Impact of psychosocial factors on medication level variability index and outcomes in pediatric liver transplant recipients.

BACKGROUND: Caregivers play an important role in maintaining a functioning graft after pediatric liver transplantation. Therefore, the psychosocial factors of both patients and caregivers can have a critical impact on transplant outcomes. Appropriate assessment and recognition of these factors pre-transplantation may allow transplant teams to better define the needs of pediatric organ recipients and develop specific countermeasures, which may then contribute toward improving transplant outcomes. METHODS: We studied 136 pediatric LT recipients followed at Texas Children's Hospital. Licensed social workers conducted comprehensive pre-transplant assessments on each patient, consisting of 22 psychosocial variables that were thought to impact adherence, which were reviewed during our study period. Non-adherence was determined using the MLVI for up to 4 years after transplantation. Biopsy-confirmed rejection episodes were assessed in the first 3 years after liver transplantation. RESULTS: Factors significantly associated with non-adherence (defined as MLVI >2) included parental age and parental education level at assessment, type of insurance, and household income. The number of ACR episodes trended higher in patients with non-adherence, and these patients had a higher number of moderate to severe rejection episodes but this trend was not statistically significant. CONCLUSIONS: Psychosocial characteristics such as parental age, education level, insurance, and household income may contribute significantly to suboptimal adherence to medications after transplantation. Identification of these psychosocial factors and early intervention is essential to the success and equitable care of our pediatric LT recipients.

Difficult Conversations.

With time running out, a nurse makes sure a family answers a crucial question.

Medication adherence in pediatric renal transplant patients: The role of family functioning and parent health locus of control.

Children and adolescents with renal disease experience daily social, emotional, and medical challenges. Renal transplantation can help to improve quality of life but requires a lifelong regimen of immunosuppressant medication to maintain health. Adherence to a daily complex regimen can be difficult, particularly for adolescents who are beginning to develop autonomy from caregivers and are faced with a unique set of socio-emotional challenges. This study examines two factors that have shown to influence adherence in other pediatric populations, namely family functioning and parent health locus of control, from mothers' perspectives, in predicting medication non-adherence for adolescents (ages 12-19 years) 1 year post-transplant. Non-adherence was defined as the percentage of missed doses and late doses of the weekly immunosuppressant doses prescribed. Regression results demonstrated that mothers' perceptions of poorer overall family functioning predicted missed medication doses (ΔR2  = 0.383, F(7, 21) = 2.570, P = 0.044) with significant contributions in the domains of problem-solving (ß = -0.795, t(21) = -2.927, P = 0.008) and affective involvement (ß = 0.872, t(21) = 3.370, P = 0.003). Moreover, mothers who perceived that their adolescent had control over his/her health also predicted more missed medication doses (ΔR2  = 0.133, F(1, 27) = 5.155, P = 0.031). Important implications for these findings include implementation of family-based interventions that promote developmentally appropriate skills for adolescents and cultivate emotional involvement within the family.

Pharmacist's Role in Improving Medication Adherence in Transplant Recipients With Comorbid Psychiatric Disorders.

Medication nonadherence rates are high in both the transplant and psychiatric populations. The consequence of medication nonadherence posttransplant is graft rejection and psychiatric decompensation, highlighting the importance of optimizing adherence to medication regimens. Pharmacists may work with transplant patients with psychiatric comorbidity to improve medication adherence through identifying patient-specific barriers and recommending an appropriate intervention. Multiple evidence-based practices for improving nonadherence have been detailed in the transplant and psychiatric population. Medication adherence aids, medication management, patient education, and motivational interviewing are all strategies that may be used to improve adherence. Selecting which interventions to make will be based on the reasons for a patient's nonadherence. Most patients benefit from medication management, patient education, and medication adherence aids. Selection of medication adherence aids may be based on patient demographics, technology literacy, and preference. Motivational interviewing may be considered in patients with intentional nonadherence relating to a lack of insight into their illness or the importance of taking medication. Pharmacists may promote adherence and potentially improve patient outcomes in transplant recipients with comorbid psychiatric disorders through assisting patients with designing a tailored medication adherence plan.

