Report of depressive symptoms on waiting list and mortality after liver and kidney transplantation: a prospective cohort study

Asian Pacific Association for the Study of the Liver clinical practice guidelines on liver transplantation

Liver transplantation is a highly complex and challenging field of clinical practice. Although it was originally developed in western countries, it has been further advanced in Asian countries through the use of living donor liver transplantation. This method of transplantation is the only available option in many countries in the Asia-Pacific region due to the lack of deceased organ donation. As a result of this clinical situation, there is a growing need for guidelines that are specific to the Asia-Pacific region. These guidelines provide comprehensive recommendations for evidence-based management throughout the entire process of liver transplantation, covering both deceased and living donor liver transplantation. In addition, the development of these guidelines has been a collaborative effort between medical professionals from various countries in the region. This has allowed for the inclusion of diverse perspectives and experiences, leading to a more comprehensive and effective set of guidelines.

Changes in Physical Activity Due to Fear of COVID-19 and Its Impact on Depression Among Post-Liver Transplant Patients in Japan: A Longitudinal Survey Study

BACKGROUND Regular physical activity (PA) is important for maintaining mental and physical health after liver transplantation (LT); however, the fluctuations in routine PA during COVID-19 and its putative impacts are currently unknown. This study examined the changes in PA during the COVID-19 pandemic and explored its association with fear and depression during the pandemic. MATERIAL AND METHODS This longitudinal study included 83 LT patients whose PA was measured using the short form of the International Physical Activity Questionnaire before and during COVID-19. Fear of COVID-19 was estimated based on previous studies, and depression was assessed using the Patient Health Questionnaire-9. Participants were also asked about important sources of information on COVID-19. PA was classified as inactive or active depending on the changes in PA, and logistic regression analyses with PA as a dependent variable were conducted to explore the associations among PA, depression, and fear of COVID-19. RESULTS Moderate and high PA exhibited decreasing trends before and during the COVID-19 pandemic, especially in males. Fear of being infected with SARS-CoV-2, the virus that causes COVID-19, while shopping was significantly higher in females and was significantly independent of inactivity during the COVID-19 pandemic. Only 1 patient reported that their transplant center was their main source of information about COVID-19. Only 4.9% of the LT participants were depressed. CONCLUSIONS Our study results indicate the need to support the provision of accurate information about COVID-19 by health care professionals in transplant centers, especially for patients with low PA, to prevent PA decline in LT patients.

Incidence of depression in kidney transplant recipients in South Korea: a long-term population-based study

Depression is associated with impaired quality of life and increased morbidity and mortality in end-stage kidney disease (ESKD) patients and kidney transplantation (KT) recipients. Depression incidence after KT is unclear. We compared depression incidence among KT recipients, ESKD patients, and healthy controls (HCs). We analyzed a nationwide health insurance database in South Korea and identified patients who underwent KT during 2007-2015. Participants were matched for age, sex, and inclusion year. KT and ESKD patients were further matched for hypertension and diabetes mellitus history. The incidence rate (IR, per 1000 patients-years) of depression was compared among KT, ESKD, and HC groups. We analyzed 5,234 patients per group. Depression incidence was markedly lower in KT than ESKD patients (IR, 18.87 vs. 58.03; hazard ratio [HR], 0.33; 95% confidence interval [CI], 0.30‒0.36), but only slightly higher in KT recipients than in HCs (IR, 18.87 vs. 17.49; HR, 1.08; 95% CI, 0.96‒1.22). After adjusting for comorbidities, the depression risk was lower in KT recipients than in HCs (adjusted HR, 0.52; 95% CI, 0.44‒0.62; p < 0.001), whereas it remained higher in ESKD patients than in HCs (adjusted HR, 1.60; 95% CI, 1.36‒1.87; p < 0.001). Among KT recipients, older age, female sex, lower economic status, and more comorbidities were associated with increased depression risk. Incident depression after KT increased mortality, graft failure, and death-censored graft failure risks in KT recipients. Our data suggest a broader role of KT than previously appreciated in terms of improving quality of life by reducing depression risk.

