Psychiatric Care of Patients Undergoing Organ Transplantation

Symptom Management in Patients with Cirrhosis: a Practical Guide

Purpose of the review

Though it is well known that cirrhosis is associated with significant morbidity and mortality, management of symptoms in cirrhosis can be difficult. This review serves to offer practical guidance in the management of liver-specific symptoms of cirrhosis as well as other symptoms with special hepatic considerations.

Recent findings

We discuss liver-specific symptoms and management, including ascites and refractory ascites, hepatic encephalopathy, pruritus, and muscle cramping. We also discuss the challenges of treating more generalized symptoms in cirrhosis, including pain, depression/anxiety, appetite, and fatigue. Medication management is, especially complex in this population given the altered metabolism of drugs, and we consider some strategies to approach this.

Summary

With the right tools, provided throughout this review, hepatologists should be well equipped to manage the nuanced liver-specific and generalized symptoms in patients with cirrhosis.

Depression, anxiety, and associated psychological outcomes in living organ transplant donors: A systematic review

With increasing demands for living organ donations, understanding the prevalence of depression and anxiety, which are the commonest psychiatric disorders in donors following organ transplantation, will serve to improve psychiatric care to safeguard donors' mental wellbeing. This descriptive systematic review examines all observational studies in English investigating prevalence of depression and anxiety in adult transplant donors using bibliographic databases. Sixty-two papers were included (kidney, n = 25; liver, n = 25; bone marrow, n = 7; uterus, n = 2; lung, n = 1; kidney and lung concurrently, n = 2). Post-transplantation depression and anxiety prevalence rates (Depression: 0-46.9%, Anxiety: 0-66.7%) did not differ significantly from pre-transplantation and were largely comparable to the general population. Other psychiatric disorders observed included bipolar disorder, conversion disorder, adjustment disorder and sleep disorder. Other psychological outcomes observed included lower quality of life, lower satisfaction of life and regret after donation. Pre-donation risk factors such as poor physical/psychological health status, and post-donation risk factors such as complicated post-surgical recovery and poor physical/psychological health in recipients were identified, predisposing donors to poor psychological outcomes. Individuals with risk factors should be monitored and provided with social support, psychoeducation, psychotherapy and long-term follow up. Future studies should adopt consistent methodological approaches to improve comparability between various studies. More research investigating poor psychological outcomes in other organ donors besides kidney and liver donors, donors who have past psychiatric history, unrelated and parent donors is warranted.

Psychosocial considerations in the assessment of hand transplant candidates: A single-center experience and brief literature review

Vascularized composite allograft, including hand transplantation (HT), has gained wider usage as a reconstructive treatment over the past 30 years. HT recipients face unique psychosocial challenges compared to their solid organ and/or bone marrow transplant counterparts. Accordingly, the psychosocial evaluation among HT candidates continues to evolve, leaving a lack of consensus as to the critical psychosocial domains and psychometric testing instruments to help evaluate individuals considering HT. The present manuscript describes the psychosocial evaluation process within the Duke HT program, which been contacted by 80 potential candidates since 2014. The Duke HT evaluation process incorporates a comprehensive psychosocial assessment within domains including personality, cognitive function, mood, behavioral adherence, social support, and substance use history, among others. Our experience underscores the potential utility of collecting thorough psychosocial evaluations, supplemented by psychometric test data, to comprehensively assess potential HT candidates.

Psychopharmacology in transplantation medicine

Organ transplantation has become a well-established treatment option in patients with end-stage organ diseases. Although quality of life has markedly improved, psychiatric disorders before and after transplantation are more frequent compared to the general population. Psychopharmacological treatment is recommended for almost all mental disorders according to current guidelines, but may pose particular problems in organ transplant patients. Changes in the metabolism and elimination of drugs during organ insufficiency, drug interactions, and overlapping side effects between psychopharmacological and immunosuppressive drugs are challenging problems in clinical management. Furthermore, questions frequently arise concerning the use of psychopharmacological treatment options for sleeping and anxiety disorders. This article reviews psychopharmacology in organ transplant patients, with particular attention to frequent psychiatric disorders observed in the disease course of end-stage organ diseases.

