Transplant Psychiatry

Journal Article Annotations
2022, 1st Quarter

Transplant Psychiatry

Annotations by Sarah R. Andrews, MD and Shehzad K. Niazi, MD, FRCPC, FACLP
January, 2022

  1. Associations Between Recipients’ Feelings of Guilt for Donor and Depressive Symptoms Before Living Kidney Transplantation.
  2. Adherence to Immunosuppressive Therapies after Kidney Transplantation from a Biopsychosocial Perspective: A Cross-Sectional Study.

PUBLICATION #1 — Transplant Psychiatry

Associations Between Recipients’ Feelings of Guilt for Donor and Depressive Symptoms Before Living Kidney Transplantation.
Satomi Doi, Mayu Sekiguchi, Ryo Motoya, Junichiro Kanazawa, Masumi Sato, Hiroshi Harada, Nobuyuki Fukuzawa, Yoshiki Wada, Tetsuo Hirano

Annotation

The finding:
This cross-sectional study included 178 patients from Japan who were undergoing living kidney transplantation from April 2009 to May 2016. Participants completed questionnaires prior to transplantation regarding depressive symptoms assessed through the Beck Depression Inventory-II and feelings of guilt for the donor. Multivariate regression analyses examined the association between depression scores and feelings of guilt. Results demonstrated that feelings of guilt were associated with depressive symptoms. Even after adjusting for participants’ clinical and background data, the association between feelings of guilt and depression scores remained significant. Kidney transplant recipients who expressed feelings of guilt were more likely to have elevated levels of depressive symptoms, specifically anhedonia, guilt, and sadness.

Strength and weaknesses:
This study had limitations, specifically the sample population was from one hospital and predominately one global region. Depressive symptoms or prior psychiatric illness were not assessed prior to the cross-sectional study. As such, the level of depression prior to the transplant process could influence feelings of guilt. The strength of this study was that it was the first to explore the relationship between feelings of guilt for donor and its association with depressive symptoms.

Relevance:
Depression in kidney transplant recipients has been associated with poor post transplant outcomes, which can include graft failure and mortality. Transplant recipients’ mental health is a vital aspect of the transplant process and must be appropriately managed prior to and following transplant. Guilt in kidney transplant recipients is common in those who received a living donor transplant due to concerns about the donor’s health that may arise following donation. This study indicated that feelings of guilt for donors were associated with depressive symptoms in the transplant population. Given that depression can worsen post transplant outcomes, we must help identify and discuss potential guilt and the impact of guilt on mental health pre and post transplant. These findings suggest a role for pre transplant psychological interventions to reduce guilt and depression among living kidney donor recipients.


PUBLICATION #2 — Transplant Psychiatry

Adherence to Immunosuppressive Therapies after Kidney Transplantation from a Biopsychosocial Perspective: A Cross-Sectional Study.
Justyna Zachciał, Izabella Uchmanowicz, Magdalena Krajewska, Mirosław Banasik
Annotation

The finding:
In this Polish study, the authors conducted a cross-sectional study to assess the adherence with refilling and taking immunosuppressant medications among 210 kidney transplant recipients. Validated rating scales measured  quality of life (QOL), cognition, illness-acceptance, depression, 
anxiety, and frailty. Patients with higher acceptance of illness as measured by the Polish version of the Acceptance of Illness Scale were more likely to be adherent to immunosuppressant medications after kidney transplants. On the other hand, frail patients; those who had lower cognitive capabilities as measured by Mini-Mental State Examination; and those who had hypercholesteremia were more likely to be nonadherent.

Strength and weaknesses:
The authors used validated scales and robust statistical methodology that considered the issue of collinearity of multiple variables by calculating VIF (Variance Inflation Factor). The observed VIF of 3.53 suggests there was no multicollinearity among variables of interest. Depression and anxiety as measured by HADS had no significant association with adherence. The study was cross-sectional and hence subject to recall bias; the results cannot be used to infer causality. Additionally, it is difficult to comment on the temporal relationship among variables such as frailty, hypercholesteremia, cognitive status, and non-adherence or acceptance of illness and improved adherence. This is a single-center study in a country where the Polish National Health System pays the cost of immunosuppressant medications, and the out-of-pocket cost is only $1.00/medication pack. As a result, the authors did not explore associations between socioeconomic factors on compliance. Hence, generalizability to patient populations to other healthcare systems, such as the USA, is limited.

Relevance:
Findings of the study are clinically relevant to the clinicians as adherence to immunosuppressant medications is critical to achieve graft survival after kidney transplant. These findings suggest that the clinicians may even more closely monitor adherence in higher risk patients who are frail or cognitively impaired.

Transplant Psychiatry

Journal Article Annotations
2021, 4th Quarter

Transplant Psychiatry

Annotations by Sarah R. Andrews, MD
December, 2021

  1. Coping strategies, anxiety and depression related to the COVID-19 pandemic in lung transplant candidates and recipients. Results from a monocenter series.
  2. Factors Having an Impact on Relapse and Survival in Transplant Recipients With Alcohol-Induced Liver Disease.

PUBLICATION #1 — Transplant Psychiatry

Coping strategies, anxiety and depression related to the COVID-19 pandemic in lung transplant candidates and recipients. Results from a monocenter series.
Alice Savary, Malika Hammouda, Lucie Genet, Cendrine Godet, Vincent Bunel, Gaelle Weisenburger, Tiphaine Goletto, Chahine Medraoui, Gilles Jebrak, Armelle Marceau, Alexy Tran-Dinh, Pierre Mordant, Yves Castier, Philippe Montravers, Herve Mal, Jonathan Messika, Bichat Lung Transplant Group

Annotation

The finding:
This single-study retrospective study evaluated 49 lung transplant recipients and 14 lung transplant candidates for anxiety and depression symptoms through the Hospital Anxiety and Depression Scale. Coping strategies were also assessed by using the Coping Inventory for Stressful Situations questionnaire. From these 63 participants, 11 (17%) and 18 (29%) patients exhibited depressive and anxiety symptoms, respectively. Anxiety was more common in patients who experienced lockdown outside versus inside their usual home. Task-focused strategies were the preferred coping strategy for patients. No significant differences were found between lung transplant recipients and candidates. 