Patients prioritize waitlist over posttransplant outcomes when evaluating kidney transplant centers.

Factors that patients value when choosing a transplant center have not been well studied. In order to guide the improvement of patient-facing materials, we conducted an anonymous electronic survey of patients that assessed the relative importance of patient experience, practical considerations, transplant center reputation, center experience, and waitlist when selecting a transplant center. A total of 409 respondents completed the survey, of whom 68% were kidney transplant recipients and 32% had chronic kidney disease or were on dialysis. Participants had mean age 56 ± 12 years and were predominantly female (61%), white (79%), and had an associate's degree or higher (68%). Participants most often prioritized waitlist when evaluating transplant centers (transplanted 26%, chronic kidney disease 40%), and waitlist was almost twice as likely as outcomes to be ranked most important (30% vs 17%). Education level and transplant status were significantly associated with factors used for center prioritization. Waitlisted respondents most commonly (48%) relied on physicians for information when selecting a center, while a minority cited transplant-specific organizations. In order to improve shared decision-making, materials outlining center-specific waitlist features should be prioritized. Novel patient-oriented metrics for measuring transplant center quality that align with patient priorities must be explored.

Correlation Between the Transplant Evaluation Rating Scale (TERS) and Medical Outcomes in Living-Donor Kidney Transplant Recipients: A Retrospective Analysis.

BACKGROUND: Pretransplant psychosocial evaluation of living-donor kidney transplantation (LDKT) candidates identifies recipients with potentially inferior posttransplant outcomes. Rating instruments, based on semi-standardized interviews, help to improve and standardize psychosocial evaluation. The goal of this study was to retrospectively investigate the correlation between the Transplant Evaluation Rating Scale (TERS) and transplant outcome in LDKT recipients. METHODS: TERS scores were retrospectively generated by 2 raters based on comprehensive interviews of 146 LDKT recipients conducted by mental health professionals (interrater reliability, 0.8-0.9). All patients were eligible for transplantation according to pretransplant psychosocial evaluation. Patients were classified into 2 groups according to their TERS scores, in either two thirds excellent risk (TERS <29) and one third at least moderate risk (TERS ≥29) candidates. Analyzed medical parameters were change in estimated glomerular filtration rate and acute rejection (AR) episodes within the first year posttransplant. In addition, a subgroup of 65 patients was tested for de novo donor-specific HLA antibodies (DSA) posttransplant. RESULTS: There was no significant difference between the excellent (n = 97) and at least moderate (n = 49) risk candidates according to TERS in terms of organ function (estimated glomerular filtration rate decline >25%: 17 of 97 vs 11 of 49; P = .51) and episodes of AR (19 of 97 vs 15 of 49; P = .15). Patients developing de novo DSA (n = 18 [28%]) did not have higher pretransplant TERS scores (DSA positive, 11 of 42 vs 7 of 23; P = .78). CONCLUSIONS: Classifying LDKT recipients according to TERS score did not predict medical outcome at 1 year posttransplant or the occurrence of de novo DSA.

A Randomized Trial of a Multicomponent Intervention to Promote Medication Adherence: The Teen Adherence in Kidney Transplant Effectiveness of Intervention Trial (TAKE-IT).

