The Utility of a Pre-Transplant Psychosocial Evaluation in Predicting Post-Liver Transplant Outcomes

Association of psychosocial risk factors and liver transplant evaluation outcomes in metabolic dysfunction-associated steatotic liver disease

The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) is a standardized psychosocial assessment tool used in liver transplantation (LT) evaluation and has been primarily studied in patients with alcohol-associated liver disease. We aimed to evaluate the relationship between SIPAT score and metabolic syndrome severity and LT waitlist outcomes in a large cohort of patients with metabolic dysfunction-associated steatotic liver disease (MASLD). We performed a single-center retrospective cohort study of patients with MASLD evaluated for LT from 2014 to 2021. The utility of the previously defined total SIPAT cutoff (<21 [excellent/good candidates] vs. ≥21 [minimally acceptable/high-risk candidates]) was studied. Multivariable logistic regression analyses examined associations between continuous SIPAT scores and LT waitlisting outcomes. The Youden J statistic was used to identify the optimal SIPAT cutoff for patients with MASLD. A total of 480 patients evaluated for transplant with MASLD were included. Only 9.4% of patients had a SIPAT score ≥21. Patients with SIPAT score ≥21 had higher hemoglobin A1c compared to patients with lower psychosocial risk (median [IQR]: 7.8 [6.0-9.7] vs. 6.6 [5.8-7.9]; p = 0.04). There were no other differences in metabolic comorbidities between SIPAT groups. Increasing SIPAT score was associated with decreased odds of listing (OR: 0.82 per 5-point increase; p = 0.003) in multivariable models. A SIPAT of ≥12 was identified as the optimal cutoff in this population, resulting in an adjusted OR for a listing of 0.53 versus SIPAT <12 ( p = 0.001). In this large cohort of patients with MASLD evaluated for LT, few patients met the previously defined high SIPAT cutoff for transplant suitability. Nevertheless, increasing the SIPAT score was associated with waitlist outcomes. Our suggested SIPAT cutoff of ≥12 for patients with MASLD warrants further external validation using data from other centers.

Identification of Psychosocial Issues in Pediatric Patients Undergoing or Waiting for Organ Transplant: A Systematic Review

OBJECTIVES

Despite increased rates of survival, pediatric organ transplant is characterized by clinical complexities and psychosocial challenges. Understanding and addressing the psychosocial issues inherent in this population are crucial for optimizing their overall well-being and transplant outcomes. In this systematic review, we thus aimed to provide a comprehensive analysis of the psychosocial issues encountered by pediatric patients undergoing or awaiting organ transplant.

MATERIALS AND METHODS

This systematic review was conducted by retrospectively searching PubMed, Scopus, ScienceDirect, and Cochrane electronic databases using the keywords "pediatric kidney transplantation" or "pediatric liver transplantation" or "pediatric heart transplantation" and "psychosocial problems" or "psychosocial issues" or "psychosocial outcomes" or "psychosocial needs." The literature review resulted in 3746 initial studies, with 6 studies included in this systematic review.

RESULTS

Examination of psychosocial problems experienced by pediatric organ transplant recipients in included studies showed factors such as depression, anxiety, quality of life, medication adherence, psychological distress, children's psychosocial characteristics, healthy behaviors, mental and somatic well-being, fear of rejection, fear of recurrence, fear of secondary diseases, sleep problems, sadness, and exhaustion.

CONCLUSIONS

Pediatric organ transplant intertwines complex medical procedures with intricate psychosocial dynamics, placing nurses at the forefront of care delivery for pediatric transplant recipients and their families. In embracing a holistic approach to care, nurses advocate for the integration of psychosocial support into standard practice protocols, recognizing that optimal health outcomes extend beyond physiological parameters.

Liver transplantation for alcohol-associated liver disease

Alcohol-associated liver disease (ALD) is a major cause of morbidity and mortality worldwide, and a leading indication for liver transplantation (LT) in many countries, including the United States. However, LT for ALD is a complex and evolving field with ethical, social, and medical challenges. Thus, it requires a multidisciplinary approach and individualized decision-making. Short-term and long-term patient and graft survival of patients undergoing LT for ALD are comparable to other indications, but there is a continued need to develop better tools to identify patients who may benefit from LT, improve the pretransplant and posttransplant management of ALD, and evaluate the impact of LT for ALD on the organ donation and transplantation systems. In this review, we summarize the current evidence on LT for ALD, from alcohol-associated hepatitis to decompensated alcohol-associated cirrhosis. We discuss the indications, criteria, outcomes, and controversies of LT for these conditions and highlight the knowledge gaps and research priorities in this field.

