Transplant Psychiatry

Annotated Abstracts of Journal Articles
2014, 3rd Quarter

Transplant Psychiatry

Annotations by Paula Zimbrean, MD, FAPM
September 2014

  1. The effect of bright light therapy on sleep and circadian rhythms in renal transplant recipients: a pilot randomized, multicentre wait-list controlled trial
  2. Long-Term Quality of Life after Liver Donation in the Adult to Adult Living Donor Liver Transplantation Cohort Study (A2ALL)
  3. Cross-sectional psychosocial evaluation of heart transplantation candidates

PUBLICATION #1 — Transplant Psychiatry
The effect of bright light therapy on sleep and circadian rhythms in renal transplant recipients: a pilot randomized, multicentre wait-list controlled trial

Burkhalter H, Wirz-Justice A, Denhaerynck K, et al
Transpl Int 2014 Sep 2 [Epub ahead of print]

ANNOTATION (Paula Zimbrean)

The Finding: This is a feasibility study, randomized control trial looking at the effects of bright light therapy (BLT) on sleep in kidney transplant recipients with sleep-wake disturbances. BLT was an acceptable intervention; 61% of patients agreed to participate, 85% of those enrolled completed the study, and adherence with BLT was reported at 100%. No adverse events were recorded. BLT showed some efficacy in increasing the sleep time, decreasing latency of sleep, and improving depressive symptoms, but effects were not statistically significant.

Strength and Weaknesses: This is the first study to assess the feasibility and impact of BLT in this category of patients. This was a randomized controlled study. It took into consideration melatonin serum levels and medications which could impact the melatonin levels. Limitations include the small number of subjects (which leads to limited information about efficacy) and the length of the treatment (the authors suggest that 5 weeks of BLT rather than 3 weeks should be used in the future to assess the impact of BLT).

Relevance: BLT is a promising intervention for mood and sleep with no significant side effects. Considering the high prevalence of depression and sleep disturbance in organ recipients, and their multiple medical comorbidities, it is important that non-pharmacologic interventions for these conditions are explored.


This study assessed the effect and feasibility of morning bright light therapy (BLT) on sleep, circadian rhythms, subjective feelings, depressive symptomatology and cognition in renal transplant recipients (RTx) diagnosed with sleep-wake disturbances (SWD).

This pilot randomized multicentre wait-list controlled trial included 30 home-dwelling RTx randomly assigned 1:1 to either 3 weeks of BLT or a wait-list control group. Morning BLT (10 000 lux) was individually scheduled for 30 min daily for 3 weeks. Wrist actimetry (measuring sleep and circadian rhythms), validated instruments (subjective feelings and cognition) and melatonin assay (circadian timing) were used. Data were analysed via a random-intercept regression model.

Of 30 RTx recipients (aged 58 ± 15, transplanted 15 ± 6 years ago), 26 completed the study. While BLT had no significant effect on circadian and sleep measures, sleep timing improved significantly. The intervention group showed a significant get-up time phase advance from baseline to intervention (+24 min) [(standardized estimates (SE): -0.23 (-0.42; -0.03)] and a small (+14 min) but significant bedtime phase advance from intervention to follow-up (SE: -0.25 (-0.41; -0.09). Improvement in subjective feelings and depressive symptomatology was observed but was not statistically significant.

Bright light therapy showed preliminary indications of a beneficial effect in RTx with sleep-wake disturbances.

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PUBLICATION #2 — Transplant Psychiatry
Long-Term Quality of Life after Liver Donation in the Adult to Adult Living Donor Liver Transplantation Cohort Study (A2ALL)

Ladner DP, Dew MA, Forney S, et al
J Hepatol 2014 Sep 4 [Epub ahead of print]

ANNOTATION (Paula Zimbrean)

The Finding: Both the mental component summary and the physical component summary of quality of life (measured by SF-36) were higher in liver organ donors than in the general population. Predictors of poor PCS were death of the recipient within 2 years from the measurement and 3-month post-donation time point compared with other points.