Relationship Between Stress Coping Mechanisms and Depression in Kidney Transplant Recipients

BACKGROUND

It has been reported that transplant recipients are exposed to physical and psychosocial stresses even after transplant surgery and exhibit psychological disorders such as depression.

PURPOSE

In this study, we extracted trends concerning how recipients of kidney transplants cope with stress, and we also examined how they cope with depression and its countermeasures.

METHOD

We administered questionnaire surveys to 109 kidney transplant recipients. These included items on personal attributes, medical information, depression, and stress-coping type scales. Statistical analysis was performed using factor analysis and multiple regression analysis.

RESULTS

Fifteen out of 109 (13.8%) were found to be high-risk patients for depression based on responses to the questionnaire using the depression scale. We extracted 2 factors of stress-coping type, namely Factor 1, "Directly coping with the problem," of patients who try to directly resolve the problem in a positive manner and Factor 2, "Stress-release while avoiding the problem," for those who relieve their feelings in response to the stress without resolving the problem itself. When multiple regression analysis was conducted with the depression scale as the dependent variable and the stress-coping factor as the independent variable, Factor 1 tended to be associated with reduced depression and Factor 2 with increased depression.

CONCLUSIONS

Results showed that to improve the mental health of those who receive kidney transplants, it is necessary to examine the depression and stress-coping types of such patients at an early stage and carry out education on stress-coping, focusing on resolving the actual problem.

Towards Standardizing the Alcoholism Evaluation Of Potential Liver Transplant Recipients

Aims

For teams around the world, alcoholic liver disease patients comprise the largest, and clinically most controversial, group applying for liver transplant. And yet evaluation decisions for them remain highly variable by locale.

Methods

Targeting standardized assessment, we provide guidelines on what information the transplant team should seek, from what sources, and how best to make use of it. This report focuses on 'what to do and how to do it' in providing appropriate assessments for this complex patient group.

Results

Proper evaluation includes (a) taking the clinical history from the patient and a required, corroborating third person, (b) assessing patient cognition, (c) establishing alcohol/substance use diagnosis to differentiate alcohol dependence, abuse and polysubstance dependence, (d) assessing ambivalence in primary alcohol addiction, (e) measuring social stability and (f) using Vaillant's factors for abstinence prognosis.

Conclusions

Properly applied, these six factors will allow standardized selection in most cases taken across programs despite differences in resources, available expertise and decision practices.

Short Summary

This report focuses on the essentials of the psychiatric/behavioral evaluation for 'alcoholic' persons referred for liver transplant. Attention to those essentials offers clinical standardization across transplant programs in different locales.

The 2018 ISHLT/APM/AST/ICCAC/STSW recommendations for the psychosocial evaluation of adult cardiothoracic transplant candidates and candidates for long-term mechanical circulatory support

The psychosocial evaluation is well-recognized as an important component of the multifaceted assessment process to determine candidacy for heart transplantation, lung transplantation, and long-term mechanical circulatory support (MCS). However, there is no consensus-based set of recommendations for either the full range of psychosocial domains to be assessed during the evaluation, or the set of processes and procedures to be used to conduct the evaluation, report its findings, and monitor patients' receipt of and response to interventions for any problems identified. This document provides recommendations on both evaluation content and process. It represents a collaborative effort of the International Society for Heart and Lung Transplantation (ISHLT) and the Academy of Psychosomatic Medicine, American Society of Transplantation, International Consortium of Circulatory Assist Clinicians, and Society for Transplant Social Workers. The Nursing, Health Science and Allied Health Council of the ISHLT organized a Writing Committee composed of international experts representing the ISHLT and the collaborating societies. This Committee synthesized expert opinion and conducted a comprehensive literature review to support the psychosocial evaluation content and process recommendations that were developed. The recommendations are intended to dovetail with current ISHLT guidelines and consensus statements for the selection of candidates for cardiothoracic transplantation and MCS implantation. Moreover, the recommendations are designed to promote consistency across programs in the performance of the psychosocial evaluation by proposing a core set of content domains and processes that can be expanded as needed to meet programs' unique needs and goals.