Reexamining "psychosocial clearance": A procedural framework for psychosocial evaluation in liver transplantation

Psychosocial and "nonmedical" phenomena are commonly encountered in liver transplantation (LT) evaluations. They are simultaneously crucial decision-making factors and some of the most difficult and controversial clinical matters clinicians confront. Epidemiology, societal trends, and the preponderance of psychological and behavioral factors underpinning common end-stage liver diseases ensure that LT teams will continue to encounter highly complex psychosocial patient presentations. Psychosocial policies, practices, and opinions vary widely among clinicians and LT centers. Liver clinicians already report insufficient psychosocial expertise, which creates a large gap between the stark need for psychosocial expansion, improvement, and innovation in LT and the lack of accompanying guidance on how to achieve it. While the clinical domains of an LT psychosocial evaluation have been well-described, few articles analyze the procedures by which teams determine candidates' "psychosocial clearance" and no conceptual frameworks exist. This article proposes a framework of core domains of psychosocial evaluation procedures, common pitfalls, and practical improvement strategies.

Assessing reliability and validity of SIPAT and opportunities for improvement: A single-center cohort study

Psychosocial assessment is a standard component of patient evaluations for transplant candidacy. The Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) is a widely used measure to assess psychosocial risk for transplant. However, there are questions regarding the SIPAT's reliability and validity. We examined the SIPAT's psychometric performance and its impact on equitable access to transplant in a diverse cohort of 2825 patients seeking liver transplantation between 2014 and 2021 at an urban transplant center. The SIPAT demonstrated good internal consistency reliability at the overall score [Cronbach's α = 0.85, 95% CI (0.83, 0.86)] and domain levels (0.80 > α > 0.70). There was mixed support for structural validity, with poor overall model fit in confirmatory factor analysis and 50% of questions achieving the 0.70-factor loadings threshold. Adjusting for sociodemographic variables, the odds of not being waitlisted for psychosocial reasons were three times higher for patients with Medicaid insurance than patients with private insurance [OR 3.24, 95% CI (2.09, 4.99)] or Medicare [OR 2.89, 95% CI (1.84, 4.53)], mediated by higher SIPAT scores. Black patients had nearly twice the odds of White patients [OR 1.88, 95% CI (1.20, 2.91)], partially mediated by higher social support domain scores. Patients with Medicaid, non-White patients, and those without a college degree scored significantly higher on collinear questions, disproportionately contributing to higher SIPAT scores. The SIPAT did not perform equally across insurance type, race/ethnicity, and education groups, with the lowest subgroup validity associated with patient readiness and psychopathology domains. The SIPAT should be interpreted with caution, especially as a composite score. Future studies should examine validity in other populations.

Association of the Stanford Integrated Psychosocial Assessment for Transplant and 1-Year Outcome of Living Kidney Transplantation in Japan

BACKGROUND

Because most kidney transplantations in Japan are performed on the basis of living donors, after-transplant outcomes should achieve optimum results, overcoming participants' possible reduced adherence.

OBJECTIVE

To investigate the association between the Japanese version of the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT-J) and outcomes, 1 year after the patient's living kidney transplant (LKT).

METHODS

The prospective cohort study was undertaken at Tokyo Women's Medical University Hospital from January 2020 to July 2021, with a 1-year follow-up period. The SIPAT-J assesses 18 psychosocial risk factors: (1) Patient's Readiness Level and Illness Management (SIPAT A), (2) Social Support System Level of Readiness (SIPAT B), (3) Psychological Stability and Psychopathology (SIPAT C), and (4) Lifestyle and Effect of Substance Use (SIPAT D). The evaluators, a psychiatrist and 3 clinical psychologists, conducted an independent, blinded application of the SIPAT-J using participants' medical records. The study focused on physical composite outcomes, psychiatric outcomes, and nonadherent behaviors.