Strengths and Weaknesses: This is an important study resulted form the A2ALL project which followed the donors prospectively for 11 years. The main limitation of the study is that the UNOS listing criteria were changed during the study, it did not include adult to children donors.

Relevance: The findings of this study are important when the decision to donate is being discussed with a potential liver donor. The fact that the QOL of liver donors is good should encourage living donation. In addition, the study identifies some groups at risk for a poorer QOL which may allow targeted intervention in the future.


Background and Aims: There are few long-term studies of health-related quality of life (HRQOL) in living liver donors. This study aimed to characterize donor HRQOL in the Adult to Adult Living Donor Liver Transplantation Study (A2ALL) up to 11 years post-donation.

Methods: Between 2004-2013, HRQOL was assessed at evaluation, and 3 months and yearly post-donation in prevalent liver donors using the Short Form survey (SF-36), which provides a physical (PCS) and a mental component summary (MCS).

Results: Of the 458 donors enrolled in A2ALL, 374 (82%) had SF-36 data. Mean age at evaluation was 38 (range 18-63), 47% were male, 93% white, and 43% had a bachelor’s degree or higher. MCS and PCS means were above the US population at all time points. However, at every time point there were some donors who reported poor scores (>1/2 standard deviation below the age and sex adjusted mean) (PCS: 5.3%-26.8%, MCS: 10.0%-25.0%). Predictors of poor PCS and MCS scores included recipient death within the two years prior to the survey and education less than a bachelor’s degree; poor PCS scores were also predicted by time since donation, Hispanic ethnicity, and at the 3-month post-donation time point.

Conclusions: In summary, most living donors maintain above average HRQOL up to 11 years prospectively supporting the notion that living donation does not negatively affect HRQOL. However, targeted support for donors at risk for poor HRQOL may improve overall HRQOL outcomes for living liver donors.

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PUBLICATION #3 — Transplant Psychiatry
Cross-sectional psychosocial evaluation of heart transplantation candidates

Sánchez R, Baillés E, Peri JM, , et al
Gen Hosp Psychiatry 2014 Jul 26 [Epub ahead of print]

ANNOTATION (Paula Zimbrean)

The Finding: 30.4% of the heart transplant candidates met criteria for an Axis I disorder: 7.2% primary insomnia, 6.4% major depression, 5.4% generalized anxiety disorder.

Strengths and Weaknesses: To our knowledge, this is the largest cohort of heart transplant recipients assessed systematically for psychiatric disorders. Its main limitation is due to the cross-sectional design.

Relevance: For the transplant psychiatrist initiating a consultation service with the heart transplantation team, this study may help in estimating the pathology and the clinical needs of the service.


Introduction and Objectives: Heart transplantation (HT) is a potentially life-saving procedure for people with terminal cardiac disease. In the last decades researchers of HT programs have attempted to identify the existence of psychosocial factors that might influence the clinical outcome before and after the transplantation. The main objective of this study was to describe epidemiological, psychiatric and psychological features of a large sample of HT candidates.

Methods: Cross-sectional, observational and descriptive study. A psychiatric and psychological assessment of 125 adult patients was performed at the moment of being included in the HT waiting list, between 2006 and 2012. The assessment consisted in: Clinical, epidemiological and psychosocial form; Spanish version of Hospital Anxiety and Depression Scale; Structured Clinical Interview for DSM-IV axis I disorders; Coping questionnaire (COPE); Five Factors Inventory Revised (NEO-FFI-R); Apgar-Family questionnaire and the Multidimensional Health Locus of  Control scale.

Results: Axis I diagnoses were present in a 30.4% of patients. COPE showed that this group of patients used most frequently engagement strategies. Personality factors profile of NEO-FFI-R were similar to general population and locus of control scale also presented similar scores compared with other chronic diagnostic groups. Statistically significant associations were found between personality factors and COPE scales/dimensions and psychopathology, mainly neuroticism and disengagement.

Conclusions: This is the first study to assess systematically psychosocial factors in a large sample of HT candidates. We have found that around one third of these patients have a psychiatric disorder. Neuroticism and disengagement coping styles can serve as markers of emotional distress.

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