Neurological complications of solid organ transplantation

ABSTRACT Solid organ transplantation is a significant development in the treatment of chronic kidney, liver, heart and lung diseases. This therapeutic approach has increased patient survival and improved quality of life. New surgical techniques and immunosuppressive drugs have been developed to achieve better outcomes. However, the variety of neurological complications following solid organ transplantation is broad and carries prognostic significance. Patients may have involvement of the central or peripheral nervous system due to multiple causes that can vary depending on time of onset after the surgical procedure, the transplanted organ, and the intensity and type of immunosuppressive therapy. Neurological manifestations following solid organ transplantation pose a diagnostic challenge to medical specialists despite extensive investigation. This review aimed to provide a practical approach to help neurologists and clinicians assess and manage solid organ transplant patients presenting with acute or chronic neurological manifestations.

Pediatric Liver Transplantation: Unique Concerns for the Critical Care Team

Liver transplantation originated in children more than 50 years ago, and these youngest patients, while comprising the minority of liver transplant recipients nationwide, can have some of the best and most rewarding outcomes. The indications for liver transplantation in children are generally more diverse than those seen in adult patients. This diversity in underlying cause of disease brings with it increased complexity for all who care for these patients. Children, still being completely dependent on others for survival, also require a care team that is able and ready to work with parents and family in addition to the patient at the center of the process. In this review, we aim to discuss diagnoses of particular uniqueness or importance to pediatric liver transplantation. We also discuss the evaluation of a pediatric patient for liver transplant, the system for allocating them a new liver, and also touch on postoperative concerns that are unique to the pediatric population.

Psychosocial Predictors of Mortality Following Lung Transplantation

Lung transplantation has become an increasingly common treatment for patients with end-stage lung disease. Few studies have examined psychosocial risk factors for mortality in transplant recipients, despite evidence suggesting that elevated levels of negative affect are associated with greater mortality following major cardiac surgery. We therefore examined the relationship between negative affect early after lung transplantation and long-term survival in a sample of 132 lung transplant recipients (28 cystic fibrosis, 64 chronic obstructive pulmonary disease, 26 idiopathic pulmonary fibrosis, 14 other) followed for up to 13.5 years (median 7.4 years) following transplantation. Patients underwent both medical and psychosocial assessments 6 months following transplantation, which included the Beck Depression Inventory-II (BDI-II), Spielberger Anxiety Inventory, and General Health Questionnaire (GHQ). Over the course of follow-up, 80 (61%) participants died. Controlling for demographic factors, native lung disease, disease severity, family income, education level, social support, and frequency of posttransplant rejection, elevated symptoms of depression (BDI-II: HR = 1.31, p = 0.011) and distress (GHQ: HR = 1.28, p = 0.003) were associated with increased mortality. Higher levels of depression and general distress, but not anxiety, measured 6 months following lung transplantation are associated with increased mortality, independent of background characteristics and medical predictors.

Psychosocial Status of Liver Transplant Candidates in Iran and Its Correlation with Health-Related Quality of Life and Depression and Anxiety

