breve y sencillo, basado en preguntas al paciente sobre su propensión a tomar la medicación, aprobado para cuantificar la adherencia en pacientes con enfermedad renal crónica. Numerosos estudios se han dirigido a medir la adherencia al tratamiento y su repercusión en el egreso en pacientes con mala adherencia, pero hasta el momento no contamos con ningún estudio de este tipo en México. El Centro Médico Nacional de Occidente (CMNO) es el que presenta el mayor número de casos de trasplantes renales en pacientes pediátricos en México, por lo que consideramos oportuno realizar este estudio en el número de habitantes del CMNO. El objetivo de esta investigación fue determinar la relación de adherencia al tratamiento estimada por el SAMQ en los pacientes pediátricos con antecedentes de egreso al trasplante renal en nuestra clínica. Se realizó una investigación cruzada en pacientes pediátricos con trasplante renal del Hospital Pediátrico del CMNO. Se revisaron las historias clínicas de los pacientes que acudieron a consulta en enero de 2017 y se aplicó el SMAQ a dichos pacientes. Se aplicó un total de 89 encuestas durante el período. El SMAQ demostró que los pacientes con unión útil se adhirieron al tratamiento en un 96,7%, mientras que los pacientes con unión inválida tuvieron una adherencia al tratamiento de la mitad. Los pacientes sin adherencia al tratamiento tienen un mayor riesgo de rotura de riñón (p<0,001). Cuando la adherencia al tratamiento es inferior al 95%, el riesgo de rotura de riñón es del 39% (p=0,006), en comparación con los individuos que muestran una adherencia al tratamiento del 95% o más. Según el SMAQ, los pacientes que no se adhieren al tratamiento y los individuos que tienen una adherencia al tratamiento inmunosupresor inferior al 95%, tienen un mayor riesgo de rotura de riñón.

Introducción: La falta de adherencia en pacientes con trasplante renal es, en cierta medida, una causa directa o posiblemente un factor relacionado con la pérdida de la unidad y la muerte. La falta de adherencia también repercute en la satisfacción personal de los pacientes con trasplante renal, así como en los costes sanitarios relacionados con la enfermedad de base, normalmente al requerir un traslado posterior y diálisis. El porcentaje evaluado de pacientes con trasplante renal resistentes a los regímenes de tratamiento oscila entre el 20% y el 54%. En los traslados renales, la falta de adherencia se estima que supone el 20% de las bajas graves y el 16% de las pérdidas de la unidad. Entre los factores relacionados con la falta de adherencia al tratamiento inmunosupresor se encuentran la edad, la depresión, el estrés, la cantidad de dosis diarias, los efectos secundarios del tratamiento inmunosupresor, la falta de confianza en la prescripción prescrita, la baja independencia del paciente, haber recibido el tratamiento de un participante vivo y la falta de percepción social de los servicios humanos. Debido a la importancia clínica de la adherencia, ésta debe ser cuidadosamente comprobada en las convenciones clínicas de rutina para los receptores de órganos fuertes. El grado de adherencia es particularmente significativo en los receptores de trasplante renal, ya que la tasa de pacientes que no aceptan las convenciones de tratamiento inmunosupresor es mayor en este grupo que en aquellos que reciben otros tipos de trasplantes. La adherencia se puede estimar utilizando una estimación objetivo (percepción directa de las prescripciones utilizadas) o mediante técnicas indirectas, por ejemplo, estimando la cantidad de medicamento en análisis de sangre o suero, marcadores biológicos o pruebas electrónicas. También existen estimaciones emocionales, por ejemplo, sentimiento clínico o declaración del paciente. No hay acuerdo sobre un método ideal para estimar la adherencia en la práctica clínica. No obstante, se indicó que el uso combinado de técnicas abstractas y aberrantes proporciona una medida extremadamente delicada para evaluar la consistencia. El Cuestionario Simplificado de Adherencia a la Medicación es un instrumento breve y sencillo basado en preguntas formuladas directamente al paciente sobre sus hábitos de toma de medicación, que fue aprobado inicialmente para la valoración de la adherencia en pacientes en tratamiento antirretroviral. En el campo de la nefrología, este instrumento se ha utilizado para evaluar la adherencia al tratamiento restrictivo de fosfato en pacientes en hemodiálisis, a pesar de que no ha sido aprobado para este grupo de pacientes. En este estudio, presentamos la aprobación de una encuesta SMAQ que ha sido adaptada para su uso en pacientes transferidos. Nuestro objetivo fue proporcionar un instrumento que sea adecuado en la práctica clínica habitual, tanto solo como en combinación con estrategias aberrantes, para identificar a los pacientes transferidos que están en riesgo de rebeldía con el fármaco inmunosupresor recetado, con el fin de aumentar el control y limitar los posibles efectos adversos.

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.