History of psychosis and mania, and outcomes after kidney transplantation - a retrospective study

The Outcomes of Liver Transplantation in Highly Dependent Incapacitated Patients with Intellectual and Developmental Disabilities

Background/Objectives: Data regarding the outcomes of liver transplantation in disabled, highly dependent, and legally incapacitated adults are scarce, likely due to the infrequency of these procedures in such populations. Multicenter studies in adult transplant centers have shown that patients with coexisting intellectual and developmental disabilities (IDDs) may be denied transplantation because of their expected low longevity and the complexities associated with managing post-transplant care. We examined the long-term patient and graft outcomes in highly dependent, incapacitated patients with IDDs who underwent elective transplantation for chronic liver disease. Methods: Six adult patients who underwent liver transplantation for primary biliary cholangitis (n = 2), hepatitis C cirrhosis (n = 2), Wilson's disease (n = 1), and autoimmune hepatitis (n = 1) were included. The main causes of their disability were infantile cerebral palsy, myotonia, and Niemann-Pick disease. Results: Four of the six patients were women, with a median age of 26 (range: 23-36) years. Only one patient died during follow-up. Their 1- and 5-year survival rates were 100 and 75%, respectively, which were not statistically different from those of the general cohort of electively transplanted patients (95.8 and 90.1%, respectively) (p = 0.35). Conclusions: Adult patients who are highly dependent, disabled, or legally incapable should not be denied liver transplantation because of poor long-term survival rates. Physiological disorders and psychiatric comorbidities should not prevent patients from receiving life-saving surgeries due to poor postoperative compliance or low quality of life.

Chronic kidney disease and severe mental illness: a scoping review

BACKGROUND

People who have severe mental illness experience higher rates of long-term conditions and die on average 15-20 years earlier than people who do not have severe mental illness, a phenomenon known as the mortality gap. Long-term conditions, such as diabetes, impact health outcomes for people who have severe mental illness, however there is limited recognition of the relationship between chronic kidney disease and severe mental illness. Therefore, the aim of this scoping review was to explore the available evidence on the relationship between chronic kidney disease and severe mental illness.

METHODS

Electronic databases, including MEDLINE, Embase, CINAHL, and PsycINFO were searched. The database searches were limited to articles published between January 2000-January 2022, due to significant progress that has been made in the detection, diagnosis and treatment of both SMI and CKD. Articles were eligible for inclusion if they explored the relationship between SMI and CKD (Stages 1-5) in terms of prevalence, risk factors, clinical outcomes, and access to treatment and services. Severe mental illness was defined as conditions that can present with psychosis, including schizophrenia, schizoaffective disorder, bipolar disorder, and other psychotic disorders. Thirty articles were included in the review.

RESULTS

The included studies illustrated that there is an increased risk of chronic kidney disease amongst people who have severe mental illness, compared to those who do not. However, people who have severe mental illness and chronic kidney disease are less likely to receive specialist nephrology care, are less likely to be evaluated for a transplant, and have higher rates of mortality.

CONCLUSION

In conclusion, there is a dearth of literature in this area, but the available literature suggests there are significant health inequalities in kidney care amongst people who have severe mental illness. Further research is needed to understand the factors that contribute to this relationship, and to develop strategies to improve both clinical outcomes and access to kidney care.

Chronic Kidney Disease and Severe Mental Illness: Addressing Disparities in Access to Health Care and Health Outcomes

