- Optionally fill in the patient demographics (name, age, sex, date) in the fields at the top — these are used only if you print the report and are never transmitted or stored.
- BAASIS (Adherence): Ask the patient to think about the past 4 weeks. For each question, select the frequency of non-adherent behavior. Even one "Once" or higher response identifies medication risk. Share the result with the transplant coordinator immediately when significant non-adherence is detected.
- KTQ (Quality of Life): Ask the patient to rate each item on a 1–7 scale for the past 2 weeks (1 = worst / always, 7 = best / never). Domain scores are expressed 0–100 (higher = better). Domain scores below 50 flag areas needing clinical attention.
- PHQ-9 (Depression): Patient rates each of the 9 depressive symptom items for the past 2 weeks (0–3). Item 9 (suicidal ideation) triggers a crisis hotline alert automatically if answered above zero — address this before proceeding. PHQ-9 ≥ 10 warrants clinical evaluation for major depressive disorder.
- GAD-7 (Anxiety): Patient rates each of the 7 anxiety symptom items for the past 2 weeks (0–3). GAD-7 ≥ 10 warrants clinical evaluation for generalized anxiety disorder.
- Print the report using the "Print / Save as PDF" button to generate a structured printout for the medical record or to send to the transplant coordinator.
- Schedule follow-up based on results: immediate review for BAASIS non-adherence or PHQ-9 item 9 positive; 2–4 week follow-up for PHQ-9 ≥ 10 or GAD-7 ≥ 10; routine monitoring otherwise.
When to Use
Use these tools at every post-transplant clinic visit — ideally at 1, 3, 6, and 12 months, then annually — and at any visit where adherence, quality of life, or mental health are clinical concerns. Patient-reported outcome measures (PROMs) detect problems that clinicians miss in standard history-taking: immunosuppressant non-adherence is estimated at 20–36% of kidney transplant recipients globally, yet it remains undetected in the majority of cases without structured assessment. Depression affects 20–25% of transplant recipients; anxiety is even more prevalent.
Appropriate population
Kidney transplant recipients at any time post-transplantation — from the first outpatient visit to long-term follow-up. The BAASIS and KTQ are specific to transplant recipients. PHQ-9 and GAD-7 are validated broadly across medical populations and have been specifically studied in transplant recipients. All four can be self-administered on a tablet or with clinician guidance. Minimum reading level: approximately Grade 6 English. For patients with limited English literacy, administer in the preferred language with interpreter assistance.
When NOT to rely solely on these scores
These are screening and monitoring tools, not diagnostic instruments. A high BAASIS non-adherence score does not establish the reason for non-adherence (cost, side effects, cognitive impairment, health beliefs) — the clinical interview does. PHQ-9 and GAD-7 scores require clinical follow-up for diagnostic confirmation. Never withhold organ function workup, medication adjustment, or referral based solely on a score; always integrate with clinical assessment, medication logs, and drug-level monitoring.
Pearls & Pitfalls
Non-adherence is treatable when detected
The majority of non-adherence in transplant patients is unintentional — forgetting (most common), timing errors, and cost-related omission. Once identified with BAASIS, targeted interventions work: pill organizers reduce forgetting-related non-adherence by 30–40%; pharmacy co-payment assistance programs dramatically reduce cost-driven omission; and motivational interviewing reduces volitional non-adherence. Detecting the problem with BAASIS is the prerequisite for fixing it.
Integrate PROMs with drug-level monitoring
BAASIS detects self-reported non-adherence; tacrolimus intra-patient variability (IPV) — the standard deviation or coefficient of variation in serial trough levels — detects objective non-adherence that patients may not disclose. Both measures are complementary. A patient who reports perfect adherence on BAASIS but has high tacrolimus IPV warrants gentle, non-accusatory exploration of barriers. High IPV is independently associated with late rejection and reduced allograft survival.
Depression and corticosteroids — a diagnostic challenge
Corticosteroids can cause PHQ-9 item overlap: insomnia, fatigue, appetite changes, and concentration difficulties may be steroid side effects rather than depression. When PHQ-9 scores are elevated, assess whether symptoms appeared with steroid initiation or dose changes. The PHQ-9 "cognitive" items (worthlessness/guilt, concentration on item 7, suicidality on item 9) are less likely to be steroid-driven and are more diagnostically specific for true depressive disorder. Do not attribute all PHQ-9 elevation to steroids without careful assessment.
PHQ-9 item 9 — never ignore it
A score of 1 or higher on PHQ-9 item 9 ("Thoughts that you would be better off dead, or of hurting yourself") must always be addressed before proceeding. The calculator displays the NCMH Crisis Hotline (1553) automatically. Document the response, perform a brief safety assessment, and contact the patient's psychiatry or mental health contact if one exists. Do not defer this to the next scheduled visit. Transplant patients have elevated suicide risk compared to the general population, particularly in the first year post-transplant and during rejection episodes.
Why Use It
Non-adherence to immunosuppressive therapy is the leading modifiable cause of late allograft failure. Every missed dose raises the risk of donor-specific antibody development, subclinical rejection, and ultimately graft loss. Yet patients consistently underreport non-adherence in unstructured clinical interviews — structured instruments such as the BAASIS elicit 3–4 times more disclosures than open questions alone.
Quality-of-life assessment with the KTQ identifies domains where patients are suffering but have not volunteered concerns: fatigue (the most common post-transplant symptom, affecting up to 60% at 1 year), anxiety about rejection (which drives both over-adherence behaviors and rejection of follow-up), and appearance changes from corticosteroids and calcineurin inhibitors that significantly impair social functioning and self-esteem.