Strength and weaknesses:
The strength of this study is involving both coping strategies as well as evaluating anxiety and depression. It also has limitations, including the small sample size from one location given that patients from different countries or populations may have differing responses to the COVID-19 pandemic.

Relevance:
Anxiety and depression are common in the lung transplant population, both in recipients and candidates, and the COVID-19 pandemic has worsened the risk of psychiatric symptoms in this fragile population. The study is relevant to the Cl-L psychiatrist in helping to identify anxiety or depression-provoking situations within this population.


PUBLICATION #2 — Transplant Psychiatry

Factors Having an Impact on Relapse and Survival in Transplant Recipients With Alcohol-Induced Liver Disease.
Terry D Schneekloth, Juan P Arab, Douglas A Simonetto, Tanya M Petterson, Shehzad K Niazi, Daniel K Hall-Flavin, Victor M Karpyak, Bhanu P Kolla, James E Roth, Walter K Kremers, Charles B Rosen

Annotation

The finding
This retrospective cohort study included 236 liver transplant recipients with alcohol-induced liver disease from one transplant center from 2000 until 2012. From these liver recipients, over 90 percent had completed pre-transplant treatment and over half attended Alcoholics Anonymous (AA). After five years post-transplant, 16.3% who had completed pre-transplant treatment relapsed, while 8.2% of those who engaged in weekly AA meetings had relapsed. Smoking prior to transplant was associated with relapse, and smoking at transplant was associated with death.

Strengths and weaknesses
This study had several strengths, including the ongoing close follow-up of  transplant recipients regarding alcohol consumption. One weaknesswas the unclear objective assessment of evaluating patients’ alcohol consumption post-transplant given that return to alcohol consumption when self-reported can be underreported. Furthermore, AA meetings and treatment pre-transplant can vary significantly in quality.

Relevance
This study is relevant to transplant psychiatrists evaluating and managing liver transplant recipients with alcohol-induced liver disease. The association between smoking prior to and following transplant with morbidity and mortality will be helpful as we guide patients through the transplant process and help them reduce their alcohol and tobacco consumption.

Transplant Psychiatry

Journal Article Annotations
2021, 3rd Quarter

Transplant Psychiatry

Annotations by Sarah R. Andrews, MD
September, 2021

  1. Results of Early Transplantation for Alcohol-Related Cirrhosis: Integrated Addiction Treatment with Low Rate of Relapse.
  2. Transplant-related trauma, personal growth and alcohol use outcomes in a cohort of patients receiving transplants for alcohol associated liver disease.

     


    PUBLICATION #1 — Transplant Psychiatry

    Results of Early Transplantation for Alcohol-Related Cirrhosis: Integrated Addiction Treatment with Low Rate of Relapse.
    Lauren Carrique, Jill Quance, Adrienne Tan, Susan Abbey, Isabel Sales, Les Lilly, Mamatha Bhat, Zita Galvin, Mark Cattral, Anand Ghanekar, Ian McGilvray, Trevor Reichman, Gonzalo Sapisochin, Blayne Sayed, Markus Selzner, Marie-Josée Lynch, Nazia Selzner

    Annotation

    The finding:
    This prospective pilot study, based in Canada, challenges the 6-month-rule of abstinence for transplant in patients with alcohol-associated liver disease. Between May 2018 and October 2020, 703 referrals were made for liver transplant. Of these referrals, 14% were listed and 6% received transplants. There was no significant difference in survival rate among patients who had six months of sobriety prior to transplant compared to those who did not. Length of abstinence was not a predictor for returning to alcohol use, but younger age and lower Model for End-Stage Liver Disease (MELD) scores were. There
    was no significant difference with non-pilot patients with greater than six months of abstinence versus alcohol-liver disease pilot patients in return to alcohol use.

    Strength and weaknesses:
    This study is one of the first to pilot early liver transplantation beyond acute alcohol-associated hepatitis to include alcohol-related liver disease. One notable weakness of the study is the need for ongoing follow-up data to assess for sustained abstinence. 

    Relevance:
    As the rate for early transplantation in acute alcohol-associated hepatitis has increased, this study focuses on more equitable transplant care for all patients with alcohol-related liver disease and how relapse prevention therapy and monitoring biomarkers can assist in decreased relapse rates and improving survival. This study is relevant for consulting transplant psychiatrists to better understand how to evaluate patients for transplant: simply suggesting abstinence for six months may not be as predictive of good clinical outcomes as other markers, such as MELD score.


    PUBLICATION #2 — Transplant Psychiatry

    Transplant-related trauma, personal growth and alcohol use outcomes in a cohort of patients receiving transplants for alcohol associated liver disease.
    Katherine M Kruckenberg, Neeta Shenai, Mary Amanda Dew, Galen Switzer, Christopher Hughes, Andrea F DiMartini

    Annotation

    The finding:
    This prospective cohort study evaluated depressive symptoms and sleep patterns among 66 lung or heart transplant patients for several years post-transplant. At six months following transplantation, patients were more likely to be sedentary and over one-third had increased depressive symptoms. Impaired quality of sleep was associated with increased depressive symptoms while better sleep quality was associated with less risk of hospitalization or death.

    Strength and weaknesses:
    The strength of this study was identifying the importance of sleep quality and transplant outcomes. Objective outcome measures improved internal validity: sleep quality was assessed from actigraphy-based data, which has been shown to be comparable in validity and reliability to polysomnography. Depressive symptoms were measured using the Centers for Epidemiologic Study of Depression (CESD).  However, one weakness is that these data rely on association and do not show causation. The sample size is small, and the investigators lacked sleep data for recipients prior to transplant. It remains unclear how interventions on sleep might correlate with clinical outcomes.

