Journal Article Annotations
2017, 2nd Quarter

Transplant Psychiatry

Annotations by Paula Zimbrean, MD, FAPM
July 2017

Cognitive function after heart transplantation: comparing everolimus-based and calcineurin inhibitor-based regimens
Delirium after lung transplantation: association with recipient characteristics, hospital resource utilization, and mortality

Also of interest:

Kasiske BL, Asrani SK, Dew MA, et al: The Living Donor Collective: a scientific registry for living donors
Am J Transplant 2017 May 18 (Epub ahead of print)

This article describes the plan to establish a living kidney and liver donor registry for long-term follow-up of the organ donors. Ten transplant centers agreed to participate and the implementation of this registry is expected to take four years. The registry will include medical data from the evaluation for organ donation, and information obtained via surveys administered selectively every year after donation. The registry will also link to other national databases in order to assess prevalence of specific post-donation complications, such as end stage kidney disease. The registry also aims to allow development of other investigator-initiated trials, which may be of interest to psychiatrists involved in mental health evaluations for organ donation.

PUBLICATION #1 — Transplant Psychiatry

Cognitive function after heart transplantation: comparing everolimus-based and calcineurin inhibitor-based regimens

Bürker BS, Gullestad L, Gude E, et al

Clin Transplant 2017 Apr; 31(4)

BACKGROUND: Studies have shown conflicting results concerning the occurrence of cognitive impairment after successful heart transplantation (HTx). Another unresolved issue is the possible differential impact of immunosuppressants on cognitive function. In this study, we describe cognitive function in a cohort of HTx recipients and subsequently compare cognitive function between subjects on either everolimus- or calcineurin inhibitor (CNI)-based immunosuppression.

METHODS: Cognitive function, covering attention, processing speed, executive functions, memory, and language functions, was assessed with a neuropsychological test battery. Thirty-seven subjects were included (everolimus group: n=20; CNI group: n=17). The extent of cerebrovascular pathology was assessed with magnetic resonance imaging.

RESULTS: About 40% of subjects had cognitive impairment, defined as performance at least 1.5 standard deviations below normative mean in one or several cognitive domains. Cerebrovascular pathology was present in 33.3%. There were no statistically significant differences between treatment groups across cognitive domains.

CONCLUSIONS: Given the high prevalence of cognitive impairment in the sample, plus the known negative impact of cognitive impairment on clinical outcome, our results indicate that cognitive assessment should be an integrated part of routine clinical follow-up after HTx. However, everolimus- and CNI-based immunosuppressive regimens did not show differential impacts on cognitive function.

On PubMed: Clin Transplant 2017 Apr; 31(4)

Annotation

The finding: 39.4% of heart transplant recipients had some form of cognitive impairment, while one-third had cerebrovascular pathology noted on brain imaging. There were no significant differences in cognitive impairment between the two medication groups (everolimus versus calcineurin inhibitor-based regimen).

Strength and weaknesses: This study is remarkable by the extent of the cognitive assessment (17 measures) and by the fact that brain imaging was also performed, allowing discussion of the cause of the cognitive impairment. The limitations of this study reside in its cross-sectional design and in the fact that the study was done at one single centre in Norway with a relatively homogenous population, which questions the generalizability of its findings.

Relevance: This study reinforces the high prevalence of cognitive impairment in heart transplant recipients. It suggests that cognitive screening should be considered routinely in these patients. In addition, the study underlines the need for further prospective studies and studies exploring the causality of the cognitive impairment in these patients, likely through multicentre trials.

PUBLICATION #2 — Transplant Psychiatry

Delirium after lung transplantation: association with recipient characteristics, hospital resource utilization, and mortality

Sher Y, Mooney J, Dhillon G, Lee R, Maldonado JR

Clin Transplant 2017 May; 31(5)

BACKGROUND: Delirium is associated with increased morbidity and mortality. The factors associated with post-lung transplant delirium and its impact on outcomes are under characterized.

METHODS: The medical records of 163 consecutive adult lung transplant recipients were reviewed for delirium within 5 days (early-onset) and 30 hospital days (ever-onset) post-transplantation. A multivariable logistic regression model assessed factors associated with delirium. Multivariable negative binomial regression and Cox proportional hazards models assessed the association of delirium with ventilator duration, intensive care unit (ICU) length of stay (LOS), hospital LOS, and one-year mortality.

RESULTS: Thirty-six percent of patients developed early-onset, and 44% developed ever-onset delirium. Obesity (OR 6.35, 95% CI 1.61-24.98) and bolused benzodiazepines within the first postoperative day (OR 2.28, 95% CI 1.07-4.89) were associated with early-onset delirium. Early-onset delirium was associated with longer adjusted mechanical ventilation duration (P=.001), ICU LOS (P<.001), and hospital LOS (P=.005). Ever-onset delirium was associated with longer ICU (P<.001) and hospital LOS (P<.001). After adjusting for clinical variables, delirium was not significantly associated with one-year mortality (early-onset HR 1.65, 95% CI 0.67-4.03; ever-onset HR 1.70, 95% CI 0.63-4.55).

CONCLUSIONS: Delirium is common after lung transplant surgery and associated with increased hospital resources.

On PubMed: Clin Transplant 2017 May; 31(5)

Annotation

The finding: Almost half (44%) of lung transplant patients develop delirium at some point during their post-procedure hospitalization. Delirium in this population is associated with longer length of stay and longer stay in the intensive care unit, but not with mortality at 1 year posttransplantation. Risk factors for developing delirium post lung transplant include obesity and use of benzodiazepines.

Strength and weaknesses: This study assessed systematically the presence of delirium in a large cohort of lung transplant recipients. Particularly relevant for the clinician is the separate analysis of the early versus ever onset delirium in relation to the transplant surgery. The main limitation of this study comes, of course, from its retrospective chart review design.

Relevance: This study underscores the high incidence of delirium in lung transplant recipients and supports the finding, known to consultation-liaison psychiatrists but often challenged by other medical providers, that benzodiazepines increase the risk of delirium. These findings support the need for prospective studies of this topic and suggest that delirium prevention measures should be considered prior to lung transplantation or in the immediate postoperative period.