Journal Article Annotations
2019, 4th Quarter

Transplant Psychiatry

Annotations by Andrea DiMartini
December 2019

Donor outcomes in anonymous live liver donation
Mental health and chemical dependency services at US transplant centers. American Journal of Transplantation.

Also of interest:

Goldberg D and Lynch R: Improvements in organ donation: Riding the coattails of a national tragedy. Clinical Transplantation
November 19, 2019. https://doi.org/10.1111/ctr.13755.

In this brief communication to determine the proportion of the increase in organ donors attributable to drug-related deaths the authors evaluated the data from the Organ Procurement and Transplantation Network (OPTN) over a ten-year period from 1/1/2009 to 12/31/2018. Using the Organ Procurement Organizations (OPOs) coding of donor mechanism of death they categorized donor deaths into drug-related vs not drug related. Over that ten-year period the number of donors whose mechanism of death was “drug intoxication” increased by 336% and aggregated together all drug-related death accounted for 102% of the increased number of donors in 2018 relative to 2009. The authors conclude although there have been improvements in the OPOs performance, nationally the increase in the number of organ donors is almost wholly attributable to the drug epidemic.

PUBLICATION #1 — Transplant Psychiatry

Donor outcomes in anonymous live liver donation.

Goldaracena N, Jung J, Aravinthan AD, Abbey SE, Krause S, Pritlove C et al.

Abstract: J Hepatol. 2019 Nov;71(5):951-959. doi: 10.1016/j.jhep.2019.06.027.

BACKGROUND & AIMS:
Death rates on liver transplant waiting lists range from 5%-25%. Herein, we report a unique experience with 50 anonymous individuals who volunteered to address this gap by offering to donate part of their liver to a recipient with whom they had no biological connection or prior relationship, so called anonymous live liver donation (A-LLD).

METHODS:
Candidates were screened to confirm excellent physical, mental, social, and financial health. Demographics and surgical outcomes were analyzed. Qualitative interviews after donation examined motivation and experiences. Validated self-reported questionnaires assessed personality traits and psychological impact.

RESULTS:
A total of 50 A-LLD liver transplants were performed between 2005 and 2017. Most donors had a university education, a middle-class income, and a history of prior altruism. Half were women. Median age was 38.5 years (range 20-59). Thirty-three (70%) learned about this opportunity through public or social media. Saving a life, helping others, generativity, and reciprocity for past generosity were motivators. Social, financial, healthcare, and legal support in Canada were identified as facilitators. A-LLD identified most with the personality traits of agreeableness and conscientiousness. The median hospital stay was 6 days. One donor experienced a Dindo-Clavien Grade 3 complication that completely resolved. One-year recipient survival was 91% in 22 adults and 97% in 28 children. No A-LLD reported regretting their decision.

CONCLUSIONS:
This is the first and only report of the characteristics, motivations and facilitators of A-LLD in a large cohort. With rigorous protocols, outcomes are excellent. A-LLD has significant potential to reduce the gap between transplant organ demand and availability.

LAY SUMMARY:
We report a unique experience with 50 living donors who volunteered to donate to a recipient with whom they had no biological connection or prior relationship (anonymous living donors). This report is the first to discuss motivations, strategies and facilitators that may mitigate physical, social and ethical risk factors in this patient population. With rigorous protocols, anonymous liver donation and recipient outcomes are excellent; with appropriate clinical expertise and system facilitators in place, our experience suggests that other centers may consider the procedure for its significant potential to reduce the gap between transplant organ demand and availability.

KEYWORDS:
Anonymous living donation; Live donor liver transplantation; Living liver donation

PMID:31279899

Annotation

Findings:
In this descriptive work authors at the University Health Network in Toronto provide the first report on the physical and psychological outcomes of anonymous live liver donor (A-LLD- no biological connection or prior relationship) using a mixed methods approach. During the period of study January 2005 to December 2017, 50 A-LLDs donated (representing 6.7% of their LLD donors). Twenty six of 41 A-LLDs (63%) who were >3 months post-donation agreed to participate. Validated self-reported questionnaires assessed personality traits, relationship style, and psychological growth. Qualitative interviews after donation examined motivation and experiences. Surveys showed A-LLDs endorsed personality traits of agreeableness, conscientiousness with low neuroticism and 50% endorsed a secure attachment style. Donors also reported significant post-donation growth in areas of relating to others, personal strength, and appreciation of life. Themes arising from the qualitative interviews included the concept of a good deed, random act of kindness without the expectation of reciprocity, moral obligation to help someone in need, and anonymity helped to preserve the value of doing a good deed.Social, financial, healthcare, and legal support in Canada were identified as facilitators of A-LLD donation.