    Relevance:
    C-L psychiatrists managing patients pre- and post- heart or lung transplant should carefully assess sleep symptoms, which correlate with both psychiatric and medical outcomes. It may well be that improving patients’ sleep may not only improve quality of life but also prolong life.

    Transplant Psychiatry

    Journal Article Annotations
    2021, 2nd Quarter

    Suicide

    Annotations by Sarah R. Andrews, MD
    April, 2021

    1. Marijuana use among adult liver transplant candidates and recipients.
    2. Quality of Life and Mental Health in Kidney Transplant Recipients During the COVID-19 Pandemic.

      PUBLICATION #1 — Suicide

      Marijuana use among adult liver transplant candidates and recipients.
      Alisa Likhitsup, Naba Saeed, Gerald Scott Winder, Ammar Hassan, Christopher J Sonnenday, Robert J Fontana

      Annotation

      The finding:
      This large retrospective study evaluated liver transplant candidates and their self-reported marijuana (MJ) use history. Nearly one-quarter of liver transplant candidates reported a history of MJ use, and 11% reported use in the last year. The probability of listing for transplant decreased among MJ users with longer time to listing compared to non-users. Among the transplanted patients, survival post-transplant was similar in both MJ users and non-users.

      Strength and weaknesses:
      This study has several strengths, including analysis of a large sample size for liver transplant candidates, even though it was only a single-site study. The limitations of the study include that MJ use was self-reported and collected from medical records. MJ use was difficult to quantify.

      Relevance:
      Given the controversial issue whether or not MJ use should be a contraindication for solid organ transplantation, this study is useful for C-L psychiatrists evaluating liver transplant patients in order to help determine the significance and relevance of marijuana use in transplant: there were no significant differences with post-transplant survival depending on marijuana use. Further studies should continue to address MJ in the transplant population.

      Type of study (EBM guide):
      Retrospective study


      PUBLICATION #2 — Suicide

      Quality of Life and Mental Health in Kidney Transplant Recipients During the COVID-19 Pandemic.
      Concetta De Pasquale, Maria Luisa Pistorio, Pierfrancesco Veroux, Rossella Gioco, Alessia Giaquinta, Francesca Privitera, Massimiliano Veroux

      Annotation

      The finding:
      This study evaluated 89 kidney transplant recipients in the setting of the COVID-19 pandemic. The Middle Hospital Questionnaire (MHQ) was used to evaluate anxiety, depression, somatic concerns, and insomnia as well as the SF-36 Health Survey regarding physical and emotional health. Over one-quarter of recipients reported changes in their emotional state. Sixteen percent reported difficulties in sleep. There was no demonstrated significant impact on socialization. Fifty percent of patients reported changes in their emotional state due to the pandemic. Despite the stressors of the pandemic, there was no significantly observed impact on the overall functioning of this transplant patient population when compared to a preceding time period.

      Strength and weaknesses:
      The strength of this study was that this cohort of transplant patients had recorded data prior to and during the pandemic, which allowed for longitudinal comparison. Additional time points should be further analyzed to determine if the ongoing length and severity of the pandemic worsens or improves psychosocial outcomes. One weakness includes that interaction between variables were not controlled in the study given the type of study. Sample size calculations were also not included in the study, which could have impacted the results.

      Relevance:
      As C-L psychiatrists have been managing patients during the pandemic, this study is vital to understanding the impact of the pandemic on transplant patients, which does not appear to be consistent with the general population. It will be important to continue to study the impact of the pandemic on the psychological health of kidney transplant patients.

       

      Type of study (EBM guide): Observational and cross-sectional study

      Transplant Psychiatry

      Journal Article Annotations
      2021, 1st Quarter

      Transplant Psychiatry

      Annotations by Sarah Andrews, MD and Shehzad K. Niazi, MD
      March, 2021

      1. The association of post-operative delirium with patient-reported outcomes and mortality after lung transplantation.

        PUBLICATION #1 — Transplant Psychiatry

        The association of post-operative delirium with patient-reported outcomes and mortality after lung transplantation.
        DeBolt CL, Gao Y, Sutter N, Soong A, Leard L, Jeffrey G, Kleinhenz ME, Calabrese D, Greenland J, Venado A, Hays SR, Shah R, Kukreja J, Trinh B, Kolaitis NA, Douglas V, Diamond JM, Smith P, Singer J.

        Annotation

        The finding:
        This prospective cohort study performed secondary analysis of the “Breath Again” study, evaluating adults undergoing first-time lung transplantation between January 2010 and April 2017. While patients were in the ICU, delirium was identified through the Confusion Assessment Method for the ICU (CAM-ICU). Associations between delirium, depressive symptoms, Health-Related Quality of Life (HRQL), and mortality were examined. Post-operative delirium was evident in 14% of the participants, increased risk of mortality, and worsened HRQL.

        Strength and weaknesses:
        The study identified delirium as a risk factor for mortality and decreased quality of life. This study had several strengths including the large cohort of lung transplant patients. There was limited missing data. Some limitations include the lower-than-expected rate of delirium as compared to other published studies.

        Relevance:
        This study is relevant for C-L psychiatrists who evaluate or manage lung transplant patients. While evaluating patients pre-transplant, steps should be taken to help reduce risk of post-operative delirium. Interventions include simplifying medication regimens and avoiding deliriogenic medications such as benzodiazepine and antihistamines. There is significant need to further explore the association between delirium and mortality.

