Journal Article Annotations
2020, 2nd Quarter

Transplant Psychiatry

Annotations by Paula Zimbrean, MD
June 24, 2020

The Preimplantation Psychosocial Evaluation and Prediction of Clinical Outcomes During Mechanical Circulatory Support: What Information Is Most Prognostic?
High prevalence of falsely declaring nicotine abstinence in lung transplant candidates.

Also of interest:

Kidney transplantation and donation in the transgender population: A single-institution case series

PUBLICATION #1 — Transplant Psychiatry

The Preimplantation Psychosocial Evaluation and Prediction of Clinical Outcomes During Mechanical Circulatory Support: What Information Is Most Prognostic?

Dew MA, Hollenberger JC, Obregon LL, Hickey GW, Sciortino CM, Lockard KL, Kunz NM, Mathier MA, Ramani RN, Kilic A, McNamara DM, Simon MA, Keebler ME, Kormos RL. .

Abstract: Transplantation. 2020 Apr 27. doi: 10.1097/TP.0000000000003287. Online ahead of print.

BACKGROUND
Psychosocial evaluations are required for long-term mechanical circulatory support (MCS) candidates, no matter whether MCS will be destination therapy (DT) or a bridge to heart transplantation. Although guidelines specify psychosocial contraindications to MCS, there is no comprehensive examination of which psychosocial evaluation domains are most prognostic for clinical outcomes. We evaluated whether overall psychosocial risk, determined across all psychosocial domains, predicted outcomes, and which specific domains appeared responsible for any effects.

METHODS
A single-site retrospective analysis was performed for adults receiving MCS between 4/2004-12/2017. Using an established rating system, we coded psychosocial evaluations to identify patients at low, moderate, or high overall risk. We similarly determined risk within each of 10 individual psychosocial domains. Multivariable analyses evaluated whether psychosocial risk predicted clinical decisions about MCS use (DT vs. bridge), and postimplantation mortality, transplantation, rehospitalization, MCS pump exchange, and standardly-defined adverse medical events (AEs).

RESULTS
In 241 MCS recipients, greater overall psychosocial risk increased the likelihood of a DT decision (Odds Ratio[OR]=1.76, p=.017); and postimplantation pump exchange and occurrence of AEs (Hazard Ratios[HRs]≥1.25, p’s≤.042). The individual AEs most strongly predicted were cardiac arrhythmias and device malfunctions (HRs≥1.39, p’s≤.032). The specific psychosocial domains predicting at least 1 study outcome were mental health problem severity, poorer medical adherence, and substance use (OR and HRs≥1.32, p’s≤.010).

CONCLUSIONS
The psychosocial evaluation predicts not only clinical decisions about MCS use (DT vs. bridge), but important postimplantation outcomes. Strategies to address psychosocial risk factors before or soon after implantation may help to reduce postimplantation clinical risks.

PMID: 32345866

Annotation

The finding
Psychosocial factors were associated with clinical decisions about mechanical circulatory support (MCS) and with adverse events post implantation. Specifically, increased psychosocial risk was associated with a higher likelihood that MCS was pursued as destination therapy, rather than bridge to transplantation. Patients with a higher severity of mental health problems and greater difficulty adhering to their preimplantation medical regimen were at higher risk of adverse events post implantation, specifically cardiac arrhythmias and device malfunctions. Substance use at the time of the evaluation was associated with a higher risk of device malfunction.

Strength and weaknesses
This is a retrospective analysis of prospectively collected data of 241 patients (the largest such cohort to date) who received MCS and/or heart transplantation. The study analysed psychosocial risks factors individually and clearly defined the outcome measures including the clinical decision for implantation and transplant/MCS related outcomes. The statistical analyses took into consideration the underlying cardiac condition and patients who improved after MCS to the point of MCS removal (which cannot have MCS- related adverse events).

The limitations of the study originate in its retrospective interpretation and coding of the psychosocial risk, even if the data was prospectively collected. The data were collected based on a semi-structured interview, but there is no discussion on the validity of this instrument. In addition, the analysis of adverse events did not take into consideration medical co-morbidities that may influence the risks of such events (e.g. cerebrovascular accidents, diabetes).

Relevance
This is the first study to evaluate which specific psychosocial domains appear responsible for any predictive effects on MCS recipients. These findings further support the importance of comprehensive psychosocial evaluation before MCS.

Type of study
retrospective cohort study

PUBLICATION #2 — Transplant Psychiatry

High prevalence of falsely declaring nicotine abstinence in lung transplant candidates.