Objectives. The study was aimed at providing a psychosocial profile for Iranian liver transplant candidates referred to an established liver transplantation program. Material and Methods. Patients assessed for liver transplant candidacy in Imam Khomeini Hospital (Tehran, Iran) between March 2013 and September 2014 were included. The following battery of tests were administered: Psychosocial Assessment of Candidates for Transplant (PACT), the Short-Form health survey (SF-36), and Hospital Anxiety and Depression Scale (HADS). Results. Psychosocial assessment in 205 liver transplant candidates revealed significant impairments in several SF-36 domains; social functioning was the least and physical functioning was the most impaired domains. The prevalence of cases with probable anxiety and depressive disorders, according to HADS, was 13.8% and 5.6%, respectively. According to PACT, 24.3% of the assessed individuals were considered good or excellent candidates. In 11.2%, transplantation seemed poor candidate due to at least one major psychosocial or lifestyle risk factor. Poor candidate quality was associated with impaired health-related quality of life and higher scores on anxiety and depression scales (p < 0.05). Conclusions. Transplant programs could implement specific intervention programs based on normative databases to address the psychosocial issues in patients in order to improve patient care, quality of life, and transplant outcomes.

The Stanford Integrated Psychosocial Assessment for Transplantation: A Prospective Study of Medical and Psychosocial Outcomes

BACKGROUND

Psychosocial factors may significantly affect post-transplant outcomes. The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) was developed as an assessment tool to enhance the pre-transplant psychosocial evaluation.

METHODS

We identified heart, lung, liver, or kidney transplant recipients assessed with the SIPAT pre-transplantation and transplanted between June 1, 2008, and July 31, 2011, at our institution. We analyzed prospectively accumulated psychosocial and medical outcomes at 1 year of follow-up.

RESULTS

217 patients were identified and included in the analysis. The primary outcomes of organ failure and mortality occurred in 12 and 21 patients, respectively, and were not significantly associated with the pre-transplant SIPAT scores. On the other hand, SIPAT scores were significantly correlated with the probability of poor medical and psychosocial outcomes (secondary outcomes). In fact, higher SIPAT scores predicted higher rates of rejection episodes (Spearman ρ = 0.15, 95% 95% confidence interval [CI] = 0.02-0.28, p = .023), medical hospitalizations (ρ = 0.29, 95% CI = 0.16-0.41, p < .001), infection rates (p = .020), psychiatric decompensation (p = .005), and support system failure (area under the curve = 0.70, 95% CI = 0.60-0.79, p < .001). The relationship with nonadherence suggested a trend, but no statistical significance was observed (area under the curve = 0.60, 95% CI = 0.50-0.71, p = .058).

CONCLUSIONS

Study outcomes suggest that SIPAT is a promising pre-transplantation assessment tool that helps identify candidate's areas of psychosocial vulnerability and whose scores are associated with both psychosocial and medical outcomes after transplantation.

Review article: depression and the use of antidepressants in patients with chronic liver disease or liver transplantation

BACKGROUND

The scale of depression in patients with chronic liver disease (CLD) and those who have received orthotopic liver transplantation (OLT) is poorly characterised. Clinicians are uncertain of how best to manage depression within these patients.

AIMS

To review the literature evaluating both the prevalence and impact of depression in patients with CLD and post-OLT, and to assess the safety and efficacy of antidepressant use within this context.

METHODS

A PubMed search using the phrases 'chronic liver disease', 'cirrhosis', 'liver transplantation', 'depression', 'antidepressant' and the names of specific causes of liver disease and individual antidepressants.

RESULTS

Over 30% of cirrhotic patients have depressive features, and they experience worse clinical outcomes than nondepressed cirrhotic patients. CLD patients with chronic hepatitis C are particularly prone to depression, partly related to the use of interferon therapy. OLT patients with depression have higher mortality rates than nondepressed patients; appropriate antidepressant use reverses this effect. Selective serotonin reuptake inhibitors (SSRIs) and selective noradrenaline reuptake inhibitors (SNRIs) are effective and generally safe in both CLD and OLT patients.

CONCLUSIONS

Depression is much more prevalent in CLD or OLT patients than is generally recognised, and it adversely affects clinical outcomes. The reasons for this relationship are complex and multifactorial. Antidepressants are effective in both CLD and post-OLT, although lower doses or a reduced dosing frequency may be required to minimise side effects, e.g. exacerbation of hepatic encephalopathy. Further research is needed to establish optimal management of depression in these patients, including the potential role of nonpharmacological treatments.