Assessment of mental health in patients with chronic liver disease

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Post-liver transplant outcomes in patients with major psychiatric diagnosis in the United States

INTRODUCTION AND OBJECTIVES

Higher rates of psychiatric disorders are reported among cirrhotic patients. This study examines the demographic and clinical outcomes post-liver transplant (LT) among cirrhotic patients with a major psychiatric diagnosis (cases) compared to those without psychiatric diagnosis (controls).

MATERIALS AND METHODS

Retrospective case control design was used among 189 cirrhotic patients who had undergone LT at Methodist University Hospital Transplant Institute, Memphis, TN between January 2006 and December 2014. Multivariable regression and Cox proportional hazard regression were conducted to compare allograft loss and all-cause mortality.

RESULTS

The study sample consisted of a matched cohort of 95 cases and 94 controls with LT. Females and those with Hepatic Encephalopathy (HE) were more likely to have psychiatric diagnosis. Patients with hepatocellular carcinoma (HCC) were twice as likely to have allograft loss. Psychiatric patients with HCC had two and a half times (HR 2.54; 95% CI: 1.20-5.37; p = 0.015) likelihood of all-cause mortality. Data censored at 1-year post-LT revealed that patients with psychiatric diagnosis have a three to four times higher hazard for allograft loss and all-cause mortality compared to controls after adjusting for covariates, whereas when the data is censored at 5 year, allograft loss and all-cause mortality have two times higher hazard ratio.

CONCLUSIONS

The Cox proportional hazard regression analysis of censored data at 1 and 5 year indicate higher allograft loss and all-cause mortality among LT patients with psychiatric diagnosis. Patients with well-controlled psychiatric disorders who undergo LT need close monitoring and medication adherence.

Psychosocial evaluation for liver transplantation: A brief guide for gastroenterologists

Liver transplantation is a lifesaving treatment that improves survival and quality of life. The procedure requires adequate transplant candidate selection carried out by a multidisciplinary team. Psychosocial evaluation is a necessary part of recipient selection and its primary aims are to identify problems and psychosocial needs of the patient and his/her family, to improve transplantation outcomes. Different psychosocial conditions are considered risk factors for morbidity and mortality after transplantation. The presence of those factors per se is not an absolute contraindication, thus adequate evaluation promotes equal access to healthcare, improves results, and optimizes resources. The present review provides an overview of and guidelines for the most important psychosocial issues during the pretransplantation phase.

KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation

The 2020 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation is intended to assist health care professionals worldwide who evaluate and manage potential candidates for deceased or living donor kidney transplantation. This guideline addresses general candidacy issues such as access to transplantation, patient demographic and health status factors, and immunological and psychosocial assessment. The roles of various risk factors and comorbid conditions governing an individual's suitability for transplantation such as adherence, tobacco use, diabetes, obesity, perioperative issues, causes of kidney failure, infections, malignancy, pulmonary disease, cardiac and peripheral arterial disease, neurologic disease, gastrointestinal and liver disease, hematologic disease, and bone and mineral disorder are also addressed. This guideline provides recommendations for evaluation of individual aspects of a candidate's profile such that each risk factor and comorbidity are considered separately. The goal is to assist the clinical team to assimilate all data relevant to an individual, consider this within their local health context, and make an overall judgment on candidacy for transplantation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Guideline recommendations are primarily based on systematic reviews of relevant studies and our assessment of the quality of that evidence, and the strengths of recommendations are provided. Limitations of the evidence are discussed with differences from previous guidelines noted and suggestions for future research are also provided.

Impact of psychosocial status on liver transplant process

Liver transplant candidates and recipients are at high risk of psychological distress. Social, psychological and psychiatric patterns seem to influence morbidity and mortality of patients before and after transplant. An accurate organ allocation is mandatory to guarantee an optimal graft and recipient survival. In this context, the pre-transplant social, psychological and psychiatric selection of potential candidates is essential for excluding major psychiatric illness and for estimating the patient compliance. Depression is one of the most studied psychological conditions in the field of organ transplantation. Notably, an ineffectively treated depression in the pre-transplant period has been associated to a worst long-term recipient survival. After transplant, personalized psychological intervention might favor recovery process, improvement of quality of life and immunosuppressant adherence. Active coping strategy represents one of the most encouraging ways to positively influence the clinical course of transplanted patients. In conclusion, multidisciplinary team should act in three directions: prevention of mood distress, early diagnosis and effective treatment. Active coping, social support and multidisciplinary approach might improve the clinical outcome of transplanted patients.

