Journal Article Annotations
2023, 4th Quarter

Transplant psychiatry

Annotations by Sarah Andrews, MD and Gregory Nikogosyan, DO
January, 2024

Sleepiness and Health-Related Quality of Life Among Kidney Transplant Recipients in a Low-Middle Income Country: A Cross-Sectional Study.
Clinical Utility and Impact of Phosphatidylethanol Testing in Liver Transplantation Evaluations.

PUBLICATION #1 — Transplant psychiatry

Sleepiness and Health-Related Quality of Life Among Kidney Transplant Recipients in a Low-Middle Income Country: A Cross-Sectional Study.

Mayssaa Hoteit, Ahmad Al-Masry, Martine Elbejjani, Mabel Aoun, Rana Abu-Dargham, Walid Medawar, Hilal Abou Zeinab, Laila Farhood, Sahar H Koubar.

Abstract: Multicenter Study. 2023 Nov 1:36:11547. doi: 10.3389/ti.2023.11547. eCollection 2023.

This study aims to describe daytime sleepiness and health-related quality of life (HRQoL) among Lebanese kidney transplant (KT) recipients and to examine the medical, psychosocial and transplant factors related to them. It is a cross-sectional multi-center study involving KT recipients >18 years. Daytime sleepiness was assessed using ESS Questionnaire. HRQoL was measured using the SF-36 questionnaire. Social support was self-reported. A multivariable regression analysis evaluated factors associated with daytime sleepiness and HRQoL in our sample. 118 patients were recruited over a 2 years period. Excessive daytime sleepiness was prevalent in 12.7%. It was associated with Diabetes Mellitus (OR 3.97, 95% CI 0.94-16.81, p = 0.06) and obesity (OR 1.13, 95% CI 1.02, 1.27, p = 0.02). Social support and higher eGFR were associated with better scores on the MCS (β 24.13 p < 0.001 and β 0.26 p < 0.01) and the PCS (β 15.48 p < 0.01 and β 0.22 P 0.02). Conversely, depression and hospitalization were negatively associated with the MCS (β -27.44, p < 0.01 and β -9.87, p < 0.01) and the PCS (β -0.28.49, p < 0.01 and β -10.37, p < 0.01).

Annotation

The finding:
The cross-sectional study aimed to examine how kidney transplant recipients were affected by daytime sleepiness and quality of life. Daytime sleepiness was associated with obesity and diabetes mellitus. Social support was positively associated with decreased perceived memory and pain symptoms, and its effect might be mediated by depression. Furthermore, hospitalizations within the past year and depression were correlated with lower health-related quality of life (HRQoL) scores, while enhanced kidney function and perceived social support were correlated with higher HRQoL scores.

Strengths and weaknesses:
This study focuses on the Middle Eastern or North African (MENA) demographic, which was grouped into the white race category in most research studies due to the current limited U.S. Census classification. Unfortunately, study participants were from Lebanon, which may confound other variations with different MENA ethnicities. This cross-sectional design limited understanding of post-transplant sleepiness, given there was no data on pre-transplant sleep disorders for participants. Furthermore, the study had a small sample size, limiting generalizability and possible false negatives due to the inability to detect other factors associated with daytime sleepiness. The study did not have a healthy control comparison or objective measures such as polysomnographic sleep tests.

Relevance:
This study helps highlight what appears to be modifiable factors to improve sleep quality and quality of life. Given the sleep disruption association with obesity and diabetes, among other factors such as psychosocial outcomes, healthcare providers may standardize the assessment and management of such issues to improve health outcomes.

PUBLICATION #2 — Transplant psychiatry

Clinical Utility and Impact of Phosphatidylethanol Testing in Liver Transplantation Evaluations.

David C Fipps, Rachel Meyer, Jeffrey Woods, Kymberly Watt, Terry Schneekloth, Jennifer Gifford, Bhanu Prakash Kolla.

Abstract: J Acad Consult Liaison Psychiatry. 2023 Dec 1:S2667-2960(23)00844-3. doi: 10.1016/j.jaclp.2023.11.683. Online ahead of print.

Background:
Phosphatidylethanol (PEth) is a serum biomarker that can detect alcohol use within the last 28 days with excellent sensitivity and specificity. Urinary ethyl glucuronide (uEtG) is commonly used in transplant settings to screen for alcohol use; however, it has several limitations relevant to liver transplantation. Transplant centers are beginning to regularly utilize PEth as part of the screening process for high-risk liver transplantation candidates although the clinical utility of uniform pre-transplant PEth testing is unclear.

Methods:
This was a retrospective chart review of all patients evaluated for liver transplantation from December 1, 2019, through May 31, 2022, at a large academic tertiary referral center utilizing uniform serum PEth and uEtG screening. Information regarding the patients’ transplantation status, age, sex, race, Model for End-Stage Liver Disease score, and PEth levels was obtained. In those with a positive PEth, we examined if the result would have been detected with uEtG, identified a discrepancy from the documented patient report of last use, led to a change in the Psychosocial Assessment of Candidate for Transplantation score, or influenced the transplant selection committee’s decision.

Results:
Our sample included 865 individuals (mean age = 55.20, 61.27% male and 82.54% white) with calculated Model for End-Stage Liver Disease-Sodium scores ranging from 6.43 to 50.65 (mean: 18.09; median: 16.46). Forty-eight patients were found to have a positive PEth (PEth range 20-1833); 75% of the sample had alcohol-associated liver disease. In 23 of 48 (47.91%) cases, the positive PEth identified alcohol use missed by a concomitant uEtG screen. A positive PEth test identified a discrepancy from patients’ self-report in 29 (60.42%) cases and influenced the selection committee’s decision in 28 cases (58.33%).

Conclusion:
Uniform pretransplant PEth screening of liver transplant candidates at the time of initial evaluation identified alcohol use that would have been missed by uEtG testing, identified discrepancies from the patient’s self-report, and influenced clinical decision-making in a significant number of cases. These findings support the use of uniform PEth screening in liver transplantation evaluations.

Annotation

The finding:
This retrospective study examined the clinical utility of phosphatidylethanol (PEth) in liver transplantation evaluations. Positive PEth results identified alcohol use that uEtG would have missed in up to half of all cases. A discrepancy of the PEth results with patients’ self-reports influenced clinical decision-making, resulting in a change in level-of-care recommendations and deferring or denial of transplantation in most cases.

Strength and weaknesses:
This study is one of the few that addresses how uniform PEth testing impacts liver transplant candidacy decisions. Other past studies ordered PEth testing at providers’ discretion. Furthermore, it looked at pre- and post-liver-transplant outcomes. The overall number of participants with a positive PEth test was a small percentage of the overall participant number, limiting the power of the study results. Another limitation includes varying cut-off scores for alcohol intake across studies. The higher threshold in this study would increase the false negatives.

Relevance:
PEth testing is further identified as an important tool in assessing for alcohol use which has significant clinical impact for transplant listing. This further supports the notion for standardized uniform PEth testing for liver transplant candidates given discrepancy of self-report and false negative uEtG testing. The authors discuss a combination of uEtG and PEth testing would be best given PEth can have false negatives if alcohol intake is only shortly before testing.