Risk factors for alcohol relapse following orthotopic liver transplantation: a systematic review

BACKGROUND

Each year, 5000-6000 individuals undergo orthotopic liver transplantation (OLT) in the United States, and of these, nearly 18% have alcoholic liver disease. Relapse to alcohol occurs in more than 40% of patients with OLT for alcoholic liver disease.

OBJECTIVES

We sought to identify factors that predict relapse to alcohol or medication nonadherence following OLT in patients with alcoholic liver disease and to review what randomized clinical interventions have addressed these factors following OLT. Our hypothesis was that there would be factors before and after OLT that predict relapse to alcohol following OLT, and that these, if targeted, might improve sobriety and associated outcomes of adherence with medications and appointments.

METHODS

We performed a review (focusing on articles published since 2004) with PubMed and MEDLINE searches using the following search terms: liver transplantation, recidivism, alcohol relapse, and predictors of alcohol relapse. We supplemented the online searches with manual reviews of article reference lists and selected relevant articles for further review by author consensus.

RESULTS

In largely white populations, prospective studies document that shorter length of pretransplantation sobriety is a significant predictor of time to first drink and time to binge use. Presence of psychiatric comorbidity, high score on standardized High-risk Alcoholism Relapse Scale, and diagnosis of Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) alcohol dependence are predictive of posttransplantation alcohol relapse. Pretransplantation alcohol use history variables (e.g., family history of alcoholism) reliably discriminate between complete abstainers and those who drink, while medical and psychosocial characteristics at early post-liver transplantation period (e.g., more bodily pain) maximally discriminate patterns of alcohol use. Alcoholic individuals with early-onset, rapidly accelerating moderate use and early-onset, continuously increasing heavy use have more than double the prevalence of steatohepatitis or rejection on biopsy and graft failure and more frequent mortality resulting from recurrent alcoholic liver disease than late-onset (i.e., peak of heaviest drinking at 6y posttransplantation) alcohol users do. Fortunately, pretransplantation screening combined with a structured pretransplantation management program and a 12-step program attendance reduced recidivism. No randomized clinical trials have been performed that target pretransplantation risk factors in individuals with alcoholic liver disease before or after OLT to improve post-OLT outcomes.

CONCLUSIONS

Recent research findings suggest that screening can reveal individuals who are vulnerable to alcohol relapse and targeted intervention can prevent their relapse to alcohol. Based on existing addiction treatments (e.g., relapse prevention plan construction), randomized clinical trials tailored to post-OLT patients should be conducted to improve their survival and quality of life.

Informed consent: what the patient heard

Transplant Psychiatrist: "Why is it important to take (routine) medications after transplantation?" Transplant candidate: "To protect the liver." Doctor: "How?"

PATIENT

"I don't know." Doctor: "Think about it for a moment."

PATIENT

"To prevent rejection and infection." Doctor: "Which one: rejection or infection?"

PATIENT

"Both." This article reports significant conceptual limitations in patient medical knowledge. In the course of customary comprehensive psychiatric evaluation, patients with end-stage renal and/or hepatic disease were asked about knowledge of benefits and side effects of required post-transplant medication. Liver transplant candidates were asked about their understanding of primary organ function and instructed in reference to components of Model for End-stage Liver Disease status on the deceased donor transplant list. Candidates for renal transplantation were selectively asked about risks regarding medical dietary compliance, including dangers of hyperkalemia. PATIENTs had less than expected understanding of required immunosuppression. Liver transplant candidates, with infrequent exception, described the organ as a filter. Those with medical compliance problems related to end-stage renal disease had limited understanding of the kidney's role in homeostasis and impact of hyperkalemia on neurologic function. Additional teaching centered on narrative and analogy specific to individual life experience and skills. Historical reference to Sir Peter Medawar's Nobel Prize-winning work on skin allograft failure for treatment of World War II burn victims effectively illustrated the primacy of immunosuppression for successful organ transplantation. PATIENTs were receptive to this teaching approach. Many expressed gratitude for improved understanding. Clinical awareness of patient skills and life experience can enrich understanding of transplantation objectives and importance of medical compliance.

