Liver versus cardiothoracic transplant candidates and their pretransplant psychosocial and behavioral risk profiles: good neighbors or complete strangers?

Psychosocial Characteristics of Patients Evaluated for Kidney, Liver, or Heart Transplantation

OBJECTIVE

Psychosocial parameters play a pivotal role in organ recipient evaluation before wait-listing for transplantation because of their impact on organ and patient outcome. Patients in need of heart (HTx), liver (LTx), or kidney transplantation (KTx) face distinct physical and psychological challenges. This study compares the psychosocial characteristics and preferences for additional therapy for patients undergoing assessment for these three types of organ transplantation to optimize patient-tailored psychological, social, and other supportive interventions.

METHODS

We conducted a cross-sectional, observational study with 1110 potential transplantation candidates (LTx, n = 544; KTx, n = 330; HTx, n = 236), psychosocial status was determined for depressive symptoms (Patient Health Questionnaire Depression Scale), anxiety symptoms (seven-item Generalized Anxiety Disorder Screener), health-related quality of life (36-Item Short Form Health Survey), perceived social support (Perceived Social Support Questionnaire), sense of coherence (SoC; short form of the Sense of Coherence Scale), self-efficacy (General Self-Efficacy Short Scale), and body image (German Body Image Questionnaire-20). Preferences for additional supportive therapy were assessed dichotomously. Data were analyzed using multivariate analysis of covariance and χ2 tests.

RESULTS

Patient groups differed significantly regarding depression ( F (2,1107) = 35.283, p < .001, partial η2 = 0.01), anxiety ( F (2,1107) = 15.027, p < .001, partial η2 = 0.03), health-related quality of life (physical: F (2,1107) = 96.772, p < .001, partial η2 = 0.15; mental: F (2,1107) = 11.442, p < .001, partial η2 = 0.02), perceived social support ( F (2,1107) = 20.813, p < .001, partial η2 = 0.04), SoC ( F (2,1107) = 12.920, p < .001, partial η2 = 0.02), self-efficacy ( F (2,1107) = 17.308, p < .001, partial η2 = 0.03), and body image (rejecting body evaluation: F (2,1107) = 5.006, p = .007, partial η2 = 0.01; vital body dynamics: F (2,1107) = 40.216, p < .001, partial η2 = 0.07). Patients evaluated for HTx showed the highest psychosocial impairment and the highest inclination regarding additional supportive therapy.

CONCLUSIONS

Patients evaluated for HTx, LTx, and KTx have distinct psychosocial characteristics and treatment preferences. HTx patients display the highest psychosocial impairment. We suggest psychocardiological treatment structures for optimal outcome.

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.

Depression and psychosocial correlates of liver transplant candidates: a systematic review

INTRODUCTION

Liver transplant candidates are vulnerable to develop depression. This paper aims to ascertain the prevalence of depression in liver transplant candidates and its psychosocial factors in a systematic review.

METHODS

An extensive review via electronic databases (PubMed, EMBASE, CINAHL) and hand search were carried out to retrieve published articles up to December 15, 2013, using (Incidence OR Prevalence) AND Depress* AND liver transplant as the keywords. Information on the study design, patient characteristics, prevalence of depression, and its associated risk factors were extracted from included studies.

RESULTS

There were 22 studies included in this review with a total of 3055 patients. The prevalence of depression in the liver transplant candidates ranges between 2% and 80%. Studies that used diagnostic tools found a narrower range of prevalence (4.5-43%) as compared to the self-administered questionnaires (2-80%). Studies that used Beck Depression Inventory reported a higher prevalence than those studies which used Hospital Anxiety and Depression Scale (median = 28%, range = 2-80% versus median 17%, range 6.1-25.8%). A number of socio-demographic factors, illness-related and psychosocial factors were found to be associated with depression.

CONCLUSION

Prevalence of depression in liver transplant candidates is high, and early detection will improve survival and quality of life.

