Introduction: The Pediatric Transplant Rating Instrument (P-TRI; Fung & Shaw, 2008) is a 17-item scale developed to assess psychosocial risk factors for poor outcomes after solid organ transplantation. Research has identified limitations of the original instrument and proposed revisions to improve clinical utility (Fisher et al., 2011). The goals of this study were to revise the P-TRI and examine rates and patterns of risk in pediatric patients being evaluated for kidney transplant.
Methods: Members of a multidisciplinary team revised the P-TRI to address limitations identified in prior work. Subsequently, a social worker and a psychologist collaboratively completed the modified instrument after pre-transplant evaluations for 37 youth (Mage=11.51; 78% male; 48.6% White). Electronic medical records were reviewed for transplant status (e.g., transplanted, active on waitlist, inactive) at one-year post-evaluation. Exploratory cluster analyses, followed by chi-square tests, examined patterns of risk and correlates with cluster membership.
Results: The modified P-TRI (α=.74) included 10 items from the original 17 with each item representing one construct. Responses were recoded to reflect presence or absence of difficulties in each domain (Fisher et al., 2011). Three clusters were identified based on perceived risk. The High-Risk group (n=11;29.7%) was characterized by difficulties with medication and appointment adherence, strained relationships with the medical team, and the presence of parent psychiatric history. The Medium-Risk group (n=13;35.1%) was characterized by difficulties with parent knowledge, financial strain, and risk factors for medication adherence. The Low-Risk group (n=13;35.1%) was perceived to demonstrate no difficulties with medication and appointment adherence or financial strain. All groups displayed some deficits in social support. Groups differed by transplant status at one-year post-evaluation; 66% of patients who received a transplant fell in the Low-Risk group, whereas 75% of patients who were either still awaiting transplant or inactive fell in the High- or Medium-Risk groups. Cluster membership did not differ by age, race, or insurance (private/public).
Conclusions: Use of standardized instruments at pre-transplant evaluations can inform the use of targeted, multidisciplinary interventions based on identified risk. A revised P-TRI with a modified scoring paradigm may be useful in understanding psychosocial barriers to transplantation as findings suggest risk level appeared to be prospectively related to transplant status in our sample. Targeted interventions that address modifiable factors such as adherence and medical team relationships may improve access to more timely transplantation for this population. Future work should explore potential provider rating biases and include patient- and family-reported outcomes.