Neurologic aspects of multiple organ transplantation

Complex multiorgan failure may require simultaneous transplantation of several organs, including heart-lung, kidney-pancreas, or multivisceral transplantation. Solid organ transplantation can also be combined with hematopoietic stem cell transplantation to modulate immunologic response to a solid organ allograft. Combined multiorgan transplantation may offer a lower rate of allograft rejection and lower immunosuppression needs. In recent years, intestinal and multivisceral transplantations became viable as a rescue treatment for patients with irreversible intestinal failure who can no longer tolerate total parenteral nutrition with 70% survival after 5 years which is comparable to other types of solid organ allografts. Post-transplant neurologic complications were reported in up to 86% of allograft recipients and greatly overlap in intestinal and multivisceral allograft recipients, without a significant effect on the outcome of transplantation. Other common organ combinations in multiorgan transplantation include kidney-pancreas, which is mostly used for patients with renal failure and uncontrolled diabetes, and heart-lung for patients with congenital heart disease and idiopathic pulmonary arterial hypertension. Kidney-pancreas transplantation frequently results in an improvement of diabetic complications, including diabetic neuropathy. Heart-lung allograft recipients have very similar clinical course and spectrum of neurologic complications to lung transplant recipients. At this time there are no reports of an increased risk of graft-versus-host disease with combined transplantation of solid organ allograft and hematopoietic stem cells. Chronic immunosuppression and complex toxic-metabolic disturbances after multiorgan transplantation create a permissive environment for development of a wide spectrum of neurologic complications which largely resemble complications after transplantations of individual components of complex multiorgan allografts.

Psychiatric consultation after kidney transplantation: a 10-year single-center study including outpatients in Japan

BACKGROUND

The aim of this study was to elucidate the clinical characteristics and frequency of psychiatric consultation in a routine clinical setting after kidney transplantation.

METHODS

Subjects were 1,139 consecutive recipients who received kidney transplantation at our hospital between January 1997 and September 2006. The hospital patient database was searched to determine whether these recipients received psychiatric consultation after their transplantation during this period.

RESULTS

Among 1,139 recipients, 118 (10%) received psychiatric consultation after their transplantation. There were significantly more women among these recipients (p = 0.036). Many of the recipients had received psychiatric consultation before transplantation (p < 0.0001) and had received dialysis for a long time (p = 0.018). There were three main psychiatric diagnoses according to ICD-10 diagnostic criteria in these 118 recipients: 42 (36%) had neurotic, stress-related, and somatoform disorders (F4); 35 (30%) had organic, including symptomatic, mental disorders (F0); and 27 (23%) had mood (affective) disorders (F3). The median length of time between kidney transplantation and initial psychiatric consultation was 57 days (interquartile range: 10-650 days). The lengths were 7 days (6-17 days) for F0, 75 days (18-650 days) for F4, 243 days (35-1,004 days) for F3, and 253 days (10-1,393 days) for other diagnostic groups. Significant differences were observed among these four groups (Jonckheere-Terpstra test, p < 0.001).

CONCLUSION

Our results show that appropriate psychiatric intervention is necessary not only in early stages after kidney transplantation but also over the long term.

Predicting intentions and adherence behavior in the context of organ transplantation: gender differences of provided social support

OBJECTIVES

Medication non-adherence is a common problem in organ transplantation patients with severe consequences for the patients' health. This study aimed at examining the determinants of intention formation and adherence behavior based on the Theory of Planned Behavior (TPB). Moreover, to account for the role of patients' partners, provided social support by partners was included. Here, support provided by female partners was hypothesized to be more effective than support provided by male partners.