Individuals with severe mental illness, including conditions such as schizophrenia and bipolar disorder, are at a higher risk of developing CKD. Higher incidences of CKD in this population can be partially explained by known risk factors, such as the use of lithium treatment and higher rates of cardiovascular disease. However, this does not fully explain the higher proportion of CKD in individuals with severe mental illness, and further research investigating the factors influencing disease onset and progression is needed. Similarly, although it is well documented that mental health difficulties, such as depression and anxiety, are highly prevalent among individuals with CKD, there is a lack of published data regarding the rates of severe mental illness in individuals with CKD. Furthermore, for individuals with CKD, having severe mental illness is associated with poor health outcomes, including higher mortality rates and higher rates of hospitalizations. Evidence also suggests that individuals with severe mental illness receive suboptimal kidney care, have fewer appointments with nephrologists, and are less likely to receive a kidney transplant. Limited research suggests that care might be improved through educating kidney health care staff regarding the needs of patients with severe mental illness and by facilitating closer collaboration with psychiatry. Further research investigating the rates of severe mental illness in patients with CKD, as well as the barriers and facilitators to effective care for this population, is clearly required to inform the provision of appropriate supports and to improve health outcomes for individuals with CKD and co-occurring severe mental illness.

Prevalence of Mental Disorders in a German Kidney Transplant Population: Results of a KTx360°-Substudy

In patients after kidney transplantation (KTx) an increased rate of affective and anxiety disorders has been observed. Repeatedly, a relationship between mental health issues and increased morbidity and mortality in KTx recipients has been reported. However, information on the prevalence of mental disorders in KTx patients is scarce. As part of the structured multimodal follow-up program (KTx360°), mental disorders were examined in 726 patients after KTx through structured diagnostic interviews using the Mini-DIPS Open Access. Overall, 27.5% had a current and 49.2% a lifetime mental disorder. Only 14.5% with a current mental disorder reported to be in treatment. Affected patients were younger, more often female, reported more symptoms of anxiety and depression and less perceived social support. While comparable to the rate in general population samples, the prevalence of mental disorders should attract attention. The low treatment rate requires an improved identification of afflicted patients and provision of specialist treatment.ISRCTN registry, https://doi.org/10.1186/ISRCTN29416382 , date of registry: 03.05.2017.

Inequitable Access to Transplants: Adults With Impaired Decision-Making Capacity

Inequitable access to deceased donor organs for transplantation has received considerable scrutiny in recent years. Emerging evidence suggests patients with impaired decision-making capacity (IDC) face inequitable access to transplantation. The "Ethical and Legal Issues" working group of the European Society of Transplantation undertook an expert consensus process. Literature relating to transplantation in patients with IDC was examined and collated to investigate whether IDC is associated with inferior transplant outcomes and the legitimacy of this healthcare inequality was examined. Even though the available evidence of inferior transplant outcomes in these patients is limited, the working group concluded that access to transplantation in patients with IDC may be inequitable. Consequently, we argue that IDC should not in and of itself be considered as a barrier to either registration on the transplant waiting list or allocation of an organ. Strategies for non-discrimination should focus on ensuring eligibility is based upon sound evidence and outcomes without reference to non-medical criteria. Recommendations to support policy makers and healthcare providers to reduce unintended inequity and inadvertent discrimination are set out. We call upon transplant centres and national bodies to include data on decision-making capacity in routine reporting schedules in order to improve the evidence base upon which organ policy decisions are made going forward.

Psychosocial Evaluation of Candidates for Solid Organ Transplantation

Transplant candidates should undergo an assessment of their mental health, social support, lifestyle, and behaviors. The primary aims of this "psychosocial evaluation" are to ensure that transplantation is of benefit to life expectancy and quality of life, and to allow optimization of the candidate and transplant outcomes. The content of psychosocial evaluations is informed by evidence regarding pretransplant psychosocial predictors of transplant outcomes. This review summarizes the current literature on pretransplant psychosocial predictors of transplant outcomes across differing solid organ transplants and discusses the limitations of existing research. Pretransplant depression, substance misuse, and nonadherence are associated with poorer posttransplant outcomes. Depression, smoking, and high levels of prescription opioid use are associated with reduced posttransplant survival. Pretransplant nonadherence is associated with posttransplant rejection, and nonadherence may mediate the effects of other psychosocial variables such as substance misuse. There is evidence to suggest that social support is associated with likelihood of substance misuse relapse after transplantation, but there is a lack of consistent evidence for an association between social support and posttransplant adherence, rejection, or survival across all organ transplant types. Psychosocial evaluations should be undertaken by a trained individual and should comprise multiple consultations with the transplant candidate, family members, and healthcare professionals. Tools exist that can be useful for guiding and standardizing assessment, but research is needed to determine how well scores predict posttransplant outcomes. Few studies have evaluated interventions designed to improve psychosocial functioning specifically pretransplant. We highlight the challenges of carrying out such research and make recommendations regarding future work.

