Annotated Abstracts of Journal Articles
2015, 4th Quarter
Annotations by Paula Zimbrean, MD, FAPM
Also of interest:
ANNOTATION (Paula Zimbrean)
The Finding: Patients with alcoholic hepatitis not responding to medical therapy may successfully undergo early liver transplantation.
Strength and Weaknesses: This is the first case series reported in the USA of patients with acute hepatitis undergoing early liver transplantation. Most liver transplant programs in the USA require a period of abstinence (6 months, in 80% of programs) prior to transplantation. The number of patients in this study is small. Since only patients with a favourable psychosocial profile were selected, it is not possible to extrapolate what factors contributed to the low rate of alcohol relapse in these patients.
Relevance: Liver transplant for acute alcoholic hepatitis is a highly controversial topic in organ transplantation, especially in the context of severe organ shortage. This study is the first to report on the outcome of liver transplantation for this selected group of patients.
Early liver transplantation (LT) in European centers reportedly improved survival in patients with severe alcoholic hepatitis (AH) not responding to medical therapy. Our aim was to determine if a strategy of early LT for severe AH could be applied successfully in the United States. We reviewed 111 patients with severe AH at our center from January 2012 to January 2015. The primary end point was mortality at 6 months or early LT, with a secondary end point of alcohol relapse after LT. Survival was compared between those receiving early LT and matched patients who did not. Using a process similar to the European trial, 94 patients with severe AH not responding to medical therapy were evaluated for early LT. Overall, 9 (9.6%) candidates with favorable psychosocial profiles underwent early LT, comprising 3% of all adult LT during the study period. The 6-month survival rate was higher among those receiving early LT compared with matched controls (89% vs 11%, p<0.001). Eight recipients are alive at a median of 735 days with 1 alcohol relapse. Early LT for severe AH can achieve excellent clinical outcomes with low impact on the donor pool and low rates of alcohol relapse in highly selected patients in the United States.
ANNOTATION (Paula Zimbrean)
The Finding: Increase in depressive symptoms and decline in quality of life in the first 2 weeks of hospitalization for HCT correlated with later development of PTSD symptoms.
Strengths and Weaknesses: This is a prospective cohort study which looked at the correlation between change in depressive symptoms (as opposed to a one-time measurement of depression) and the presence of PTSD symptoms after hematopoietic stem cell transplantation. The study controlled for demographic parameters but not for prior psychiatric history (e.g., prior history of depression or PTSD).
Relevance: The main contribution of this study is that it analysed the correlation between the change in depression and QOL scores, rather than only one–time measurement of these parameters. The change is likely to be a more accurate predictor for development of psychosocial complications posttransplantation.
Background: During hospitalization for hematopoietic stem cell transplantation (HCT), patients experience a steep deterioration in quality of life (QOL) and mood. To our knowledge, the impact of this deterioration on patients’ QOL and posttraumatic stress disorder (PTSD) symptoms after HCT is unknown.
Methods: We conducted a prospective longitudinal study of patients hospitalized for HCT. They assessed QOL using the Functional Assessment of Cancer Therapy-Bone Marrow Transplantation (FACT-BMT) and depression and anxiety symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9) at the time of admission for HCT, during hospitalization, and 6 months after HCT. We also used the Hospital Anxiety and Depression Scale (HADS) to measure patients’ anxiety and depression symptoms at baseline and during HCT hospitalization. The PTSD Checklist was used to assess for PTSD symptoms. Multivariable linear regression models were used to identify predictors of QOL and PTSD symptoms at 6 months.
Results: We enrolled 90 of 93 consecutively eligible patients (97%) undergoing autologous and allogeneic HCT. Data at 6 months were available for 67 participants. At 6 months, 28.4% of participants met the criteria for PTSD and 43.3% had clinically significant depression. On multivariable regression analyses adjusting for significant covariates, changes in QOL and depression scores from week 2 of HCT hospitalization to baseline predicted worse QOL (changes in scores between week 2 and baseline [Δ] QOL: β, 0.94 [P<.0001] and Δ PHQ-9: β, -2.59 [P = 0.001]) and PTSD symptoms (Δ QOL: β, -0.40 [P<.0001] and Δ PHQ-9: β, 1.26 [P<.0001]) at 6 months after HCT.
Conclusions: Six months after HCT, a significant percentage of patients met the criteria for PTSD and depression. A decline in QOL and an increase in depressive symptoms during hospitalization for HCT were found to be the most important predictors of 6-month QOL impairment and PTSD symptoms. Therefore, managing symptoms of depression and QOL deterioration during HCT hospitalization may be critical to improving QOL at 6 months and reducing the risk of PTSD.
ANNOTATION (Paula Zimbrean)
The Finding: This is a multicenter retrospective/prospective study of the renal status of two transition programs for young patients with renal transplantation. The study included a questionnaire that asked patients to assess retrospectively the transition programs. The clinical data was collected prospectively in real time. 21% of patients had a significant increase of creatinine after their last pediatric visit.
Strengths and Weaknesses: Non-adherence to medical treatment in adolescents with organ transplantation is a well known problem in organ transplantation. There is currently an ongoing effort in designing programs that can improve adherence and facilitate the transition of these patients to the adult clinics. This is one of the first studies to report outcomes of such a program.
The main questionable weakness of this study is its generizability outside Europe, specifically Germany and Austria. The program included an inpatient rehabilitation (education) curriculum and an intense outpatient program prior to transitioning the patients to the adult clinic. Other factors which may contribute to increase creatinine (comorbid medical conditions, non-adherence, use of other medications or substances) were beyond the scope of this study.
Relevance: This study shows that even with careful planning of the transition to adult clinic, renal transplant recipients can still display worsening in their renal status; however, irreversible events such as graft loss are rare.
Transition from child to adult-oriented care is widely regarded a challenging period for young people with kidney transplants and is associated with a high risk of graft failure.We analyzed the existing transition structures in Germany and Austria using a questionnaire and retrospective data of 119 patients transferred in 2011 to 2012.Most centers (73%) confirmed agreements on the transition procedure. Patients’ age at transfer was subject to regulation in 73% (18 years). Median age at transition was 18.3 years (16.5-36.7). Median serum creatinine increased from 123 to 132 μmol/L over the 12 month observation period before transfer (P = 0.002). A total of 25/119 patients showed increased creatinine ≥20% just before transfer. Biopsy proven rejection was found in 10/119 patients. Three patients lost their graft due to chronic graft nephropathy. Mean coefficient of variation (CoV%) of immunosuppression levels was 0.20 ± 0.1. Increased creatinine levels ≥20% just before transfer were less frequently seen in patients with CoV < 0.20 (P = 0.007).The majority of pediatric nephrology centers have internal agreements on transitional care. More than half of the patients had CoV of immunosuppression trough levels consistent with good adherence. Although, 20% of the patients showed increase in serum creatinine close to transfer.