METHOD

This cross-sectional study comprised 121 heart, liver, lung, and kidney transplant recipients (n=81 men; mean age=54.32, SD=13.32) and their partners (mean age=51.99, SD=13.67). Patients completed a questionnaire with TPB variables and a validated measure of self-reported adherence. Partners reported their provided social support with regard to medication adherence of the patients.

RESULTS

For the prediction of intention to adhere to medication, the non-significant main effect of provided social support was qualified by partners' gender: Support provided by women was positively related to patients' intention to adhere, whereas support provided by men was slightly negatively related to the intention to adhere in their female spouses. Intentions in turn emerged together with relationship quality as the most important predictor of adherence behavior.

CONCLUSION

The beneficial effects of support provided by women could be replicated within the framework of the TPB in the context of organ transplantation. Interventions should focus on increasing the effectiveness of support provision of male partners and on promoting relationship quality.

Early liver transplantation for severe alcoholic hepatitis

BACKGROUND

A 6-month abstinence from alcohol is usually required before patients with severe alcoholic hepatitis are considered for liver transplantation. Patients whose hepatitis is not responding to medical therapy have a 6-month survival rate of approximately 30%. Since most alcoholic hepatitis deaths occur within 2 months, early liver transplantation is attractive but controversial.

METHODS

We selected patients from seven centers for early liver transplantation. The patients had no prior episodes of alcoholic hepatitis and had scores of 0.45 or higher according to the Lille model (which calculates scores ranging from 0 to 1, with a score ≥ 0.45 indicating nonresponse to medical therapy and an increased risk of death in the absence of transplantation) or rapid worsening of liver function despite medical therapy. Selected patients also had supportive family members, no severe coexisting conditions, and a commitment to alcohol abstinence. Survival was compared between patients who underwent early liver transplantation and matched patients who did not.

RESULTS

In all, 26 patients with severe alcoholic hepatitis at high risk of death (median Lille score, 0.88) were selected and placed on the list for a liver transplant within a median of 13 days after nonresponse to medical therapy. Fewer than 2% of patients admitted for an episode of severe alcoholic hepatitis were selected. The centers used 2.9% of available grafts for this indication. The cumulative 6-month survival rate (±SE) was higher among patients who received early transplantation than among those who did not (77 ± 8% vs. 23 ± 8%, P<0.001). This benefit of early transplantation was maintained through 2 years of follow-up (hazard ratio, 6.08; P = 0.004). Three patients resumed drinking alcohol: one at 720 days, one at 740 days, and one at 1140 days after transplantation.

CONCLUSIONS

Early liver transplantation can improve survival in patients with a first episode of severe alcoholic hepatitis not responding to medical therapy. (Funded by Société Nationale Française de Gastroentérologie.).

Reliability of INTERMED Spanish version and applicability in liver transplant patients: a cross-sectional study

Background

Integrated delivery methods in healthcare systems have been proposed to confront the increasing complexity in general health care. INTERMED is an empirically derived, observer-rated instrument to measure case complexity. It was intended as a visualized, action-oriented decision-support tool for the early assessment of bio-psychosocial health risks and health needs. This study aims to document the reliability and applicability of the Spanish version of INTERMED in liver transplant patients.

Methods

Cross-sectional study of patients who had been included in the liver transplant waiting list. Two nurses interviewed the patients with INTERMED, and scored the instrument blind to each other. Kappa and w-kappa, Spearman, Kendall and intraclass correlation coefficients, and Cronbach's alfa were calculated.

Results

No patient refused the interview. Satisfactory coefficients were documented in most INTERMED items. Kappa was = 0.858 for the categorization of patients as "complex", and 21 of them (48.8%) were classified in this category, and were considered to need integrated treatment.

Conclusions

The Spanish version of INTERMED is reliable. Its applicability in liver transplant patients adds to its generalizability.