Psychological and Psychopathological Aspects of Kidney Transplantation: A Systematic Review

Kidney transplantation is a serious event that involves profound psychological, relational and social changes both for the patient and his family context. Assessment of personality profile, awareness of disease, family and social support of the patient candidate for kidney transplantation are necessary because factors not adequately considered, can influence the success of the transplant and alter the psychological stability of the patient. The present study aims to provide a systematic review of the literature of the last twelve years (2006-2018), focusing in particular on patient's readiness level and illness management and on possible psychopathology. Sixty-two studies were examined. Based on the Downs and Black checklist, most studies (n = 32) were of high quality; 15 of which related to lifestyle, health education, and therapeutic adherence in post-renal transplantation, 17 studies concerned the possible existence of psychopathology and cognitive impairment of renal deceased transplanted subjects. The literature used has shown that the population of kidney transplant patients is exposed to a high risk of psychiatric disorders with repercussions on the quality of life and the risk of rejection. Therefore, an adequate pre-transplant psychosocial assessment is necessary, which allows a more in-depth knowledge of the candidate to plan coping strategies and possible post-transplant psychotherapy.

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 in cirrhosis - a prospective evaluation of the prevalence, predictors and development of a screening nomogram

BACKGROUND

Depression is associated with substantial morbidity and mortality in cirrhosis, but is underdiagnosed and undertreated.

AIMS

Using the Mini International Neuropsychiatric Interview (MINI) as a gold-standard, to determine prevalence, predictors, and outcomes of depression, and to develop a screening nomogram for use in cirrhosis patients.

METHODS

Cirrhotic outpatients 18-80 years of age, not on anti-depressants, were consecutively recruited from liver clinics at three tertiary care hospitals. Baseline health-related quality of life (HRQoL) and frailty were determined by the chronic liver disease questionnaire, EQ-VAS, Clinical Frailty Scale and Fried Frailty Criteria. Depression was identified using the MINI and participants were followed up to 6 months to determine unplanned hospitalization/death.

RESULTS

Of 305 patients, 62% were male; mean age 55(10) years; mean MELD 12.5(5), 61% Child Pugh B/C. Prevalence of depression 18% by MINI. Patients with depression had lower baseline HRQoL and higher frailty scores. Five independently predictive factors were used to develop a clinical nomogram for the diagnosis of clinical depression. These included three Hospital Anxiety and Depression Screening tool variables: "I have lost interest in my appearance" (adjusted odds ratio [aOR] 2.2, P = 0.006), "I look forward with enjoyment to things" (aOR 2.0, P = 0.02), "I feel cheerful" (aOR 2.8, P = 0.002), and two demographic variables: younger age (aOR 0.92, P = 0.001) and not being married or in a common-law relationship (aOR 0.30, P = 0.008).

CONCLUSIONS

Depression is common in patients with cirrhosis. It has a significant impact on HRQoL and functional status. The developed clinical nomogram is promising for the rapid screening of depression in patients with cirrhosis.

Impact of psychiatric comorbidities on outcomes of elderly liver transplant recipients

OBJECTIVES

This study evaluated the impact of psychiatric comorbidities in liver transplant (LT) recipients aged ≥65 years (elderly) on length of hospital-stay (LOS), death, and a composite outcome of graft loss or death.

METHODS

This retrospective study assessed impact of psychiatric comorbidities in 122 elderly LT recipients and a matched group of 122 LT recipients aged <65 years (younger). Associations were assessed using adjusted multivariable regression models.