Describing the evolution of medication nonadherence from pretransplant until 3 years post-transplant and determining pretransplant medication nonadherence as risk factor for post-transplant nonadherence to immunosuppressives: the Swiss Transplant Cohort Study

Although medication nonadherence (MNA) is a major risk factor for poor outcomes, the evolution of MNA from pre- to 3 years post-transplant among the four major organ transplant groups remains unknown. Therefore, this study described this evolution and investigated whether pretransplant MNA predicts post-transplant immunosuppressive medication nonadherence (IMNA). Adult participants (single transplant, pretransplant and ≤1 post-transplant assessment, using medications pretransplant) in the Swiss Transplant Cohort Study (a prospective nation-wide cohort study) were included. Nonadherence, defined as any deviation from dosing schedule, was assessed using two self-report questions pretransplant and at 6, 12, 24 and 36 months post-transplant. Nonadherence patterns were modelled using generalized estimating equations. The sample included 1505 patients (average age: 52.5 years (SD: 13.1); 36.3% females; 924 renal, 274 liver, 181 lung, 126 heart). The magnitude and variability of self-reported MNA decreased significantly from pretransplant to 6 months post-transplant (OR = 0.21; 95% CI: 0.16-0.27). Post-transplant IMNA increased continuously from 6 months to 3 years post-transplant (OR = 2.75; 95% CI: 1.97-3.85). Pretransplant MNA was associated with threefold higher odds of post-transplant IMNA (OR = 3.10; 95% CI: 2.29-4.21). As pretransplant MNA predicted post-transplant IMNA and a continuous increase in post-transplant IMNA was observed, early adherence-supporting interventions are indispensible.

Mental health affects the quality of life and recovery after liver transplantation

There has been little research examining the effects of mental health before liver transplantation on quality of life (QOL) and recovery after transplantation. Therefore, the purpose of the current study was to examine how pretransplant depression and anxiety affect mental health, QOL, and recovery after transplantation. Eighty-two transplant recipients provided data when they were listed for transplantation and 6 months after transplantation. Pretransplant anxiety predicted posttransplant anxiety (P < 0.001), and there was a trend in predicting posttransplant depression (P = 0.06). Pretransplant depression predicted posttransplant depression (P = 0.03), and there was a trend in predicting posttransplant anxiety (P = 0.06). Additionally, pretransplant anxiety predicted posttransplant QOL for several domains, including Body Pain, Role Limitations Due to Emotional Problems, and Mental Health, as well as the Mental Health Composite Score (P < 0.05). However, in comparison with anxiety, pretransplant depression independently predicted outcomes for more QOL domains, which included Physical Functioning, Role Limitations Due to Physical Problems, General Health, Vitality, and Social Functioning, as well as the Physical Composite Score (P < 0.05). Patients with depression at the baseline were more likely to report incomplete recovery 6 months after transplantation (P < 0.001). With respect to baseline anxiety, there was a trend suggesting that these patients were also more likely to report incomplete recovery (P = 0.09). These findings highlight the importance of evaluating transplant candidates both before and after transplantation for anxiety and depressive symptoms. Once patients with these symptoms are identified, they can be referred for treatment, which may lead to better posttransplant outcomes for mental health, QOL, and recovery.

Psychosocial issues facing lung transplant candidates, recipients and family caregivers

Although lung transplantation is an accepted treatment for many individuals with severe lung disease, transplant candidates and recipients experience a range of psychosocial stressors that begin at the initiation of the transplant evaluation and continue throughout patients' wait for donor lungs, their perioperative recovery, and their long-term adjustment to posttransplant life. Transplant programs should strive to incorporate evidence-based interventions that aim to improve physical functioning, psychological distress, global quality of life, and medical adherence as well as to integrate symptom management and palliative care strategies throughout the pre- and posttransplantation course.

The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT): a new tool for the psychosocial evaluation of pre-transplant candidates

BACKGROUND

While medical criteria have been well established for each end-organ system, psychosocial listing criteria are less standardized. To address this limitation, we developed and tested a new assessment tool: the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT).

METHODS

The SIPAT was developed from a comprehensive review of the literature on the psychosocial factors that impact transplant outcomes. Five examiners blindly applied the SIPAT to 102 randomly selected transplant cases, including liver, heart, and lung patients. After all subject's files had been rated by the examiners, the respective transplant teams provided the research team with the patient's outcome data.

RESULTS

Univariate logistic regression models were fit in order to predict the transplant psychosocial outcome (positive or negative) using each rater's SIPAT scores. These results show that SIPAT scores are highly predictive of the transplant psychosocial outcome (P < 0.0001). The instrument has excellent inter-rater reliability (Pearson's correlation coefficient = 0.853), even among novice raters.

