Predicting acute rejection in children, adolescents, and young adults with a kidney transplant by assessing barriers to taking medication



Nonadherence to immunosuppression is common among pediatric, adolescent, and young adult kidney transplant recipients and a leading cause of graft loss. Assessing barriers to medication adherence in clinical practice may identify patients at risk for rejection and provide therapeutic targets.


Kidney transplant patients and/or their caregivers were assessed for 14 barriers to medication adherence using the barriers assessment tool. We compared rejection rates between patients with at least one reported adherence barrier to those without reported adherence barriers using a Kaplan-Meier estimator and Cox proportional hazard models to adjust for other mediators of acute rejection at 2 years following barriers assessment.


Ninety-eight patients were assessed for barriers to adherence. Over the 2-year observation period, 22 patients developed biopsy-proven acute rejection (BPAR). Kaplan-Meier estimates show that patients with an identified barrier to adherence were more likely to have BPAR (p = 0.02) than patients without an identified barrier in the 24 months following barriers assessment. The median time to rejection for patients who experienced acute rejection was 175.5 days (IQR 63–276 days) from the time of barriers assessment. An identified barrier to adherence remained the only statistically significant predictor of BPAR with Cox modeling (HR 2.6, p = 0.04), after accounting for age, sex, and race.


Pediatric and adolescent kidney transplant recipients with identified adherence barriers are at increased risk for acute rejection. Barriers to adherence provide a potentially modifiable therapeutic target that can be assessed in clinic to guide targeted interventions.

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Fig. 1



Antibody-mediated rejection


Barriers assessment tool


Biopsy-proven acute rejection


Congenital anomaly of the kidney and urinary tract


Donor-specific antibody

CKD 5:

Stage 5 chronic kidney disease


T cell–mediated rejection


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CDV received funding from the National Center for Advancing Translational Sciences of the National Institutes of Health, under Award Number 2KL2TR001426-05A1.

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Participated in research design: CDV, KLR, ALHP, ACM, DKH

Participated in writing of the paper: CDV, KLR, ACM, DKH

Participated in performance of the research: CDV, KLR, ALHP, ACM, DKH

Participated in data analysis: CDV, BZ, ACC, ACM, DKH

Corresponding author

Correspondence to Charles D. Varnell Jr.

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Varnell, C.D., Rich, K.L., Zhang, B. et al. Predicting acute rejection in children, adolescents, and young adults with a kidney transplant by assessing barriers to taking medication. Pediatr Nephrol (2021).

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  • Medication adherence
  • Immunosuppression adherence
  • Pediatric transplantation
  • Acute rejection
  • Pediatric nephrology