year posttransplant) occurred in 1.2% of the excellent compliers, 14.3% of the minor subclinical noncompliers, and 22.2% of the moderate subclinical noncompliers (p<0.01). In addition, the authors correlated electronic monitor results with appointment noncompliance and drug holidays.15 Appointment non-compliance was defined as missing a single clinic appointment in the previous year. A "drug holiday" was defined as not taking any cyclosporine over any 24-hour period in the previous three months. Of the 100 heart transplant recipients, 7% were appointment noncompliers; 43% took 1 drug holiday (vs. 5% of appointment compliers; p=0.01). In addition, 57% of appointment noncompliers experienced 1 late acute rejection (vs. 2% of appointment compliers; p=0.001).

At our institution, Nevins et al,4 used the same technology to prospectively track 180 kidney transplant recipients for up to 4 years. A medication monitor was used on the azathioprine bottle, and compliance was defined as a single daily bottle opening. Most recipients had better than 90% compliance (median =97.2%). However, during each of the first six months posttransplant, an average of 43% of patients missed at least one dose of azathioprine. When medication compliance was expressed as quartiles, the risks of acute rejection (p=0.006) and graft loss (p=0.002) were highly predicted by worsening compliance. For a select patient subgroup whose compliance declined successively over the first three months; even after adjusting for gender, diabetes, donor source and early rejection, we found a 13-fold increase in the risk of acute rejection (p=0.0011) and a 4.3 fold increase in the risk for graft loss (p=0.03).4 Conversely, patients in the best compliance quartile experienced no rejections or allograft losses over 3 years of followup!

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