BACKGROUND: Poor adherence to immunosuppressive medications is a major cause of premature graft loss among children and young adults. Multicomponent interventions have shown promise but have not been fully evaluated. STUDY DESIGN: Unblinded parallel-arm randomized trial to assess the efficacy of a clinic-based adherence-promoting intervention. SETTING & PARTICIPANTS: Prevalent kidney transplant recipients 11 to 24 years of age and 3 or more months posttransplantation at 8 kidney transplantation centers in Canada and the United States (February 2012 to May 2016) were included. INTERVENTION: Adherence was electronically monitored in all participants during a 3-month run-in, followed by a 12-month intervention. Participants assigned to the TAKE-IT intervention could choose to receive text message, e-mail, and/or visual cue dose reminders and met with a coach at 3-month intervals when adherence data from the prior 3 months were reviewed with the participant. "Action-Focused Problem Solving" was used to address adherence barriers selected as important by the participant. Participants assigned to the control group met with coaches at 3-month intervals but received no feedback about adherence data. OUTCOMES: The primary outcomes were electronically measured "taking" adherence (the proportion of prescribed doses of immunosuppressive medications taken) and "timing" adherence (the proportion of doses of immunosuppressive medications taken between 1 hour before and 2 hours after the prescribed time of administration) on each day of observation. Secondary outcomes included the standard deviation of tacrolimus trough concentrations, self-reported adherence, acute rejection, and graft failure. RESULTS: 81 patients were assigned to intervention (median age, 15.5 years; 57% male) and 88 to the control group (median age, 15.8 years; 61% male). Electronic adherence data were available for 64 intervention and 74 control participants. Participants in the intervention group had significantly greater odds of taking prescribed medications (OR, 1.66; 95% CI, 1.15-2.39) and taking medications at or near the prescribed time (OR, 1.74; 95% CI, 1.21-2.50) than controls. LIMITATIONS: Lack of electronic adherence data for some participants may have introduced bias. There was low statistical power for clinical outcomes. CONCLUSIONS: The multicomponent TAKE-IT intervention resulted in significantly better medication adherence than the control condition. Better medication adherence may result in improved graft outcomes, but this will need to be demonstrated in larger studies. TRIAL REGISTRATION: Registered at ClinicalTrials.gov with study number NCT01356277.

Pre-transplant history of mental health concerns, non-adherence, and post-transplant outcomes in kidney transplant recipients.

OBJECTIVE: The association between pre-transplant mental health concerns and non-adherence and post-transplant outcomes after kidney transplantation is not fully established. We examined the relationship between a pre-transplant history of mental health concerns and non-adherence and post-transplant outcomes among kidney transplant recipients. METHODS: In this retrospective single center cohort study of adult kidney transplant recipients (n=955) the associations between the history of mental health concerns or non-adherence and the time from kidney transplant to biopsy proven acute rejection; death-censored graft failure and total graft failure were examined using Cox proportional hazards models. RESULTS: Mean (SD) age was 51 (13) years, 61% were male and 27% had a history of diabetes. Twenty-two and 11% of patients had mental health concerns and non-adherence, respectively. Fifteen percent of the patients had acute rejection, 5.6% had death-censored graft failure and 13.0% had total graft failure. The history of mental health concerns was not associated with acute rejection, death-censored graft failure or total graft failure. Patients with versus without a history of non-adherence tended to have higher cumulative incidence of acute rejection (23.3% [95% CI: 16.1, 33.2] vs. 13.6% [95% CI: 11.4, 16.2]) and death-censored graft failure (15.0% [95% CI: 6.9, 30.8] vs. 6.4% [95% CI: 4.7, 8.7]) (log rank p=0.052 and p=0.086, respectively). These trends were not significant after multivariable adjustment. CONCLUSION: In summary, a history of pre-transplant mental health concerns or non-adherence is not associated with adverse outcomes in patients who completed transplant workup and received a kidney transplant.

The effect of clinical variables on distress and depressive symptoms among heart transplant recipients.

BACKGROUND: Heart transplantation (HTx) is the standard treatment for end-stage cardiomyopathy and coronary artery disease. Although major improvements have been made in the prevention and treatment of acute graft rejection, comorbidities still limit the long-term survival of heart transplant recipients. The risk of poor outcome, such us major health status aggravation and death, can stimulate the occurrence of depression and stress in this population. The aim of this study was to determine the impact of comorbidities on depressive symptoms and distress among heart transplant recipients. MATERIAL/METHODS: The sample included 131 HTx recipients from one site. Data were collected during a follow-up in-hospital appointment, using the questionnaires assessing depression (Beck Depression Inventory Short Form) and stress (Perceived Stress Scale-10). Statistical analyses included descriptive statistics, Pearson correlations, t-tests, and generalized linear models. RESULTS: Study patients were 75.6% (n = 97) male, 100% (n = 131) Caucasian, 74% (n = 89) married, with the mean age of 54 years at time of heart transplantation. Nearly half of the participants (40.5%) presented depression symptoms at the time of evaluation. Severe stress was observed in 30% of individuals. Depression symptoms and severe distress were more commonly observed in patients with many comorbidities, requiring multiple drug therapy, and high NYHA score. Moreover, in a multivariate logistic regression, depression and high distress level occurrence were predicted by the following independent factors: cardiac allograft vasculopathy, cancer, diabetes, higher NYHA score, and comorbidities. CONCLUSIONS: The prevalence of depression and severe distress is common among heart transplant recipients. Patients with many comorbidities are at higher risk of psychological indisposition.