Pretransplant depression, antidepressant use, and outcomes of orthotopic liver transplantation

Depression is a common problem among patients awaiting organ transplantation, but little is known about the impact of depression and its treatment on the outcomes of liver transplantation. In this retrospective cohort analysis, we studied all patients over 18 years of age who underwent liver transplantation during a 5-year period (2004-2008) at a single center. Among 179 recipients, 65 patients had depression, as defined by a health care provider assessment, before transplantation. Depression was defined as past or active depression or an adjustment disorder. The associations between pretransplant depression and various outcomes (time to death, graft failure, first acute cellular rejection episode, first infection, and first rehospitalization) were assessed. In the entire sample, more patients with depression required posttransplant psychiatric care (37% versus 18%); the adjusted hazard ratio was 2.28 (1.27-4.11). The rates of other outcomes, including hospital readmission, acute cellular rejection, graft failure, mortality, and infection, were similar for patients with depression and patients without depression. Among those with depression, patients on antidepressants at the time of transplantation had acute cellular rejection less frequently than those not taking antidepressants (13% versus 40%); the adjusted hazard ratio was 0.14 (0.03-0.62). The rates of other outcomes were similar between these 2 groups. These data indicate that depression affects posttransplant psychiatric morbidity but not other medical outcomes of liver transplantation. Pharmacological treatment of depression may significantly reduce the incidence of acute cellular rejection in patients undergoing liver transplantation. However, future prospective studies of mental health and liver transplantation are required to definitively assess the effects of antidepressant medications on medical outcomes.

Posttraumatic stress disorder and depression in heart transplantation recipients: the relationship with outcome and adherence to medical treatment

OBJECTIVE

There is growing evidence of the importance of psychiatric risk factors for predicting the outcome of heart transplantation (HT) recipients. The aim of our study was to investigate the role of major depression and posttraumatic stress disorder (PTSD) in the prediction of the outcome of HT in a consecutive sample of 107 recipients.

METHOD

All subjects of the study underwent a structured diagnostic interview for assessing the presence of pretransplant and posttransplant major depression and transplantation-related PTSD 1 to 5 years after HT. The adherence to medical treatment was assessed some months after the structured interview. The medical outcome (acute rejections, cancer, mortality) was followed up for 8 years on average after the interview, using a prospective design.

RESULTS

Estimated frequency of psychiatric diagnoses after HT was 12% for transplantation-related PTSD and 41% for major depression. The presence of an episode of major depression prior to HT is a significant independent risk factor for posttransplant malignancies. Age, posttransplant malignancies and poor adherence are significant predictors of mortality in the survival analyses.

CONCLUSIONS

The present study highlights the importance of the assessment of psychosocial variables and psychiatric diagnoses before and after transplantation in HT recipients. Our findings have important clinical implications and require replication with larger samples.

Transplant center provision of education and culturally and linguistically competent care: a national study

Although transplant centers are required to educate patients about kidney transplantation (KT) and living donation (LD), little is known about the educational format, and cultural and linguistic competence necessary for patients to make informed treatment decisions. This study surveyed US transplant administrators about education provided concerning KT and LD and culturally and linguistically competent care. Transplant administrators were invited to participate in an anonymous Internet-based survey about education format, education providers, promoting LD, culturally and linguistically competent care and center characteristics. Most (61%) transplant administrators contacted (N = 280/461) completed the survey. Most administrators (91%) reported that their center provides any type of formal education in their pre-KT evaluation. Education was mostly provided by: nurses (97%), social workers (72%) and surgeons (55%), and predominantly as one-on-one (80%) versus group discussions (60%). Education was primarily delivered through written materials (93%). Written educational materials in Spanish (86%) and the provision of interpreters (82%) were emphasized over educational sessions in Spanish (39%), or employing bilingual (51%) and bicultural staff (39%). Half (55%) promoted LD as the best option. Transplant centers need to take greater efforts to consistently provide appropriate education, promote LD, and provide culturally and linguistically competent care to ensure effective communication with all patients.