Weaknesses and limitations:
This is a single center report on a small-sized cohort. There is no control group. Bias may have occurred if A-LLD non-responders had poorer outcomes.

Relevance:
This is the first report on an A-LLD cohort to examine psychological outcomes. The use of qualitative interviewing is especially relevant to understanding motives and decision making in donors.

Type of study
(http://ebm.bmj.com/content/early/2016/06/23/ebmed-2016-110401): cross sectional cohort study

PUBLICATION #2 — Transplant Psychiatry

Mental health and chemical dependency services at US transplant centers. American Journal of Transplantation.

Niazi SK, Spaulding A, Vargas E, Schneekloth T, Crook J, Rummans T, Taner CB.

Abstract: First published: 14 October 2019. https://doi.org/10.1111/ajt.15659.

The purpose of this study was to assess the availability of mental health (MH) and chemical dependency (CD) services at US transplant centers, because appropriate psychosocial assessment and care is associated with better transplant outcomes. We used the 2017-2018 American Hospital Association survey, Area Health Resource File, and Centers for Medicare & Medicaid Services Hospital Compare databases to quantify availability of services and examined associations of hospital- and health services area-level characteristics with odds of offering services with generalized linear mixed models. We found that 15% of transplant centers did not offer MH services and 62% did not offer CD services. Hospitals were more likely to offer MH services if they were larger (OR [95% CI]: 1.03 [1.01, 1.06]) and had a lower rate of uninsured patients in the health services area (OR [95% CI]: 0.89 [0.80, 0.99]) and were more likely to offer CD services if they were larger (OR [95% CI]: 1.02 [1.01, 1.03]) or were members of a system (OR [95% CI]: 2.31 [1.26, 4.24]). Additional research is needed to understand whether lack of MH or CD services at transplant centers affects patients’ ability to access comprehensive psychosocial care and whether this affects patient outcomes.

KEYWORDS:
ethics and public policy; health services and outcomes research; mental health; organ transplantation in general; quality of care/care delivery; quality of life

PMID:31612625

Annotation

Findings:
The authors sought to determine the availability of mental health (MH) and chemical dependency (CD) services in US transplant programs using databases from three sources: the 2017-2018 American Hospital Association Annual Survey (>6400 American hospitals), 2017-2018 Area Health Resource file (dataset provided by US Dept of Health and Human Services Health Resources and Services Administration) and Centers for Medicare & Medicaid Services Hospital Compare. All non-federal US transplant programs were included. MH service could include inpatient, consultation-liaison or outpatient services while CD services could include inpatient or outpatient alcoholism-chemical dependency services. Investigators used descriptive data to qualify the availability of services and generalized linear mixed models examine associations of hospital and health services area-level characteristics with the odds of offering MH and CD services. Of the 345 centers offering transplants in the US, investigators found that while 85% offered MH services only 37% offered CD services; 36% offered both MH and CD services. Hospitals were more likely to offer MH services if they were larger and had a lower percentage of uninsured patients in the health services area and were more likely to offer CD services if they were larger or were members of a system. The authors believe this suggests the costs and reimbursement levels for MH and CD services are major factors in a centers’ decision whether to offer these services. They conclude that all transplant centers should ideally provide MH services to comply with the letter and spirit of CMS and UNOS requirements as well as to meet the complex psychosocial and mental health needs of the patients they serve.

Weaknesses and limitations:
The study could not show whether transplant patients could access MH or CD services if available at the transplant program, whether these services were adequate or whether they had alternative access to MH or CD care in the community.

Relevance:
US transplant programs require comprehensive psychosocial evaluations of transplant candidates. Without available MH and CD services within the transplant hospital system transplant candidates and recipients may only be able to receive such care in the community which may not be aware of the unique needs of transplant patients, be capable of assisting in the complex evaluation process or providing the type of expert coordinated MH and CD care required of transplant patients.