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

OBJECTIVE: A psychosocial evaluation before liver transplant aims to identify risk factors for nonadherence 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 com-prehensive psychosocial variables and their ability to determine posttransplant outcomes.

Estratégias de coping nos doentes com falência do enxerto renal / Coping strategies in patients with renal graft failure

Os progressos científicos e o desenvolvimento das sociedades humanas têm contribuído para o aumento da esperança média de vida culminando numa maior incidência de doenças incapacitantes, crónicas e progressivas. A adaptação conseguida pelos indivíduos aos períodos de transição entre saúde/doença é um indicador positivo das intervenções dos enfermeiros. A doença renal crónica afeta cerca de 8% da população adulta na Europa. Segundo a SPN (2016), existem em Portugal, 19700 doentes em terapia de substituição renal. O transplante renal é reconhecido como o tratamento de 1ª linha, no entanto, a rejeição pode acontecer. Alguns estudos demonstram que a rejeição do enxerto é uma experiência stressante. O processo coping constitui a mobilização de um esforço, através do qual os indivíduos irão empreender esforços cognitivos e comportamentais para gerir esse foco de stress. O presente relatório reflete as competências do enfermeiro especialista na área médico-cirúrgica, vertente da nefrologia e descreve intervenções desenvolvidas na diálise peritoneal, consulta de esclarecimento e opções, centro de transplante renal, hemodiálise e internamento tendo como foco principal o coping dos indivíduos às exigências da doença renal crónica. O estudo de investigação descrito neste relatório procurou identificar quais as estratégias, estilos e recursos de coping utilizados por indivíduos com a falência do enxerto, há pelo menos um ano. A amostra estudada recorre maioritariamente a estratégias coping centradas na resolução de problemas. Apresenta um estilo coping do tipo autoconfiante e otimista recorrendo à família e agentes de saúde para um coping positivo, eficaz ou funcional. As limitações do estudo relacionam-se com a amostra, pequena e circunscrita a um único centro de transplantação, não serem exploradas as causas da rejeição/falência do enxerto e não permitir a comparação entre a fase imediata e mais tardia da perda do transplante. Os resultados sugerem que o reconhecimento das estratégias, estilos e recursos coping podem ajudar os enfermeiros a delinear planos terapêuticos mais eficazes e personalizados.

Scientific progress and the development of human societies have contributed to an increase in the average life expectancy, culminating in a higher incidence of disabling, chronic and progressive diseases. The adaptation achieved by individuals to the transition periods between health and disease is a positive indicator of nurses' interventions. Chronic kidney disease affects about 8% of the adult population in Europe. According to the SPN (2016), there are 1,700 patients in renal replacement therapy in Portugal. Renal transplantation is recognized as 1st line treatment, however, rejection may occur. Some studies have shown that graft rejection is a stressful experience. The coping process is the mobilization of an effort, through which individuals will engage in cognitive and behavioral efforts to manage stresses. This report reflects the competencies of the nurse specialist in the medicalsurgical area, which deals with nephrology and describes interventions developed in peritoneal dialysis, consultation of enlightenment and options, renal transplantation center, hemodialysis and hospitalization, with the focus on coping of individuals with the requirements of chronic kidney disease. The research study described in this report sought to identify which strategies, styles and coping resources used by individuals with graft failure have been for at least a year. The studied sample uses mainly coping strategies focused on problem solving. It presents a self-reliant and optimistic coping style appealing to family and healthcare agents for positive, effective, or functional coping. The limitations of the study relate to the small, circumscribed sample at a single transplantation center, the causes of graft rejection / failure and the comparison between the immediate and late phase of transplant loss are not explored. The results suggest that recognition of coping strategies, styles, and resources can help nurses devise more effective and customized therapeutic plans.