        Type of study:
        Prospective cohort study

        Transplant psychiatry

        Journal Article Annotations
        2020, 4th Quarter

        Transplant psychiatry

        Annotations by Sarah Andrews, MD, Shehzad K. Niazi, MD, FRCPC
        December, 2020

        1. Psychosocial Outcomes of Donors Whose Recipients Died After Living Donor Liver Transplantation
        2. The Utility of a Pre-Transplant Psychosocial Evaluation in Predicting Post-Liver Transplant Outcomes
        3. The Stanford Integrated Psychosocial Assessment for Transplant is Associated with Outcomes Before and After Liver Transplantation

          PUBLICATION #1 — Transplant psychiatry

          Psychosocial Outcomes of Donors Whose Recipients Died After Living Donor Liver Transplantation
          Mukadder Ispir, Birgul Cumhur, Tolga Sahin, Emrah Otan, Cuneyt Kayaalp, Sezai Yilmaz

          Annotation

          The finding:
          This cross-sectional study evaluated the psychosocial outcomes of donors whose recipients died after living donor liver transplantation, comparing them to donors whose recipients survived. Between 2012 and 2017 at a transplantation center in Turkey, 41 donors whose recipients died were compared to 87 donors with living recipients. Donors whose recipients died had increased levels of psychosocial burden, including increased rates of anxiety and depression. These donors also experienced increased regret and hopelessness. 

          Strength and weaknesses:
          The study focuses on the importance of evaluating the psychosocial stressors associated with living donation, specifically the long-term consequences based on recipient survival. One of the weaknesses was that the participation rate was only 25% in donors, which raises the concern of selection bias. 

          Relevance:
          This study is relevant for C-L psychiatrists who evaluate or manage the transplant population. Living donors should be well-educated on the potential negative effects of donation, specifically if the recipient does not survive. Living donors should be made aware of the possible regret that can occur based on recipient outcome. 

          Type of study (EBM guide):
          Cross-section study


          PUBLICATION #2 — Transplant psychiatry

          The Utility of a Pre-Transplant Psychosocial Evaluation in Predicting Post-Liver Transplant Outcomes
          Becker JH, Shemesh E, Shenoy A, Posillico A, Knight CS, Kim SK, Florman SS, Schiano T, Annunziato RA.

          Annotation

          The finding:
          This retrospective study analyzed 182 adult liver transplant recipients at least one year post-transplant, comparing their results from the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) with outcomes post-transplant. Nonadherence was evaluated through biopsy-proven rejection. SIPAT was ineffective in predicting nonadherence in patients post-transplant. 

          Strength and weaknesses:
          The strength of this study was appropriate regression analyses predicting outcomes and comparing pre-transplant assessments with post-transplant adherence. One weakness is that only transplanted patients were included in the analyses, and thus skewing results. Further, raters for the SIPAT may have not accurately identified all risks. 

          Relevance:
          This study is relevant for C-L psychiatrists as we complete psychosocial evaluations for patients pre-transplant. Part of the evaluation process is a psychosocial evaluation and attempting to predict adherence post-transplant, however patients may present differently pre-transplant as compared to reality of behaviors post-transplant. We need to continue assessing psychosocial risk and to further explore how to predict outcomes. 

          Type of study (EBM guide):
          Retrospective study


          PUBLICATION #3 — Transplant psychiatry

          The Stanford Integrated Psychosocial Assessment for Transplant is Associated with Outcomes Before and After Liver Transplantation
          Deutsch-Link S, Weinberg EM, Bitterman T, McDougal M, Dhariwal A, Jones LS, Weinrieb RM, Banerjee AG, Addis S, Serper M.

          Annotation

          The finding:
          Authors of this study demonstrate that patients with higher risk SIPAT score, using a cut-off of 21, were less likely to be waitlisted for transplant. Patients with 21 or higher SIPAT scores were also less likely to adhere with immunosuppressant medications post-transplant. Additionally, the study subjects with higher scores in readiness domain of SIPAT were at a higher risk of graft rejection.

          Strength and weaknesses:
          Even though this study was conducted at a single center, yet the study cohort is relatively diverse and large. Transplant team evaluated 1430 patients and of those the researchers analyzed 384 recipients for post-transplant outcomes. Only the clinical social workers assigned SIPAT scores, and transplant psychiatrists did not assign scores independently. Authors performed appropriate statistical analyses and conclusions are supported by the study findings. Study’s duration does allow authors to study outcomes beyond 1-year post transplant in some patients but further longitudinal follow up may provide additional information regarding SIPAT-score and transplant outcomes. An additional strength is that authors do explore gender, education and community health scores related covariates and their impact on scores, likelihood for listing and outcomes as social determinants of health and issues of equity remain important and active areas of study.

          Relevance:
          Transplant team has to carefully evaluate all potential transplant candidates. Transplant psychiatrists and social workers play a key role in assessing these patients to identify any relevant psychosocial factors that can increase the risk of poorer outcomes after transplant. However, such evaluations need to be individualized and standardized where possible. Tools such as SIPAT are used to inform psychosocial evaluations. This study contributes to the accumulating evidence base to support the utility and validity of SIPAT.

          Type of study (EBM guide):
          Retrospective case-control study

          Transplant Psychiatry

          Journal Article Annotations
          2020, 3rd Quarter

          Transplant Psychiatry

          Annotations by Paula Zimbrean, MD, FACLP
          July, 2020

          1. Factor Analyses and Validity of the Transplant Evaluation Rating Scale (TERS) in a Large Sample of Lung Transplant Candidates.

