New Study Suggests Novel EHR-Based Marker Can Identify At-Risk Transplant Patients and Reduce Organ Rejection

HOUSTON (June 15, 2026) — A new multicenter study led by researchers at the Icahn School of Medicine at Mount Sinai and Texas Children’s suggests that a novel, electronic health record–based marker can help clinicians identify transplant patients at high-risk for organ rejection due to not taking their medications as prescribed —and intervene before the rejection happens.

The study, published in the American Journal of Transplantation, evaluated the use of the Medication Level Variability Index (MLVI), a new objective marker derived from routine lab values, to flag adolescents and young adults at elevated risk following liver transplantation.

Conducted across 13 pediatric transplant centers in the United States and Canada, the randomized controlled trial screened more than 3,000 health records of patients who had undergone liver transplantation. 148 participants who were identified as high-risk based on MLVI were assigned either to standard care or to a two-year remote behavioral intervention designed to support consistent medication use.

While the study did not reach statistical significance for its primary endpoint—a combined measure of rejection, re-transplantation, and consent withdrawal—this was because rejection rates were lower than expected in both groups. Even so, patients in the intervention group experienced about half as many rejection-related events and re-transplants as those receiving standard care. Importantly, the routine use of the risk marker (MLVI) across study sites appeared to substantially reduce overall rejection rates, bringing them down to levels typically seen in low-risk patients. 

“What this study shows is that we can identify patients who are not taking their medications as prescribed using data we already have in the electronic health record —and act before serious complications occur,” said Eyal Shemesh, MD, Chief, Division of Behavioral and Developmental Health, Mount Sinai Kravis Children's Hospital, and the principal investigator of this study.  “Even without a statistically significant primary outcome, the clinical implication is clear: we can now know who is at risk, and focus our efforts and resources there, leading to substantially improved outcomes.” Dr. Shemesh is also a Professor of Pediatrics and of Psychiatry at Icahn School of Medicine at Mount Sinai.

Medication nonadherence is a leading cause of organ rejection, particularly among adolescents and young adults, yet clinicians have long lacked reliable tools to detect it early. Unlike traditional approaches that rely on self-reporting or resource-intensive monitoring, MLVI uses variability in routine immunosuppressant blood levels to identify inconsistent medication-taking behavior.

The study also demonstrated that a remote, telehealth-based intervention—delivered through regular check-ins with trained specialists—can engage even high-risk patients over an extended period, and, importantly, throughout the COVID-19 pandemic.

“Adherence has always been one of the most challenging issues we face in transplant medicine, because staying on track with complex medical care can be overwhelming, especially for adolescents,” said Benjamin L. Shneider, MD, senior author of the study, Chief of Gastroenterology, Hepatology, & Nutrition at Texas Children’s, and George Peterkin endowed chair and professor of pediatrics at Baylor College of Medicine. “This work shows it is possible to recognize nonadherence early and address it before it leads to life-threatening consequences. By using tools like the MLVI, we can help more pediatric liver transplant patients stay healthy, prevent rejection, and spend less time in the hospital. Further, these findings may improve care not only for transplant patients, but for all patients and families managing chronic diseases.”

“The findings of this team are incredibly impactful: the lessons from this trial have many positive implications for the field’s next steps in optimizing our patients’ life-long health, by early identification and correction of behaviors that put our patients at risk.” Added George Mazariegos, MD, the Chief of Pediatric Transplantation at UPMC Children’s Hospital of Pittsburgh, author of the study, and the Chair of the Starzl Network for Excellence in Pediatric Transplantation – a learning network that includes North America’s leading pediatric transplant centers.

Researchers emphasize that while the intervention itself requires further study to determine the most efficient and cost-effective model, the findings strongly support incorporating MLVI into routine clinical practice.

“This approach allows clinicians to move from reacting to rejection to preventing it,” Dr. Shemesh added. “That shift has the potential to change transplant care.”

At Texas Children’s, this project was conducted within the Texas Children’s Research Institute (TCRI), a multidisciplinary biomedical research hub focusing on translating findings from laboratory research to clinical impact through disease prevention, diagnosis, and treatment. By collaborating across specialties, the TCRI aims to eliminate common silos and advance breakthrough discoveries at an unprecedented pace and scale.

The study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health.

Title: A remote intervention to improve medication nonadherence guided by a marker of risk derived from the electronic health records of adolescent transplant recipients.
Reference: AJT1253

About Texas Children’s 
Texas Children's, a nonprofit health care organization, is committed to creating a healthier future for children and women throughout the global community by leading in patient care, education and research. Consistently ranked as the best children's hospital in Texas and among the top in the nation, Texas Children's has garnered widespread recognition for its expertise and breakthroughs in pediatric and women's health. The system includes the Texas Children's Duncan NRI; the Feigin Tower for pediatric research; Texas Children's Pavilion for Women, a comprehensive obstetrics/gynecology facility focusing on high-risk births; Texas Children's Hospital West Campus, a community hospital in suburban West Houston; Texas Children's Hospital The Woodlands, the first hospital devoted to children's care for communities north of Houston and Texas Children's Hospital North Austin, the new state-of-the-art facility providing world-class pediatric and maternal care to Austin families. The organization also created Texas Children's Health Plan, the nation's first HMO focused on children; Texas Children's Pediatrics, the largest pediatric primary care network in the country; Texas Children's Urgent Care clinics that specialize in after-hours care tailored specifically for children; and a global health program that is channeling care to children and women all over the world. Texas Children's Hospital is affiliated with Baylor College of Medicine. For more information, visit www.texaschildrens.org. 

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Through the integration of its hospitals, labs, and schools, Mount Sinai offers comprehensive health care from conception through geriatrics, leveraging innovative approaches such as artificial intelligence and informatics while keeping patients’ medical and emotional needs at the center of all treatment. The Health System includes more than 9,000 primary and specialty care physicians and 10 free-standing joint-venture centers throughout the five boroughs of New York City, Westchester, Long Island, and Florida. Hospitals within the System are consistently ranked by Newsweek’s® “The World’s Best Smart Hospitals,” “Best in State Hospitals,” “World’s Best Hospitals,” and  “Best Specialty Hospitals” and by U.S. News & World Report's® “Best Hospitals” and “Best Children’s Hospitals.” The Mount Sinai Hospital is on the U.S. News & World Report® “Best Hospitals” Honor Roll for 2025-2026. 

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