Adherence and the pediatric transplant patient.

Adherence is proving to be the Achilles heel of pediatric transplantation. Through a careful literature review on adherence in pediatric solid-organ transplantation from 2007 to 2017, this chapter reports on the incidence, measuring tools, and consequences of poor adherence. We detail adherence determinants and interventions proposed to foster it. While adherence is a major problem in the adolescent age, it clearly is not limited to this age group. Importantly, it is not one to start tackling at that time or when it becomes apparent. Rather, fostering adherence should be built throughout the continuum of the transplant journey, starting in the pretransplantation phase. Adherence is clearly a fluid state, necessitating frequent reassessments and enforcement. Adherence in addition shares similar determinants with quality of life. The severe consequences in the case of poor adherence mandate that the transplant community prioritize it as the next frontier in transplantation. Good adherence is what will pave the road to tolerance, cost-efficient transplantation, and optimized long-term outcomes.

Assessing barriers to adherence in routine clinical care for pediatric kidney transplant patients.

Patient-identified barriers to immunosuppressive medications are associated with poor adherence and negative clinical outcomes in transplant patients. Assessment of adherence barriers is not part of routine post-transplant care, and studies regarding implementing such a process in a reliable way are lacking. Using the Model for Improvement and PDSA cycles, we implemented a system to identify adherence barriers, including patient-centered design of a barriers assessment tool, identification of eligible patients, clear roles for clinic staff, and creating a culture of non-judgmental discussion around adherence. We performed time-series analysis of our process measure. Secondary analyses examined the endorsement and concordance of adherence barriers between patient-caregiver dyads. After three methods of testing, the most reliable delivery system was an EHR-integrated tablet that alerted staff of patient eligibility for assessment. Barriers were endorsed by 35% of caregivers (n=85) and 43% of patients (n=60). The most frequently patient-endorsed barriers were forgetting, poor taste, and side effects. Caregivers endorsed forgetting and side effects. Concordance between patient-caregiver dyads was fair (k=0.299). Standardized adherence barriers assessment is feasible in the clinical care of pediatric kidney transplant patients. Features necessary for success included automation, redundant systems with designated staff to identify and mitigate failures, aligned reporting structures, and reliable measurement approaches. Future studies will examine whether barriers predict clinical outcomes (eg, organ rejection, graft loss).

Maintaining the Gift of Life: Achieving Adherence in Adolescent Heart Transplant Recipients.

Since the beginning of United Network of Organ Sharing data collection in 1987, a total of 8,333 pediatric patients have received a heart transplant in the United States. Because these patients now have longer graft success with improved care and immunosuppression, many of them are entering adolescence and young adulthood. Primary care pediatric nurse practitioners need to be alert to the prevalence of noncompliance with treatment in heart transplant patients, which continues to be highest in adolescence. Low compliance in adolescence increases morbidity, contributes to decreasing quality of life, and is the leading reason for graft failure and mortality in this age group. This article will review common barriers to treatment adherence in the adolescent heart transplant patient, discuss the role of the primary care pediatric nurse practitioner in preventing noncompliance, and review strategies that the primary care pediatric nurse practitioner can implement to improve compliance in this patient population.

Women's Experiences With Flap Failure After Autologous Breast Reconstruction: A Qualitative Analysis.