RESULTS

Among elderly, median age at LT was 68 years, most were males (62%), white (85%) and 61.7% had a history of any psychiatric diagnosis. Among younger, median age was 55, most were males (67.2%), white (77.5%) and 61.5% had any psychiatric diagnosis. Median LOS was 8 days for both groups. Among elderly, after a median follow-up of 5 years, 25.4% died and 29.5% experienced graft loss or death. History of adjustment disorder, history of depression, past psychiatric medication use, and pain prior to LT were associated with an increased risk of death or the composite graft loss or death. Perioperative use of SSRIs and lack of sleeping medication use were associated with longer LOS. Among aged <65, after median follow-up of 4.7 years, 21 patients (17%) died and 25 (20%) experienced graft loss or death; history of depression, perioperative SSRIs or sleeping medications use was associated with increased mortality and graft-loss or death.

CONCLUSION

Six out of 10 patients among both elderly and younger cohorts had pre-LT psychiatric comorbidities, some of which adversely affected outcomes after LT.

Elderly recipients of liver transplantation: impact of age and psychosocial variables on outcome

PURPOSE OF REVIEW

With expanding experience and success of liver transplantation, increasing numbers of elderly candidates await and undergo liver transplantation. There is accumulating evidence that graft survival and mortality does not appear to differ significantly between the young and carefully selected elderly liver transplantation recipients. Although existing evidence suggests that psychosocial factors impact outcomes after liver transplantation in general, no such information is available specifically for elderly (age ≥65 years) liver transplantation recipients. We conducted a broad medical literature review of outcome studies of elderly liver transplantation recipients. In this review article, we summarize the findings and comment on psychosocial variables included in these studies.

RECENT FINDINGS

Ten outcome studies have reported on the impact of age on the liver transplantation outcomes. There is increasing evidence of favorable outcomes in elderly liver transplantation recipients. Few of these studies include measures of quality of life, functional improvement and other psychosocial variables.

SUMMARY

Very limited information is available about the impact of psychosocial factors on outcomes in elderly liver transplantation recipients. This dearth of information represents a critical gap in our knowledge and has implications for optimal candidate selection and outcomes after liver transplantation.

Pre-transplant history of mental health concerns, non-adherence, and post-transplant outcomes in kidney transplant recipients

OBJECTIVE

The association between pre-transplant mental health concerns and non-adherence and post-transplant outcomes after kidney transplantation is not fully established. We examined the relationship between a pre-transplant history of mental health concerns and non-adherence and post-transplant outcomes among kidney transplant recipients.

METHODS

In this retrospective single center cohort study of adult kidney transplant recipients (n=955) the associations between the history of mental health concerns or non-adherence and the time from kidney transplant to biopsy proven acute rejection; death-censored graft failure and total graft failure were examined using Cox proportional hazards models.

RESULTS

Mean (SD) age was 51 (13) years, 61% were male and 27% had a history of diabetes. Twenty-two and 11% of patients had mental health concerns and non-adherence, respectively. Fifteen percent of the patients had acute rejection, 5.6% had death-censored graft failure and 13.0% had total graft failure. The history of mental health concerns was not associated with acute rejection, death-censored graft failure or total graft failure. Patients with versus without a history of non-adherence tended to have higher cumulative incidence of acute rejection (23.3% [95% CI: 16.1, 33.2] vs. 13.6% [95% CI: 11.4, 16.2]) and death-censored graft failure (15.0% [95% CI: 6.9, 30.8] vs. 6.4% [95% CI: 4.7, 8.7]) (log rank p=0.052 and p=0.086, respectively). These trends were not significant after multivariable adjustment.

CONCLUSION

In summary, a history of pre-transplant mental health concerns or non-adherence is not associated with adverse outcomes in patients who completed transplant workup and received a kidney transplant.

Neurofibromatosis type 1: A neuro-psycho-cutaneous syndrome?

Neurofibromatosis type 1 (NF1) is an inherited disorder often associated with optic nerve gliomas, low-grade brain tumors, and readily visible signs. Though these features are frequently emphasized, the psychosocial and emotional morbidities are often overlooked. We present a patient with depressive disorder resulting in suicide in a patient with NF1.

Psychiatric risk factors predicting post-liver transplant physical and psychiatric complications: a literature review

OBJECTIVES

The psychiatric assessment of potential liver transplant recipients is becoming increasingly common in clinical practice. In such assessments, the psychiatrist is invited by the transplant team to assess the patient prior to the patient receiving a transplant liver to identify factors that could predict an unsuccessful post-transplant course, whether this is from a psychiatric or physical perspective. This review examined published research from 2000 to 2014 on psychological risk factors predicting post-transplant physical and psychiatric complications.