CONCLUSIONS

The SIPAT is a comprehensive screening tool to assist in the psychosocial assessment of organ transplant candidates. Its strengths includes the standardization of the evaluation process and its ability to identify subjects who are at risk for negative outcomes after the transplant, in order to allow for the development of interventions directed at improving the patient's candidacy. Our goal is that the SIPAT, in addition to a set of agreed upon minimal psychosocial listing criteria, would be used in combination with organ-specific medical listing criteria in order to establish standardized criteria for the selection of transplant recipients.

Psychosocial factors in noncompliance during liver transplant selection

This exploratory study attempted to identify characteristics of patients selected for transplant compared to those who had not demonstrated 6 months alcohol, drug and tobacco abstinence at the time of candidacy assessment. In a consecutive sample of 112 patients referred for liver transplant, almost half failed this criteria. Comparisons on psychometric measures of coping, social support, and health status revealed noncompliant patients to be significantly less authority abiding, less concerned about their illness, and less spiritually-oriented. Persisting alcohol use was paradoxically associated with greater psychosocial support whereas depression was related to smoking. Prior drug use was associated with more cognitive symptom complaints, emotional constriction, a vulnerability to feel dejection and a proneness to abuse medications These findings were discussed as a possible opportunity to identify and address characteristics of transplant candidates to reduce their risk of perpetuating noncompliance while competing for a life saving intervention.

Liver transplant recipients: individual, social, and environmental resources

CONTEXT

Patient characteristics are important in the liver transplant population because of proven associations between individual and environmental factors, treatment adherence, and health outcomes in general medical and other transplant populations.

OBJECTIVE

To determine generalizability of the sample to other liver transplant populations and to establish reliability of measures used to assess individual and environmental resources.

DESIGN

Cross-sectional analysis of baseline data in a longitudinal study of adherence and health outcomes.

PARTICIPANTS, SETTING

Ninety first-time adult liver transplant recipients at the University of Pittsburgh Medical Center completed assessments of sociodemographic, health history, psychosocial, and environmental factors shortly after surgery; adherence and health outcomes were tracked throughout the study.

RESULTS

The medical center cohort was older, less racially diverse, and contained more living donors than the national sample. Our sample was generally comparable to the medical center cohort on pretransplant sociodemographic and clinical characteristics. Reliability/internal consistency on psychological measures was similar between our sample and most published norms. The mean scores on all coping scales in our sample were higher than normative. Our patients indicated a more negative perception of family environment and perceived relationships with their primary caregiver more positively than did the normative group.

CONCLUSION

The generalizability of our sample to the parent population and reliability of individual and environmental measures reported here will enable us to examine relationships and the value of patient and contextual resources for predicting treatment adherence and health outcomes among liver transplant recipients.

Liver Transplant Recipients: Individual, Social, and Environmental Resources

Context

Patient characteristics are important in the liver transplant population because of proven associations between individual and environmental factors, treatment adherence, and health outcomes in general medical and other transplant populations.

Objective

To determine generalizability of the sample to other liver transplant populations and to establish reliability of measures used to assess individual and environmental resources.

Design

Cross-sectional analysis of baseline data in a longitudinal study of adherence and health outcomes.

Participants, Setting

Ninety first-time adult liver transplant recipients at the University of Pittsburgh Medical Center completed assessments of sociodemographic, health history, psychosocial, and environmental factors shortly after surgery; adherence and health outcomes were tracked throughout the study.

Results

The medical center cohort was older, less racially diverse, and contained more living donors than the national sample. Our sample was generally comparable to the medical center cohort on pretransplant sociodemographic and clinical characteristics. Reliability/internal consistency on psychological measures was similar between our sample and most published norms. The mean scores on all coping scales in our sample were higher than normative. Our patients indicated a more negative perception of family environment and perceived relationships with their primary caregiver more positively than did the normative group.

Conclusion

The generalizability of our sample to the parent population and reliability of individual and environmental measures reported here will enable us to examine relationships and the value of patient and contextual resources for predicting treatment adherence and health outcomes among liver transplant recipients.