New-onset Psychosis in an Immunosuppressed Patient With Kidney Transplantation: An Educational Case Report

Rationale

New-onset psychosis in an immunosuppressed patient post-kidney transplantation (KT) is a diagnostic challenge. A broad differential diagnosis merits consideration; however, an approach to this differential diagnosis remains to be outlined in the literature. Also, when and how to modify the maintenance immunosuppressive regimen remains a significant area of controversy.

Presenting concerns

A 23-year-old male, known for X-linked Alport syndrome for which he had undergone KT 1 year prior, presented with a 1-week history of disorganized speech, bizarre behavior, religious delusions, and visual hallucinations.

Diagnoses

After ruling out infectious, metabolic, autoimmune, and structural causes, immunosuppressant medications were changed from tacrolimus to cyclosporine. The patient did not improve after this change, and a second opinion consultation with a transplant psychiatrist led to a diagnosis of primary first-episode psychosis, later refined to bipolar disorder type I.

Interventions

The patient was started on risperidone, which led to a significant improvement in his symptoms.

Outcomes

Twelve months after discharge, his mood and behavior had returned to baseline on aripiprazole, bupropion, and citalopram. However, he developed acute allograft rejection, prompting a change from cyclosporine back to tacrolimus, with stability of his mental state and graft function.

Teaching points

This report offers learners an extensive and organized differential diagnosis to the work up of psychosis post kidney transplantation. A complete history, with input from collateral sources, and a systematic approach to the differential diagnosis, are crucial and should not be overshadowed by the risk of immunosuppressant-related neurotoxicity. We underscore the importance of multi-disciplinary management and comprehensive psychosocial assessment and re-assessment to refine the diagnosis. We also report the successful re-introduction of tacrolimus once the diagnosis of a primary psychiatric disorder is confirmed. Finally, we offer a simplified approach that can aid in distinguishing between a primary psychiatric diagnosis versus tacrolimus-associated psychosis.

Association between Posttransplant Opioid Use and Immunosuppressant Therapy Adherence among Renal Transplant Recipients

INTRODUCTION

Little is known about the effect of posttransplant opioid use on adherence to immunosuppressant therapy (IST) among adult renal transplant recipients (RTRs).

OBJECTIVE

The aim of this study was to examine the relationship between opioid use and IST adherence among adult RTRs during the first year posttransplant.

METHODS

Longitudinal data were analyzed from a retrospective cohort study examining US veterans undergoing renal transplant from October 1, 2007, through March 31, 2015. Data were collected from the US Renal Data System, Centers for Medicare and Medicaid Services Data (Medicare Part D), and Veterans Affairs pharmacy records. Dose of opioid prescriptions was collected and divided based on annual morphine milligram equivalent within a year of transplant. Proportion of days covered of greater than or equal to 80% indicated adherence to tacrolimus. Unadjusted and multivariable-adjusted logistic regression analyses were performed.

RESULTS

A study population of 1,229 RTRs included 258 with no opioid use, while 971 opioid users were identified within the first year after transplantation. Compared to RTRs without opioid usage, RTRs with opioid usage had a lower probability of being adherent to tacrolimus in unadjusted logistic regression (odds ratio [OR] (95% confidence interval [CI]): 0.22 [0.07-0.72]) and adjusted logistic regression (OR [95% CI]: 0.11 [0.03-0.44]). These patterns generally remained consistent in unadjusted and adjusted main and sensitivity analyses.