          Also of interest:

            PUBLICATION #1 — Translant Psychiatry

            Factor Analyses and Validity of the Transplant Evaluation Rating Scale (TERS) in a Large Sample of Lung Transplant Candidates.
            Mariel Nöhre, Georgios Paslakis, Özgür Albayrak, Maximilian Bauer-Hohmann, Jan Brederecke, Daniela Eser-Valeri, Igor Tudorache, Martina de Zwaan

            Annotation

            The finding:
            Two psychological traits (“emotional sensitivity” and “defiance”) were found to exhibitdifferential predictive validity to quality of life at 1-year post-transplant. After adjusting for age, sex, and lung disease, the factor “emotional sensitivity” predicted task interference while the factor “defiance” predicted physical functioning. None of the factors predicted psychological functioning at 1-year follow-up

            Strength and weaknesses:
            This is a prospective study of 390 lung transplant candidates who were systematically evaluated for psychological variables and quality of life. Limitations of the study included the definition of some of the outcomes measured (physical functioning appreciation, unspecified proportion of transplanted patients) and the fact that 38% of patients did not complete the follow up assessments.

            Relevance:
            This study “fine tunes” the use and predictive value of TERS in lung transplant recipients by analyzing prospectively the role of psychological factors (emotional sensitivity and defiance) in predicting after transplant quality of life, depression and anxiety. This will help transplant psychiatry clinicians focus psychological evaluations pre transplantation and may direct the implementation of psychotherapies across the transplant journey.

            Also of interest – PUBLICATION #2 — Transplant Psychiatry
            Perioperative mental evaluation and intervention for lung transplantation in elderly patients with COVID‐19.
            Hailong Lyu PhD, Weili Han PhD, Dandan Wang MD, Tingbo Liang PhD, Shaohua Hu PhD

            Annotation (unstructured)

            This letter to the editor describes two patients (a 66y/o woman and a 70y/o man) who received double lung transplantation as a treatment for pulmonary disease secondary to Covid 19 infections. Both patients had insomnia and delirium after transplantation and received zolpidem and olanzapine for treatment of their symptoms. There were no other psychiatric problems associated with the care of these two patients. This is the first report of post -transplant psychiatric findings in patients receiving lung transplantation for Covid-19 infection.

            Type of study:
            case report.

            Transplant Psychiatry

            Often described as the Academy’s most valuable best-kept secret, each quarter, the Academy’s Guidelines and Evidence-based Medicine Subcommittee, with contributions by experts in subspecialty areas of C-L psychiatry, post commentary on recent journal articles with particular subspecialty relevance or significance.

            Leave a Reply

            Transplant Psychiatry

            Journal Article Annotations
            2020, 2nd Quarter

            Transplant Psychiatry

            Annotations by Paula Zimbrean, MD
            June 24, 2020

            1. The Preimplantation Psychosocial Evaluation and Prediction of Clinical Outcomes During Mechanical Circulatory Support: What Information Is Most Prognostic?
            2. High prevalence of falsely declaring nicotine abstinence in lung transplant candidates.

            Also of interest: 

            PUBLICATION #1 — Transplant Psychiatry

            The Preimplantation Psychosocial Evaluation and Prediction of Clinical Outcomes During Mechanical Circulatory Support: What Information Is Most Prognostic?
            Dew MA, Hollenberger JC, Obregon LL, Hickey GW, Sciortino CM, Lockard KL, Kunz NM, Mathier MA, Ramani RN, Kilic A, McNamara DM, Simon MA, Keebler ME, Kormos RL. .

            Annotation

            The finding
            Psychosocial factors were associated with clinical decisions about mechanical circulatory support (MCS) and with adverse events post implantation. Specifically, increased psychosocial risk was associated with a higher likelihood that MCS was pursued as destination therapy, rather than bridge to transplantation. Patients with a higher severity of mental health problems and greater difficulty adhering to their preimplantation medical regimen were at higher risk of adverse events post implantation, specifically cardiac arrhythmias and device malfunctions. Substance use at the time of the evaluation was associated with a higher risk of device malfunction.

            Strength and weaknesses
            This is a retrospective analysis of prospectively collected data of 241 patients (the largest such cohort to date) who received MCS and/or heart transplantation. The study analysed psychosocial risks factors individually and clearly defined the outcome measures including the clinical decision for implantation and transplant/MCS related outcomes. The statistical analyses took into consideration the underlying cardiac condition and patients who improved after MCS to the point of MCS removal (which cannot have MCS- related adverse events).

            The limitations of the study originate in its retrospective interpretation and coding of the psychosocial risk, even if the data was prospectively collected. The data were collected based on a semi-structured interview, but there is no discussion on the validity of this instrument. In addition, the analysis of adverse events did not take into consideration medical co-morbidities that may influence the risks of such events (e.g. cerebrovascular accidents, diabetes).

            Relevance
            This is the first study to evaluate which specific psychosocial domains appear responsible for any predictive effects on MCS recipients. These findings further support the importance of comprehensive psychosocial evaluation before MCS.

            Type of study
            retrospective cohort study


            PUBLICATION #2 — Transplant Psychiatry

            High prevalence of falsely declaring nicotine abstinence in lung transplant candidates.
            Veit T, Munker D, Leuschner G, Mümmler C, Sisic A, Kauke T, Schneider C, Irlbeck M, Michel S, Eser-Valerie D, Huber M, Barton J, Milger K, Meiser B, Behr J, Kneidinger N. .

            Annotation

            The finding
            Approximately 14% of patients listed for lung transplantation tested positive for cotinine while on the transplant waiting list. Of them, approximately 85% did not report their active use.

            Strength and weaknesses
            This is a prospective study of 620 lung transplant recipients who received education about the importance of smoking cessation at the time of the listing for transplantation. Patients underwent cotinine testing prospectively and randomly. The interpretation of these results is limited by the fact that this was a single center study, and that cotinine testing was done infrequently and cannot distinguish between smoking and use of nicotine replacement products.

            Relevance
            These findings suggest that a patient’s report of nicotine use is very likely to result in inaccurate data. Cotinine level testing increases the possibility of identifying patients who actively smoke and may benefit from additional interventions.