Clinical experience suggests that flap failure after autologous breast reconstruction can be a devastating experience for women. Previous research has examined women's experiences with autologous breast reconstruction with and without complications, and patients' experiences with suboptimal outcomes from other medical procedures. The authors aimed to examine the psychosocial experience of flap failure from the patient's perspective. Seven women who had experienced unilateral flap failure after deep inferior epigastric perforator flap surgery in the past 12 years completed semistructured interviews about their breast cancer treatments, their experiences with flap failure, the impact of flap failure on their lives, and the coping strategies they used. Interpretive phenomenological analysis, a type of qualitative analysis that provides an in-depth account of participant's experiences and their meanings, was used to analyze the interview data. From these data, patient-derived recommendations were developed for surgeons caring for women who have experienced flap failure. Three main themes (6 subthemes) emerged: coming to terms with flap failure (coping with emotions, body dissatisfaction); making meaning of flap failure experience (questioning, relationship with surgeon); and care providers acknowledging the emotional experience of flap failure (experience of being treated "mechanically," suggestions for improvement). In conclusion, flap failure in breast reconstruction is an emotionally difficult experience for women. Although there are similarities to other populations of patients experiencing suboptimal outcomes from medical procedures, there are also unique aspects of the flap failure experience. A better understanding of women's experiences with flap failure will assist in providing more appropriate supports.

Medication understanding, non-adherence, and clinical outcomes among adult kidney transplant recipients.

We sought to evaluate the prevalence of medication understanding and non-adherence of entire drug regimens among kidney transplantation (KT) recipients and to examine associations of these exposures with clinical outcomes. Structured, in-person interviews were conducted with 99 adult KT recipients between 2011 and 2012 at two transplant centers in Chicago, IL; and Atlanta, GA. Nearly, one-quarter (24%) of participants had limited literacy as measured by the Rapid Estimate of Adult Literacy in Medicine test; patients took a mean of 10 (SD=4) medications and 32% had a medication change within the last month. On average, patients knew what 91% of their medications were for (self-report) and demonstrated proper dosing (via observed demonstration) for 83% of medications. Overall, 35% were non-adherent based on either self-report or tacrolimus level. In multivariable analyses, fewer months since transplant and limited literacy were associated with non-adherence (all P<.05). Patients with minority race, a higher number of medications, and mild cognitive impairment had significantly lower treatment knowledge scores. Non-white race and lower income were associated with higher rates of hospitalization within a year following the interview. The identification of factors that predispose KT recipients to medication misunderstanding, non-adherence, and hospitalization could help target appropriate self-care interventions.

Experiences of Korean adolescent renal transplant recipients.

PURPOSE: To understand the experiences of Korean adolescents who have undergone a renal transplant. DESIGN AND METHODS: Nine adolescents aged 12-18 who received a renal transplant participated in this qualitative descriptive study. Using content analysis, we analyzed in-depth interview data from individual adolescents. RESULTS: The main themes extracted were "being different from others," "not being invited as a decision maker," "becoming one of them," "still being different from others," "having mixed feeling toward mothers," and "coping with new circumstances." PRACTICE IMPLICATIONS: Interventions designed to improve adolescent renal transplant recipients' sense of autonomy and belongingness are needed.

Health Literacy Status Affects Outcomes for Patients Referred for Transplant.

BACKGROUND: It is hypothesized that limited health literacy affects outcomes for patients referred for transplant; however, research has not examined this for all types of end-stage organ disease. OBJECTIVE: The purpose of this study was to determine whether health literacy and cognitive impairment were related to listing for transplant and posttransplant outcomes. METHODS: Chart reviews were conducted on 398 patients who completed a required psychiatric evaluation before transplant listing. Information gathered from these evaluations included reading ability, math ability, and cognitive functioning. Variables before transplant and 6 months after transplantation were also collected. RESULTS: Patients with limited reading ability were less likely to be listed for transplant (p = .018) and were more likely to be removed from listing (p = .042), to miss appointments prelisting (p = .021), and to experience graft failure (p = .015). Patients with limited math ability were less likely to be listed (p = .010) and receive a transplant (p = 0.031), and more likely to be readmitted posttransplant (p = .029). Patients with cognitive impairment were less likely to be listed (p = .043) and to receive a transplant (p = .010). CONCLUSIONS: To achieve superior transplant access and outcomes, transplant providers should regularly screen patients for limited health literacy and cognitive impairment. Future studies should evaluate whether interventions result in better outcomes for these patients.