CONCLUSIONS

Findings indicate RTRs who use prescription opioids during the first year posttransplant, regardless of the dosage/amount, are less likely to be adherent to tacrolimus. Future studies are needed to better understand underlying causes of the association between opioid use and tacrolimus nonadherence.

Graft Loss Following Onset of Schizophrenia Long After Liver Transplantation

Information regarding new-onset posttransplant psychotic disorders and their effect on nonadherence and posttransplant outcome is quite limited. We report a case of new-onset posttransplant schizophrenia that led to death. The patient, a woman with Wilson disease but no history of psychiatric problems or a substance use disorder had undergone liver transplantation at age 21. She married subsequently and bore children, being well able to handle her housework, child care, and full-time employment. She continued her medications as prescribed, and good graft function was maintained. At age 41, she experienced an episode of schizophrenia, then graft loss associated with nonadherence to immunosuppressive agents. Death ensued, occurring 6 months after the onset of schizophrenia. This case highlights the possibility that schizophrenia manifesting long after liver transplantation can result in graft loss and death due to medication nonadherence. Thus, awareness of the possibility of this rare clinical scenario is critical.

Causes of premature mortality in schizophrenia: a review of literature published in 2018

PURPOSE OF REVIEW

The current review examines the recent literature on the causes of premature mortality in schizophrenia.

RECENT FINDINGS

People with schizophrenia have higher premature mortality rates compared with the general population. Suicides and accidents account for a nontrivial part of the excess mortality, but the largest part is attributable to natural causes of death. Five major causes have been identified: first, adverse effects of medication; second, suboptimal lifestyle; third, somatic comorbidity; fourth, suboptimal treatment of somatic disorders; and fifth, accelerated ageing/genetic explanations. The positive aspect is that people with schizophrenia have increasing life expectancy, at least in high-income countries, and this development seems to largely follow the increase in the general population. Especially mortality rates from unnatural causes appear to have a positive impact. Nevertheless, despite more than 100 years of research and progress, the excess mortality in persons with schizophrenia remains unacceptably high, with no prospects of reaching the level in the general population.

SUMMARY

The excess mortality in schizophrenia has received much focus. Future studies should explore the reasons for the high rates of natural causes of death, while aiming to disentangle the complex interplay between medication, lifestyle, comorbidity, treatment of somatic disorders, and genetic effects.

History of posttraumatic stress disorder and outcomes after kidney transplantation

A history of posttraumatic stress disorder (PTSD), if uncontrolled, represents a contraindication for kidney transplantation. However, no previous large study has assessed the association between pretransplant history of PTSD and posttransplantation outcomes. We examined 4479 US veterans who had undergone transplantation. The diagnosis of history of PTSD was based on a validated algorithm. Measured covariates were used to create a matched cohort (n = 560). Associations between pretransplant PTSD and death with functioning graft, all-cause death, and graft loss were examined in survival models. Posttransplant medication nonadherence was assessed using proportion of days covered (PDC). From among 4479 veterans, 282 (6.3%) had a history of PTSD. The mean age ± standard deviation (SD) of the cohort at baseline was 61 ± 11 years, 91% were male, and 66% and 28% of patients were white and African American, respectively. Compared to patients without a history of PTSD, patients with a history of PTSD had a similar risk of death with a functioning graft (subhazard ratio [SHR] 0.97, 95% confidence interval [CI] 0.61-1.54), all-cause death (1.05, 0.69-1.58), and graft loss (1.09, 0.53-2.26). Moreover, there was no difference in immunosuppressive drug PDC in patients with and without a history of PTSD (PDC: 98 ± 4% vs 99 ± 3%, P = .733 for tacrolimus; PDC: 99 ± 4% vs 98 ± 7%, P = .369 for mycophenolic acid). A history of PTSD in US veterans with end-stage renal disease should not on its own preclude a veteran from being considered for transplantation.