            Type of study
            cohort, prospective study


            Also of interest – PUBLICATION #3 — Transplant Psychiatry

            Kidney transplantation and donation in the transgender population: A single-institution case series.
            Ramadan, O. I., et al. (2020). .

            Annotation

            Annotation (unstructured)
            This is a single center case series describing a small group of transgender patients (4 kidney transplant recipients and 2 kidney donors) who all have psychiatric co-morbidities. The article describes each case individually and includes description of psychiatric, medical, and surgical complications that occurred after transplantation surgery. The manuscript concludes with suggestions for evaluation and follow up of transgender patients who receive or donate kidneys.

            Type of study
            case series

            Transplant Psychiatry

            Journal Article Annotations
            2020, 1st Quarter

            Transplant Psychiatry

            Paula Zimbrean, MD
            March 31, 2020

            1. Mental health and chemical dependency services at US transplant centers.

            Also of interest:

                PUBLICATION #1 — Transplant Psychiatry
                Mental health and chemical dependency services at US transplant centers.
                Niazi SK, Spaulding A, Vargas E, Schneekloth T, Crook J, Rummans T, Taner CB.
                Annotation

                The finding:
                85% of hospitals with a transplant centre offered mental health services and 37% offered chemical dependency services.

                Strength and weaknesses: 
                The paper reports the results of a cross sectional assessment of hospital related mental health services, as resulted from the American Hospital Association (AHA) 2017-2018 Annual Survey Hospital and form the 2017-2018 Area Health Resource File county level database. The authors analysed the availability of mental health services and chemical dependency services in hospital based on the types of transplants offered, ownership, number of hospital beds, government payment percentages and other public health parameters.

                Relevance:
                When new transplant programs begin evaluating candidates or when established programs expand, administrators and transplant physicians often assume that existing mental health services at that hospital will meet the needs for psychiatric assessment and care for liver transplant candidates, recipients and organ donors. This study shoes that in many cases these hospitals do not have mental health service established. This study did not evaluate if the existing mental health services meet the needs of the transplantation centres, as many psychiatric clinics find it difficult to provide services to patients with severe medical conditions. The results of this study are helpful for all psychiatrists who collaborate with the transplant centres as it supports the need for integrated mental health care for transplant candidates and recipients

                Type of study:
                (http://ebm.bmj.com/content/early/2016/06/23/ebmed-2016-110401):

                Also of interest – Publication #2 — Transplant Psychiatry
                Serotonin syndrome following left ventricular assist device implantation: A report and institution-specific strategy for prevention.
                Katzianer D, Chism K, Qureshi AM, Watson R, Massey HT, Boyle AJ, Reeves G, Danelich I..
                Annotation (unstructured)

                This is a case report describing a 62y/o man with a history of depression, on 50 mg of sertraline, who developed serotonin syndrome following administration of methylene blue for perioperative vasoplegia during left ventricular disease implantation. Depression has a high prevalence among patients with heart disease however it can also be difficult to diagnose when patients have neurovegetative symptoms due to their medical illness. Cl psychiatrists often must differentiate between normal illness behaviour and clinical depression. Treatment for depression typically improves quality of life and may improve medical outcomes after LVADs or transplantation, however it is important to consider the risks of antidepressant treatment in the perioperative setting, as illustrated by this case report. When psychotherapy is not indicated or feasible, delaying the start of an antidepressant or holding the antidepressant in the perioperative setting can be considered.

                Type of study:
                (http://ebm.bmj.com/content/early/2016/06/23/ebmed-2016-110401):

                Transplant Psychiatry

                Journal Article Annotations
                2019, 4th Quarter

                Transplant Psychiatry

                Annotations by Andrea DiMartini
                December 2019

                1. Donor outcomes in anonymous live liver donation
                2. Mental health and chemical dependency services at US transplant centers. American Journal of Transplantation.

                Also of interest:

                • Goldberg D and Lynch R: Improvements in organ donation: Riding the coattails of a national tragedy. Clinical Transplantation
                  November 19, 2019. https://doi.org/10.1111/ctr.13755.

                  In this brief communication to determine the proportion of the increase in organ donors attributable to drug-related deaths the authors evaluated the data from the Organ Procurement and Transplantation Network (OPTN) over a ten-year period from 1/1/2009 to 12/31/2018.  Using the Organ Procurement Organizations (OPOs) coding of donor mechanism of death they categorized donor deaths into drug-related vs not drug related. Over that ten-year period the number of donors whose mechanism of death was “drug intoxication” increased by 336% and aggregated together all drug-related death accounted for 102% of the increased number of donors in 2018 relative to 2009. The authors conclude although there have been improvements in the OPOs performance, nationally the increase in the number of organ donors is almost wholly attributable to the drug epidemic.

                  PUBLICATION #1 — Transplant Psychiatry
                  Donor outcomes in anonymous live liver donation.
                  Goldaracena N, Jung J, Aravinthan AD, Abbey SE, Krause S, Pritlove C et al.


                  Annotation

                  Findings:
                  In this descriptive work authors at the University Health Network in Toronto provide the first report on the physical and psychological outcomes of anonymous live liver donor (A-LLD- no biological connection or prior relationship) using a mixed methods approach.  During the period of study January 2005 to December 2017, 50 A-LLDs donated (representing 6.7% of their LLD donors). Twenty six of 41 A-LLDs (63%) who were >3 months post-donation agreed to participate. Validated self-reported questionnaires assessed personality traits, relationship style, and psychological growth. Qualitative interviews after donation examined motivation and experiences. Surveys showed A-LLDs endorsed personality traits of agreeableness, conscientiousness with low neuroticism and 50% endorsed a secure attachment style. Donors also reported significant post-donation growth in areas of relating to others, personal strength, and appreciation of life. Themes arising from the qualitative interviews included the concept of a good deed, random act of kindness without the expectation of reciprocity, moral obligation to help someone in need, and anonymity helped to preserve the value of doing a good deed.Social, financial, healthcare, and legal support in Canada were identified as facilitators of A-LLD donation.