Veit T, Munker D, Leuschner G, Mümmler C, Sisic A, Kauke T, Schneider C, Irlbeck M, Michel S, Eser-Valerie D, Huber M, Barton J, Milger K, Meiser B, Behr J, Kneidinger N. .

Abstract: PLoS One. 2020 Jun 18;15(6):e0234808. doi: 10.1371/journal.pone.0234808. eCollection 2020.

Tobacco use after lung transplantation is associated with adverse outcome. Therefore, active smoking is regarded as a contraindication for lung transplantation and should be excluded prior to placement on the waiting list. The aim of the study was to compare self-reporting with a systematic cotinine based screening approach to identify patients with active nicotine abuse. Nicotine use was systematically assessed by interviews and cotinine test in all lung transplant candidates at every visit in our center. Patients were classified according to the stage prior to transplantation and cotinine test results were compared to self-reports and retrospectively analyzed until June 2019. Of 620 lung transplant candidates, 92 patients (14.8%) had at least one positive cotinine test. COPD as underlying disease (OR 2.102, CI 1.110-3.981; p = 0.023), number of pack years (OR 1.014, CI 1.000-1.028; p = 0.047) and a time of cessation less than one year (OR 2.413, CI 1.410-4.128; p = 0.001) were associated with a positive cotinine test in multivariable regression analysis. The majority of non-COPD patients (n = 13, 72.2%) with a positive test had a cessation time of less than one year. 78 patients (84.7%) falsely declared not consuming any nicotine-based products prior to the test. Finally, all never smokers were test negative. In conclusion, our data demonstrate that active nicotine use is prevalent in transplant candidates with a high prevalence of falsely declaring nicotine abstinence. COPD was the main diagnosis in affected patients. Short cessation time and a high number of pack years are risk factors for continued nicotine abuse.

PMID: 32555678

Annotation

The finding
Approximately 14% of patients listed for lung transplantation tested positive for cotinine while on the transplant waiting list. Of them, approximately 85% did not report their active use.

Strength and weaknesses
This is a prospective study of 620 lung transplant recipients who received education about the importance of smoking cessation at the time of the listing for transplantation. Patients underwent cotinine testing prospectively and randomly. The interpretation of these results is limited by the fact that this was a single center study, and that cotinine testing was done infrequently and cannot distinguish between smoking and use of nicotine replacement products.

Relevance
These findings suggest that a patient’s report of nicotine use is very likely to result in inaccurate data. Cotinine level testing increases the possibility of identifying patients who actively smoke and may benefit from additional interventions.

Type of study
cohort, prospective study

Also of interest – PUBLICATION #3 — Transplant Psychiatry

Kidney transplantation and donation in the transgender population: A single-institution case series.

Ramadan, O. I., et al. (2020). .

Abstract: Am J Transplant.

The medical needs of the transgender population are increasingly recognized within the US health care system. Hormone therapy and gender-affirming surgery present distinct anatomic, hormonal, infectious, and psychosocial issues among transgender kidney transplant donors and recipients. We present the first reported experience with kidney transplantation and donation in transgender patients. A single-center case series (January 2014-December 2018) comprising 4 transgender kidney transplant recipients and 2 transgender living donors was constructed and analyzed. Experts in transplant surgery, transplant psychiatry, transplant infectious disease, pharmacy, and endocrinology were consulted to discuss aspects of care for these patients. Four transgender patients identified as male-to-female and 2 as female-to-male. Three of 6 had gender-affirming surgeries prior to transplant surgery, 1 of whom had further procedures posttransplant. Additionally, 4 patients were on hormone therapy. All 6 had psychiatric comorbidities. The 4 grafts have done well, with an average serum creatinine of 1.45 mg/dL at 2 years (range 1.01-1.85 mg/dL). However, patients encountered various postoperative complications, 1 of which was attributable to modified anatomy. Thus, transgender kidney transplant patients can present novel challenges in regard to surgical considerations as well as pre- and posttransplant care. Dedicated expertise is needed to optimize outcomes for this population.PMID: 32555678

Annotation

Annotation (unstructured)
This is a single center case series describing a small group of transgender patients (4 kidney transplant recipients and 2 kidney donors) who all have psychiatric co-morbidities. The article describes each case individually and includes description of psychiatric, medical, and surgical complications that occurred after transplantation surgery. The manuscript concludes with suggestions for evaluation and follow up of transgender patients who receive or donate kidneys.

Type of study
case series