RESULTS

The participants were 173 LKT recipients (median age [interquartile range], 51 [38-59]); 67.1% were male and 67.1% were employed. The median (interquartile range) SIPAT scores were SIPAT A [7 (5-9)], SIPAT B [7 (5-9)], SIPAT C [2 (0-4)], SIPAT D [3 (3-4)], and SIPAT total [20 (16-23)]. The physical composite outcome was 25 (14.5%), psychiatric outcome 9 (5.2%), and nonadherent behavior 17 (9.8%). SIPAT C (odds ratio = 1.34, 95% confidence interval = 1.06-1.72, P = 0.02) was significantly associated with the psychiatric outcome. SIPAT B (odds ratio = 1.49, 95% confidence interval = 1.12-1.98, P = 0.01) and SIPAT total (odds ratio = 1.13, 95% confidence interval = 1.03-1.24, P = 0.01) were significantly associated with nonadherent behaviors. There was no significant association between the SIPAT and physical composite outcomes.

CONCLUSION

This study is the first to examine the association between SIPAT and physical and psychiatric outcomes 1 year after LKT, controlling for follow-up periods and factors other than SIPAT. Comprehensive psychosocial assessment before LKT and early identification of factors that may negatively affect transplant success can allow targeted interventions to be implemented and increase the likelihood of favorable recipient outcomes.

Psychosocial assessment tools for use before transplantation are predictive of post-operative psychosocial and health behavior outcomes: a narrative review of the literature

Introduction

In end-stage diseases, transplantation may be necessary. The limited number of donors led to the development of several pre-transplant psychosocial assessment tools. We summarized the predictive value of these tools before solid-organ transplantation.

Methods

The PRISMA search strategy and the MEDLINE database were used to review the literature. From 1,050 records, we found thirteen studies using four different scales (Millon Behavioral Health Inventory [MBHI], Psychosocial Assessment of Transplant Candidates [PACT], Stanford Integrated Psychosocial Assessment for Transplantation [SIPAT], and Transplant Evaluation Rating Scale [TERS]).

Results

TERS and MBHI were associated with the highest number of positive studies concerning pre-transplant scores and primary outcomes. Psychosocial scales predict in a systematic way psychosocial and health behavioural outcomes, but generated mixed results for mortality and rejection.

Discussion

This narrative review underlines the need for multidisciplinary evaluation and well-conducted clinical trials to assist transplant teams in utilizing psychosocial evaluation effectively during evaluation of candidates.

Impact of psychosocial factors on medication level variability index and outcomes in pediatric liver transplant recipients

BACKGROUND

Caregivers play an important role in maintaining a functioning graft after pediatric liver transplantation. Therefore, the psychosocial factors of both patients and caregivers can have a critical impact on transplant outcomes. Appropriate assessment and recognition of these factors pre-transplantation may allow transplant teams to better define the needs of pediatric organ recipients and develop specific countermeasures, which may then contribute toward improving transplant outcomes.

METHODS

We studied 136 pediatric LT recipients followed at Texas Children's Hospital. Licensed social workers conducted comprehensive pre-transplant assessments on each patient, consisting of 22 psychosocial variables that were thought to impact adherence, which were reviewed during our study period. Non-adherence was determined using the MLVI for up to 4 years after transplantation. Biopsy-confirmed rejection episodes were assessed in the first 3 years after liver transplantation.

RESULTS

Factors significantly associated with non-adherence (defined as MLVI >2) included parental age and parental education level at assessment, type of insurance, and household income. The number of ACR episodes trended higher in patients with non-adherence, and these patients had a higher number of moderate to severe rejection episodes but this trend was not statistically significant.

CONCLUSIONS

Psychosocial characteristics such as parental age, education level, insurance, and household income may contribute significantly to suboptimal adherence to medications after transplantation. Identification of these psychosocial factors and early intervention is essential to the success and equitable care of our pediatric LT recipients.

Psychosocial considerations in the combined bariatric surgery and organ transplantation population: a review of the overlapping pathologies and outcomes

PURPOSE OF REVIEW

This review highlights the salient data of the psychosocial concerns that influence outcomes of bariatric surgery and organ transplantation.

RECENT FINDINGS

Bariatric surgery has emerged as an important intervention with data supporting substantial and sustained weight loss, enhanced quality of life, remission of obesity-related medical comorbidities, and improved long-term patient and graft survival in transplant patients. Depression, suicide, anxiety, posttraumatic stress disorder, alcohol use, adherence, and psychopharmacology considerations can influence outcomes of both these surgeries.