CONCLUSIONS

Based on the strength of the evidence available, our review identified four risk factors: mood disorders; social supports; substance misuse; and alcohol dependence. These factors could potentially provide a framework to guide the evaluation and prediction of psychological and physical complications post-liver transplantation.

Utility of pretransplant psychological measures to predict posttransplant outcomes in liver transplant patients: a systematic review

OBJECTIVE

Evaluation of liver transplant (LT) candidacy involves psychosocial evaluation to ensure appropriate organ allocation. However, the utility of pre-LT psychiatric and neuropsychological factors in predicting posttransplant outcomes remains uncertain. We reviewed current evidence on the prognostic value of pre-LT psychological factors for outcomes after LT.

METHOD

We conducted a systematic review of studies with adult LT recipients that investigate the relationship between pre-LT psychiatric and neuropsychological variables and posttransplant outcomes. We searched Ovid, MEDLINE, PsycINFO, EMBASE/Scopus, Cochrane Controlled trials register and Web of Science (January 1975 to May 2015) for longitudinal, peer-reviewed studies of at least 20 subjects and written in English.

RESULTS

The 19 studies included in this review are heterogeneous in population, prognosis and duration of follow-up (from 20days to more than 3 years). Findings on the prognostic value of pre-LT depression or anxiety on post-LT outcomes are mixed, though depression appears to predict lower quality of life (QOL). Pre-LT suicidal thoughts in particular are associated with post-LT depression. High submissiveness may predict rejection within 20days of LT, and low conscientiousness is associated with greater nonadherence. Whereas pre-LT cognitive performance has not been shown to predict survival, poorer performance may predict poorer QOL after LT.

CONCLUSION

Further studies are needed to examine this important element of LT candidacy evaluation. Studies should evaluate psychiatric factors in large samples, include systematic evaluations by mental health clinicians and explore broader neuropsychological domains in predicting posttransplant outcomes.

Health-related quality of life and affective status in liver transplant recipients and patients on the waiting list with low MELD scores

BACKGROUND

This study seeks to examine the impact of orthotopic liver transplantation (OLT) on Health-Related Quality of Life (HRQoL) and mental health in patients with different MELD scores.

METHODS

Patients who has undergone orthotopic liver transplant (OLT) or were on the waiting list for OLT were submitted to HRQoL and depression/anxiety assessment by questionnaire: Short-Form 36 (SF-36), Questions on Life Satisfaction (FLZ-M), Patient Health Questionnaire-4 (PHQ-4). Data were analysed following division of patients into three groups: pretransplant patients with a MELD score <10, ≥10, and OLT recipients.

RESULTS

The surveys were sent to 940 consecutive patients within one week in June 2013. Of these 940 patients, 869 (92.4%) met the inclusion criteria. In total, 291 (33.5%) eligible questionnaires (OLT group: 235, MELD <10: 25; MELD _10: 31) were suitable for analysis. General health (GH), vitality (VIT), and mental health (MH) were lower in both pretransplant groups compared to the OLT group (all p < 0.05). Anxiety and depression were higher in the MELD <10 group than in the OLT group (anxiety: p < 0.05; depression: p < 0.01).

DISCUSSION

Patients with low MELD scores seem to benefit from OLT with regards to HRQoL and mental health.

Impact of different immunosuppressive regimens on the health-related quality of life following orthotopic liver transplantation

BACKGROUND

The influence of immunosuppression on the recipients' quality of life (QoL) is of major importance after OLT and has not yet been evaluated.

METHODS

The impact of different immunosuppression regimens after OLT was evaluated in 275 patients using the Short Form 36 (SF-36) survey. The following immunosuppressive strategies were compared: (a) CNI, (b) mTOR inhibitors, and (c) mTOR combined with CNI. All regimens were prescribed alone (mono) or in combination (+) with prednisolone and/or mycophenolate mofetil (MMF).

