Predicting psychosocial risk in pediatric kidney transplantation: An exploratory cluster analysis of a revised Pediatric Transplant Rating Instrument

Abstract

Background:The Pediatric Transplant Rating Instrument (P-TRI) is a 17-item scale developed to assess psychosocial risk factors for poor outcomes after solid organ transplantation. Research has identified the limitations of the original instrument and proposed revisions to improve clinical utility. This project examined patterns of risk in children being evaluated for kidney transplant using a revised P-TRI.Methods: A multidisciplinary kidney transplant team revised the P-TRI. A social worker and a psychologist collaboratively completed the modified instrument for 37 children after the psychosocial pretransplant evaluation. Electronic medical records were reviewed for transplant status (transplanted, active waitlist, inactive) 1 year later. Exploratory cluster analyses and chi-square tests examined patterns of risk and correlates with cluster membership.Results: Three clusters were identified. The high-risk group (29.7%) had difficulties with medication and appointment adherence, strained relationships with the medical team, and the presence of parent psychiatric history. The medium-risk group (35.1%) had difficulties with parent knowledge, financial strain, and risk factors for medication nonadherence. The low-risk group (35.1%) demonstrated no difficulties with adherence or financial strain. Clusters were prospectively associated with transplant status, such that those in the high-risk group were less likely to be transplanted within 1 year post-evaluation. Conclusions:The revised P-TRI demonstrated good construct validity as risk level appeared to be associated with transplant listing status 1 year post-evaluation. These results suggest that standardized pretransplant psychosocial risk assessment tools may have value in optimizing transplant access if they can be paired with targeted, multidisciplinary interventions to address concerns early in the transplant process.

Medication adherence in pediatric kidney transplantation: How to build a bridge over troubled water

“…55,56 Recently, some papers were published on the value of pretransplant screening in pediatric kidney transplant populations too. 57,58 Indeed, a formal pretransplant psychosocial evaluation can help to identify the strengths and challenges of patients and their families, including potential risk factors for medication nonadherence.…”

“…Although findings are mixed, some papers on adult transplant populations show that pretransplant medication nonadherence is associated with a higher risk of posttransplant nonadherence and subsequent poor clinical outcomes 55,56 . Recently, some papers were published on the value of pretransplant screening in pediatric kidney transplant populations too 57,58 …”

“…Indeed, a formal pretransplant psychosocial evaluation can help to identify the strengths and challenges of patients and their families, including potential risk factors for medication nonadherence. The revised Pediatric Transplant Rating Instrument (P‐TRI), for instance, is a 10‐item instrument that can be used to assess (parent) transplant knowledge, patients' and parents' substance use and psychiatric history, social support, financial constraints, relationship with the team, appointment keeping, and medication adherence and its risk factors 58 . The P‐TRI only takes 10 min to complete based on joint discussions among the allied healthcare professional team members and might serve as a standardized psychosocial checklist bringing together all information obtained during their encounters with the patient and his/her parents/caregivers.…”

“…The revised Pediatric Transplant Rating Instrument (P-TRI), for instance, is a 10-item instrument that can be used to assess (parent) transplant knowledge, patients' and parents' substance use and psychiatric history, social support, financial constraints, relationship with the team, appointment keeping, and medication adherence and its risk factors. 58 The P-TRI only takes 10 min to complete based on joint discussions among the allied healthcare professional team members and might serve as a standardized psychosocial checklist bringing together all information obtained during their encounters with the patient and his/her parents/caregivers. Another screening tool, developed for adults, that has been used in pediatric kidney transplantation is the Pretransplant Assessment of Candidates for Transplantation (PACT).…”

The psychosocial organ transplant assessment: A call to action

“…The Organ Transplant and Procurement Center is similarly vague in its guidelines for pediatric, adolescent and young adult patients in its statement that “psychosocial assessments should identify patient and family strengths and risk factors that could affect post‐transplant outcomes with the goal of bolstering support for children (and their families) to be successful transplant recipients.” 2 As a result, transplant centers have widely divergent procedures and are susceptible to the risks of bias and subjectivity of the clinicians conducting these evaluations. This point has been emphasized in the publication by West and colleagues 3 from the Children's Hospital of Philadelphia on the topic of predicting psychosocial risk in pediatric kidney transplant recipients in this edition of Pediatric Transplantation . Given the remarkable lack of evidence to help guide pediatric transplant centers on the format of the psychosocial evaluation, it is incumbent upon mental health clinicians working in the field of transplant psychiatry to provide guidance and leadership on best practices and evidence‐based standards of care.…”