                  Weaknesses and limitations:
                  This is a single center report on a small-sized cohort. There is no control group. Bias may have occurred if A-LLD non-responders had poorer outcomes.

                  Relevance:
                  This is the first report on an A-LLD cohort to examine psychological outcomes.  The use of qualitative interviewing is especially relevant to understanding motives and decision making in donors.

                  Type of study
                  (http://ebm.bmj.com/content/early/2016/06/23/ebmed-2016-110401): cross sectional cohort study

                  PUBLICATION #2 — Transplant Psychiatry
                  Mental health and chemical dependency services at US transplant centers. American Journal of Transplantation.
                  Niazi SK, Spaulding A, Vargas E, Schneekloth T, Crook J, Rummans T, Taner CB.


                  Annotation

                  Findings:
                  The authors sought to determine the availability of mental health (MH) and chemical dependency (CD) services in US transplant programs using databases from three sources: the 2017-2018 American Hospital Association Annual Survey (>6400 American hospitals), 2017-2018 Area Health Resource file (dataset provided by US Dept of Health and Human Services Health Resources and Services Administration) and Centers for Medicare & Medicaid Services Hospital Compare.  All non-federal US transplant programs were included.  MH service could include inpatient, consultation-liaison or outpatient services while CD services could include inpatient or outpatient alcoholism-chemical dependency services. Investigators used descriptive data to qualify the availability of services and generalized linear mixed models examine associations of hospital and health services area-level characteristics with the odds of offering MH and CD services. Of the 345 centers offering transplants in the US, investigators found that while 85% offered MH services only 37% offered CD services; 36% offered both MH and CD services. Hospitals were more likely to offer MH services if they were larger and had a lower percentage of uninsured patients in the health services area and were more likely to offer CD services if they were larger or were members of a system. The authors believe this suggests the costs and reimbursement levels for MH and CD services are major factors in a centers’ decision whether to offer these services.  They conclude that all transplant centers should ideally provide MH services to comply with the letter and spirit of CMS and UNOS requirements as well as to meet the complex psychosocial and mental health needs of the patients they serve.

                  Weaknesses and limitations:
                  The study could not show whether transplant patients could access MH or CD services if available at the transplant program, whether these services were adequate or whether they had alternative access to MH or CD care in the community.

                  Relevance:
                  US transplant programs require comprehensive psychosocial evaluations of transplant candidates. Without available MH and CD services within the transplant hospital system transplant candidates and recipients may only be able to receive such care in the community which may not be aware of the unique needs of transplant patients, be capable of assisting in the complex evaluation process or providing the type of expert coordinated MH and CD care required of transplant patients.

                   

                  Transplant Psychiatry

                  Journal Article Annotations
                  2019, 3rd Quarter

                  Transplant Psychiatry

                  Annotations by Paula Zimbrean
                  September 2019

                  1. Quantitative magnetic resonance imaging indicates brain tissue alterations in patients after liver transplantation.
                  2. Alcohol relapse and its predictors after liver transplantation for alcoholic liver disease: a systematic review and meta-analysis.
                  3. Adherence Behavior in Subjects on Hemodialysis Is Not a Clear Predictor of Posttransplantation Adherence.

                    PUBLICATION #1 — Transplant Psychiatry
                    Quantitative magnetic resonance imaging indicates brain tissue alterations in patients after liver transplantation.
                    Goede LL, Pflugrad H, Schmitz B, Lanfermann H, Tryc AB, Barg-Hock H, Klempnauer J, Weissenborn K, Ding XQ.

                    Annotation

                    The finding:
                    The study assessed brain relaxation in liver transplant recipients using functional MRI. The transplant recipient group was divided by their exposure to calcineurin inhibitors (CNIs) and compared the results with those of a control group of non-transplant patients.

                    Strength and weaknesses:
                    This study is the first to report differences in the brain structure in liver transplant recipients using functional MRI, a relatively new neuroimaging technique which allows a more detailed examination of the functioning of the brain cells, in particular of the brain relaxation (assessed by measuring the spin to spin interactions). This study shows differences in the brain functioning of liver transplant recipients compared to the general population, and differences between groups with different exposure to calcineurin inhibitors.

                    The interpretation of the results is limited as it did not include any clinical measures, so the significance of these MRI findings still needs to be investigated. In addition, otherimmunosuppressants (non CNIs), which were consistently taken by the patients in this study, may have had an impact on the qMRI results of the cerebral tissue. Furthermore, the standard immunosuppressive therapy regime after OLT includes CNI and therefore no group of patients with CNI-free immunosuppressive therapy from the first day after transplantation was available. Other limitations are that this was a single-center observational study with limited transferability to other centers and unfortunately no data from before OLT was available from our patients. Finally, the sample size limits the statistical power.

                    Relevance:
                    This study represents a significant step forward in understanding the brain changes that occur after organ transplantation. Clinicians have long known that cognitive and psychiatric status are significantly altered in transplant recipients by various factors, including the medical illness, immunosuppressant medications and psychosocial factors. This study supports the fact that these changes are not mainly due to “adjustment issues” or pre-existing medical problems and opens the field to further exploration.

                    Type of study: cross sectional, cohort

                    PUBLICATION #2 — Transplant Psychiatry
                    Alcohol relapse and its predictors after liver transplantation for alcoholic liver disease: a systematic review and meta-analysis.
                    Chuncharunee L, Yamashiki N, Thakkinstian A, Sobhonslidsuk A..

                    Annotation

                    The finding:
                    This is a systematic review and meta analysis of 92 studies (over 8000 patients) aiming at identifying the risk factors for alcohol relapse in liver transplant patients. In this study, unmarried status, smoking, psychiatric co-morbidities (but not depression) and length of abstinence (less than 6 months) was associated with higher risk of alcohol relapse after transplantation.