RESULTS

Highest scores were evident in patients in the mTOR+ group. There were significantly higher values for general health perceptions (GH, p = 0.049), vitality (VIT, p = 0.020), and physical component summary (PCS, p = 0.041) when compared to CNImono and for GH (p = 0.042) and VIT (p = 0.043), when compared to mTORmono. Early conversion to mTOR inhibitors (<two months after OLT) was associated with higher values for 7 of 10 scales, when compared to a late conversion (>two months after OLT), with a statistically significant improvement for the dimension role-emotional (RE, p = 0.027).

DISCUSSION

mTOR inhibitor-based regimens appear to have beneficial effects on QoL after OLT, especially after an early conversion.

Depression and Anxiety as Risk Factors for Morbidity and Mortality After Organ Transplantation: A Systematic Review and Meta-Analysis

BACKGROUND

Depression and anxiety are common mental health problems in transplant populations. There is mixed evidence concerning whether they increase morbidity and mortality risks after transplantation. If such associations exist, additional risk reduction strategies may be needed.

METHODS

Four bibliographic databases were searched from 1981 through September 2014 for studies prospectively examining whether depression or anxiety (determined with diagnostic evaluations or standardized symptom scales) affected risk for posttransplant mortality, graft loss, acute graft rejection, chronic rejection, cancer, infection, and rehospitalization.

RESULTS

Twenty-seven studies (10 heart, total n = 1738; 6 liver, n = 1063; 5 kidney, n = 49515; 4 lung, n = 584; 1 pancreas, n = 80; 1 mixed recipient sample, n = 205) were identified. In each, depression and/or anxiety were typically measured before or early after transplantation. Follow-up for outcomes was a median of 5.8 years (range, 0.50-18.0). Depression increased the relative risk (RR) of mortality by 65% (RR, 1.65; 95% confidence interval [95% CI], 1.34-2.05; 20 studies). Meta-regression indicated that risk was stronger in studies that did (vs did not) control for potential confounders (P = .032). Risk was unaffected by type of transplant or other study characteristics. Depression increased death-censored graft loss risk (RR, 1.65; 95% CI, 1.21-2.26, 3 studies). Depression was not associated with other morbidities (each morbidity was assessed in 1-4 studies). Anxiety did not significantly increase mortality risk (RR, 1.39; 95% CI, 0.85-2.27, 6 studies) or morbidity risks (assessed in single studies).

CONCLUSIONS

Depression increases risk for posttransplant mortality. Few studies considered morbidities; the depression-graft loss association suggests that linkages with morbidities deserve greater attention. Depression screening and treatment may be warranted, although whether these activities would reduce posttransplant mortality requires study.

Prevalence of psychological problems and associated transplant-related variables at different time periods after liver transplantation

After liver transplantation, recipients often experience psychological problems that are influenced by demographic, personal, and transplant-related variables. However, because previous studies have mostly reported on psychological problems and their influencing factors in the first years after transplantation, less is known about their prevalence and influence in the long run. The aims of this study were to examine point-prevalence rates of symptoms of anxiety, depression, and posttraumatic stress (PTS) at different time periods after transplantation and to examine the transplant-related variables associated with these problems. A cross-sectional survey was performed among 373 liver transplant recipients who received transplants between 1979 and 2009 at our center. Five clinically relevant time periods were identified: 0.5 to <2 years, 2 to <5 years, 5 to <10 years, 10 to <15 years, and ≥15 years after transplantation. The response rate was 75% (n=281). Overall, 33.4% of the respondents experienced clinically relevant symptom levels of anxiety (28.7%), depression (16.5%), or PTS (10.0%). Symptoms of anxiety and depression were more prevalent in the first 2 years and in the long term after transplantation. PTS symptoms were more prevalent in the first 5 years after transplantation. However, the prevalence rates did not differ significantly between time periods. Viral hepatitis and the number of side effects of the immunosuppressive (IS) medication were found to be associated with all psychological problems. Alcoholic liver disease was associated with anxiety and depression in the short term after transplantation. In conclusion, a significant subset of transplant recipients experience psychological problems, both shortly after transplantation and in the long run. These problems are often associated with side effects from the IS medication. Therefore, the monitoring of psychological problems, the offering of psychological counseling, and the management of the medication's side effects should be part of the routine care of transplant recipients.

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.

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.