Pretransplant Psychosocial Risk Factors May Not Predict Late Nonadherence and Graft Rejection in Adult Liver Transplant Recipients

Objectives: A psychosocial evaluation before liver transplant aims to identify risk factors for non-adherence and poor outcomes posttransplant. Despite broad support for such evaluations, evidence justifying its components is thus far limited. We investigated whether variables assessed during the psychosocial evaluation before liver transplant predict immunosuppressant nonadherence and graft rejection. Materials and Methods: Our study included 248 adult liver recipients at least 1 year after transplant with at least 3 measured tacrolimus levels. Predictor variables from the pretransplant evaluation were defined a priori and included sociodemographic factors (age, race, time since transplant), psychiatric history, substance abuse history, education level, and social support. Nonadherence was determined using the medication level variability index, which is an objective measure of adherence reflective of high medication level fluctuation from nonadherence. Outcomes (medication level variability index and biopsy-confirmed rejection) were obtained 1-year posttransplant to the present. Results: We found that 50% of patients were nonadherent to tacrolimus (medication level variability index > 2.5). The 41 patients with rejection (t = 2.71, P <.01) and black patients (F = 3.10, P =.02) had significantly higher index scores. Time since transplant was correlated with medical level variability index (r = 0.15, P =.02). However, in logistic regression, none of the predefined psychosocial variables predicted nonadherence (P =.40) or rejection (P =.19). Conclusions: Our results confirmed a significant association between medication level variability index and rejection, validating it as an objective measure of clinically significant nonadherence. In a large sample with high rates of nonadherence, none of the pretransplant psychosocial variables commonly used in standard liver transplant evaluations predicted nonadherence or rejection. These findings call into question current selection criteria. Future prospective studies are needed to investigate more comprehensive psychosocial variables and their ability to determine posttransplant outcomes.