Mental health outcomes after transplant directly predict adherence, quality of life, and survival. Depression and anxiety are more prevalent in transplant recipients than in the general population and in pre-dialysis CKD patients, yet are diagnosed in fewer than half of affected patients without routine screening. Untreated depression is independently associated with reduced adherence and allograft loss.
Transplant PROM Suite — BAASIS · KTQ · PHQ-9 · GAD-7
Complete one or all four instruments. Use the tabs to switch between tools. Patient demographic fields are optional and only used if you print the report. All scoring runs locally in your browser — nothing is saved or transmitted.
For each question, select how often the situation occurred over the past 4 weeks regarding your immunosuppressive medication.
⚕ BAASIS: De Geest et al. (1994), validated for transplant recipients. KTQ: Laupacis et al. (1993), kidney transplant quality of life. PHQ-9: Kroenke et al. (2001). GAD-7: Spitzer et al. (2006). Educational tools only — results do not replace clinical evaluation. Share with your transplant team.
Next Steps
Use the result to support — not replace — clinical judgment.
- Interpret the value against the targets shown in the calculator and the Evidence section below, in the context of the full clinical picture.
- Trend serial measurements rather than acting on a single result; confirm abnormal or unexpected values before changing management.
- Apply the relevant KDIGO / specialty-guideline threshold and document the indication.
- Escalate or refer to nephrology when results are out of range, rapidly changing, or discordant with the clinical picture — and discuss the implications with the patient.
Evidence & References
Formula & Equations
BAASIS — Basel Assessment of Adherence with Immunosuppressive Medication Scale
Five items covering forgetting, timing errors, drug holidays, dose reduction, and illness-related omission. Each item is rated on a 4-point frequency scale. Adherent = all five items answered "Never." Any non-"Never" response identifies non-adherence on that dimension.
| Non-adherent items (any "Once" or higher) | Classification | Action |
|---|---|---|
| 0 | Fully adherent | Reinforce; continue current routine; discuss side effects proactively |
| 1 | Minor non-adherence | Counseling; review medication schedule; consider reminder tools (pill organizer, phone alarms) |
| 2 | Moderate non-adherence | Urgent transplant coordinator discussion; barrier identification (cost, side effects, cognitive); plan modification |
| 3–5 | Significant non-adherence | Prompt transplant team contact; social work/pharmacy referral; consider drug-level audit; increased monitoring frequency |
KTQ — Kidney Transplant Questionnaire
25 items across 5 domains rated on a 7-point Likert scale (1 = worst/always, 7 = best/never). Domain score = mean item score, linearly transformed to 0–100: [(mean – 1) / 6] × 100. Two items in the Emotional domain are reverse-scored. Higher score = better quality of life. No total score; interpret by domain.
| Domain score (0–100) | Interpretation |
|---|---|
| ≥ 75 | Good quality of life in this domain — monitor routinely |
| 50–74 | Moderate — discuss at visit; targeted education and support |
| < 50 | Poor — clinical concern; discuss barriers, offer specialist referral or symptom management |
PHQ-9 — Patient Health Questionnaire
Nine items each scored 0–3. Total score 0–27. Item 9 (suicidal ideation): any score ≥ 1 requires immediate safety assessment — the calculator displays the crisis hotline alert automatically.
| Score | Severity | Suggested action |
|---|---|---|
| 0–4 | Minimal | No intervention; monitor at routine follow-up |
| 5–9 | Mild | Watchful waiting; behavioral strategies; re-assess in 2–4 weeks |
| 10–14 | Moderate | Clinical evaluation; consider referral to psychology or psychiatry |
| 15–19 | Moderately severe | Active treatment recommended (psychotherapy and/or pharmacotherapy); prompt mental health referral |
| 20–27 | Severe | Urgent psychiatric evaluation; coordinate with transplant team |
GAD-7 — Generalized Anxiety Disorder Scale
Seven items each scored 0–3. Total score 0–21.
| Score | Severity | Suggested action |
|---|---|---|
| 0–4 | Minimal | No intervention; monitor at routine follow-up |
| 5–9 | Mild | Relaxation strategies; peer support; re-assess in 2–4 weeks |
| 10–14 | Moderate | Clinical evaluation; consider referral; discuss corticosteroid dose effects on mood |
| 15–21 | Severe | Urgent mental health referral; coordinate with transplant team |
Evidence & References
All four instruments have published validation data in general medical and transplant-specific populations. Below are the primary sources.
- De Geest S, Borgermans L, Gemoets H, et al. Incidence, determinants, and consequences of subclinical noncompliance with immunosuppressive therapy in renal transplant recipients. Transplantation. 1995;59(3):340–347. [BAASIS development]
- Schafer-Keller P, Steiger J, Bock A, Denhaerynck K, De Geest S. Diagnostic accuracy of measurement methods to assess non-adherence to immunosuppressive drugs in kidney transplant recipients. Am J Transplant. 2008;8(3):616–626. [BAASIS validation]
- Laupacis A, Pus N, Muirhead N, et al. Disease-specific questionnaire for patients with a renal transplant. Nephron. 1993;64(2):226–231. [KTQ development and validation]
- Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–613.
- Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092–1097.
- Dew MA, DiMatteo MR. Depression, anxiety, and non-adherence in organ transplant recipients. Curr Opin Organ Transplant. 2020;25(2):175–183. [Mental health and adherence link in transplant]
- Drent G, Moons P, De Geest S, et al. Immunosuppressive medication non-adherence in adult liver transplant recipients: a systematic review of prevalence and risk factors. Transpl Int. 2016;29(11):1175–1191.
- Kidney Disease: Improving Global Outcomes (KDIGO) Transplant Work Group. KDIGO clinical practice guideline for the care of kidney transplant recipients. Am J Transplant. 2009;9(Suppl 3):S1–S155.