SUMMARY

Obesity is increasingly prevalent among patients pursuing transplantation surgery, and it is often a factor in why a patient needs a transplant. However, obesity can be a barrier to receiving a transplant, with many centers implementing BMI criteria for surgery. Furthermore, obesity and obesity-related comorbidities after transplant can cause poor outcomes. In this context, many transplant centers have created programs that incorporate interventions (such as bariatric surgery) that target obesity in transplant candidates. A presurgery psychosocial assessment is an integral (and required) part of the process towards receiving a bariatric surgery and/or a transplantation surgery. When conducting a dual (bariatric and transplantation surgery) psychosocial assessment, it is prudent to understand the overlap and differentiation of specific psychosocial components that influence outcomes in these procedures.

Association between social determinants of health and rates of liver transplantation in individuals with cirrhosis

BACKGROUND AND AIMS

This study evaluated the association between neighborhood-level social determinants of health (SDOH) and liver transplantation (LT) among patients with cirrhosis who have universal access to health care.

APPROACH AND RESULTS

This was a retrospective population-based cohort study from 2000-2019 using administrative health care data from Ontario, Canada. Adults aged 18-70 years with newly decompensated cirrhosis and/or HCC were identified using validated coding. The associations between five neighborhood level SDOH quintiles and LT were assessed with multivariate Fine-Gray competing risks regression to generate subdistribution HRs (sHRs) where death competes with LT. Overall, n = 38,719 individuals formed the cohort (median age 57 years, 67% male), and n = 2788 (7%) received LT after a median of 23 months (interquartile range 3-68). Due to an interaction, results were stratified by sex. After multivariable regression and comparing those in the lowest versus highest quintiles, individuals living in the most materially resource-deprived areas (female sHR, 0.61; 95% CI, 0.49-0.76; male sHR, 0.55; 95% CI, 0.48-0.64), most residentially unstable neighborhoods (female sHR, 0.61; 95% CI, 0.49-0.75; male sHR, 0.56; 95% CI, 0.49-0.65), and lowest-income neighborhoods (female sHR, 0.57; 95% CI, 0.46-0.7; male sHR, 0.58; 95% CI, 0.50-0.67) had ~40% reduced subhazard for LT (p < 0.01 for all). No associations were found between neighborhoods with the most diverse immigrant or racial minority populations or age and labor force quintiles and LT.

CONCLUSIONS

This information highlights an urgent need to evaluate how SDOH influence rates of LT, with the overarching goal to develop strategies to overcome inequalities.

The role of preoperative psychosocial counseling on the improvement of the recipient compliance and speed of recovery after liver transplantation - A systematic review of the literature and expert panel recommendations

BACKGROUND

Psychosocial disorders ranging from anxiety to severe psychiatric diseases and active alcohol/substance abuse are frequent in liver transplant candidates and potentially associated with worse post- transplant outcomes. Therefore, psychosocial evaluation is mandatory to optimize success after liver transplantation. However, how to carry out this evaluation, the type of intervention needed and its potential impact on patient outcome remain unclear.

OBJECTIVES

To investigate whether psychosocial assessment may help in predicting risks of poor outcome; and to investigate whether psychosocial interventions may mitigate these risks and improve posttransplant outcomes, in particular compliance and speed of recovery.

DATA SOURCES

Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central.

METHODS

Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. The protocol was registered on PROSPERO CRD42021238361. Main outcomes assessed were mortality, alcohol relapse, rejection, and medication compliance.

RESULTS

Fifteen studies were analyzed including five observational comparative and ten observational noncomparative studies. Preoperative psychosocial evaluation of LT candidates was associated with higher concordance with the treatment plan (i.e., higher adherence to treatment and lower alcohol relapse) and lower rates of rejection. Psychosocial assessment tools were used in some studies to guide the evaluation, but their predictive ability remains debated, and they should not be used in isolation. Most of the interventions were studied in patients with alcohol related issues. In this context, support by specialized teams was associated with better posttransplant outcome, especially through a decrease in post-transplant alcohol relapse.

CONCLUSIONS

Preoperative psychosocial assessment should be provided in order to detect patients at increased risk of poorer post-transplant outcome, in particular in terms of concordance to the treatment plan (Quality of Evidence; Low | Grade of Recommendation; Strong/For). The experts suggest that, when possible, provision of preoperative psychological assessment and concomitant interventions aimed at improving the concordance to treatment plans will positively impact the success of liver transplantation. (Quality of Evidence; Very Low | Grade of Recommendation; Strong/For].