                    Strength and weaknesses:

                    This was a systematic review conducted by standard protocols and using systematic statistical tools. The clinical interpretation of these results is limited by the bias of unpublished negative results and by the heterogenity of these studies in terms of length of follow up, assessment of relapse and type of study.

                    Relevance:
                    The most memorable finding is the fact that psychiatric co-morbidities (but not depression) was the most significant factor in predicting the alcohol relapse in this group. Interestingly, the impact of the psychiatric co-morbidities upon risk of relapse increased as the time to transplantation increased. For clinicians, this can help guide focusing the mental health services on patients identified at higher risk by the time spent on the waiting list.

                    Type of study: Systematic review and meta-analysis

                    PUBLICATION #3 — Transplant Psychiatry
                    Adherence Behavior in Subjects on Hemodialysis Is Not a Clear Predictor of Posttransplantation Adherence.
                    Hucker A, Lawrence C, Sharma S, Farrington K.

                    Annotation

                    The finding:
                    This is a retrospective study that investigated the significance of non-adherence with hemodialysis in predicting adherence with medical treatment post transplantation. The authors found that non-adherence in the year before transplantation did not predict post-transplant non adherence.

                    Strength and weaknesses:
                    The predictive role of pre-transplant adherence has rarely been challenged and in clinical practice lack of adherence with dialysis is often seen as a factor that needs to be corrected before transplantation is considered. The study is limited by its retrospective design and reliance on medical records without a systematic measurement of adherence. In addition, the medication adherence, which is crucial post transplantation, was measured only via the proxy of tacrolimus level, without any behavioural measurement.

                    Relevance:
                    The findings of this study question the predictive role of pre transplant non adherence for post transplant adherence and invites to more research on this topic.

                    Type of study: retrospective cohort

                    Transplant Psychiatry

                    Journal Article Annotations
                    2019, 1st Quarter

                    Transplant Psychiatry

                    Paula Zimbrean, MD
                    March 2019

                    1. Psychosocial consequences of living kidney donation: a prospective multicentre
                      study on health-related quality of life, donor-recipient relationships and
                      regret.
                    2. Liver Transplant Recipients Older Than 60 Years Show Executive and Memory
                      Function Improvement Comparable to Younger Recipients.

                    PUBLICATION #1 — Transplant Psychiatry
                    Psychosocial consequences of living kidney donation: a prospective multicentre
                    study on health-related quality of life, donor-recipient relationships and
                    regret.
                    Wirken L(1)(2), van Middendorp H(1)(2), Hooghof CW(3), Sanders JF(4), Dam RE(5),
                    van der Pant KAMI(6), Wierdsma JM(7), Wellink H(8), van Duijnhoven EM(9), Hoitsma
                    AJ(3), Hilbrands LB(3), Evers AWM(1)(2)(10).


                    Annotation

                    Type of study: (http://ebm.bmj.com/content/early/2016/06/23/ebmed-2016-110401): cohort, prosepctive

                    The finding: Clinically relevant improvements of psychological functioning were found in 13–20% of donors, and a clinically relevant worsening was found in 11–27% of donors. There were no changes in the donor’s mental health functioning over time after surgery. Donor’s life was less influenced by the recipient’s kidney disease after transplantation (P < 0.001) compared to pre-transplantation, with 59% of donors experiencing moderate–much influence pre-donation, and 29–33% 6 and 12 months post-donation. Donors also felt less responsible for their recipient’s wellbeing than before transplantation.

                    Fourteen percent of the donors expressed regret of the donation. Higher levels of regret were associated with different pre-donation factors: worse emotional functioning of the recipient, more donor feelings of responsibility about the recipient , higher expectations about donor benefits, more anxiety, lower age,. Among the post-donation factors that influenced regret were: more influence of the recipient’s transplantation on the donor’s life, worse health perceptions, worse social functioning and worse surgery recovery. 

                    Strength and weaknesses:  This was a prospective study of the psychological status of kidney donors, who assessed quality of life , health perceptions and regret after donation in 230 kidney donors at 6 and 12 months after surgery. The study provides important information about factors associated with regret of the donation. The main limitations of this study consists in the non specific evaluation of the psychological well being (assessed by the SF 36 scale), as well as lack of analysis of other factors that may impact the quality of life, such as social support or perceived stress.

                    Relevance: the study provides important infomraiton about factors associated with regret of the donation in living kidney donors.

                    PUBLICATION #2 — Transplant Psychiatry
                    Liver Transplant Recipients Older Than 60 Years Show Executive and Memory
                    Function Improvement Comparable to Younger Recipients.
                    Ferman TJ(1), Keaveny AP(2), Schneekloth T(3), Heckman MG(4), Vargas E(5),
                    Vasquez A(1), Rummans T(6), Taner CB(2), Niazi SK(7).


                    Annotation

                    Type of study:(http://ebm.bmj.com/content/early/2016/06/23/ebmed-2016-110401): prospective cohort

                    The finding: the study found that elderly patients who received a liver transplant showed cognitive improvement after surgery comparable with young liver transplant recipients.

                    Strength and weaknesses: it is important to note the assessments were collected prospectively so the change in cognitive function could be properly assessed. The cognitive assessments evaluated various aspects of cognitive function, including language and executive function. The limitations of this study consists in low numbers of subjects which did not allow a complete analysis of other factors that may have contributed to the change in cognitive function in this group. In addition, there is no information about potential liver candidates of similar age who received a transplant but opted out of the study.

                    Relevance: the findings of this study are important when decisions are being made on using age as a criteria for listing for transplantation. There is a tendency in the practice of transplantation to offer transplantation at a more advanced age, to patients who in the past used ot be excluded from listing as considered to be “too old”. This study shows that selected patients can improve cognitively post transplantation.