Journal Article Annotations
2020, 4th Quarter

Transplant psychiatry

Annotations by Sarah Andrews, MD, Shehzad K. Niazi, MD, FRCPC
December, 2020

Psychosocial Outcomes of Donors Whose Recipients Died After Living Donor Liver Transplantation
The Utility of a Pre-Transplant Psychosocial Evaluation in Predicting Post-Liver Transplant Outcomes
The Stanford Integrated Psychosocial Assessment for Transplant is Associated with Outcomes Before and After Liver Transplantation

PUBLICATION #1 — Transplant psychiatry

Psychosocial Outcomes of Donors Whose Recipients Died After Living Donor Liver Transplantation

Mukadder Ispir, Birgul Cumhur, Tolga Sahin, Emrah Otan, Cuneyt Kayaalp, Sezai Yilmaz

Abstract: J Gastrointest Cancer. 2020 Dec;51(4):1200-1208. doi: 10.1007/s12029-020-00496-8.

Purpose:
Our aim was to investigate the psychosocial outcomes of the donors whose recipients died after living donor liver transplantation (LDLT).

Methods:
Forty-one donors whose recipients died and 87 donors whose recipients were alive after LDLT at Inonu University Liver Transplantation Institute between 2012 and 2017 were included into the study. Demographic data form, Beck anxiety scale, Beck depression scale, Beck Hopelessness Scale, Posttraumatic Growth Inventory, Decision Regret Scale, Multidimensional Scale of Perceived Social Support, and general evaluation questionnaire (24 questions) were used in all donors by face to face questioning. In addition to the descriptive statistical analysis, chi-square and student’s t tests were used to evaluate the differences between the groups.

Results:
Recipient death after living donor liver transplantation is a factor that negatively increases the level of anxiety, depression, hopelessness levels, and repentance of donors, and adversely affects the psychological growth of the donors after donation experience.

Conclusion:
Regular follow-up of the donors should be done psychosocially in the postoperative period, especially the donors whose recipients have died should be followed up more frequently, and their support and treatment should be provided when needed. The donors should also be informed about the psychosocial implications of operative management and postoperative period. More studies are needed regarding the psychosocial problems of the donors.

Keywords:
Donors; Living donor liver transplantation; Psychosocial outcome; Recipient death.

Annotation

The finding:
This cross-sectional study evaluated the psychosocial outcomes of donors whose recipients died after living donor liver transplantation, comparing them to donors whose recipients survived. Between 2012 and 2017 at a transplantation center in Turkey, 41 donors whose recipients died were compared to 87 donors with living recipients. Donors whose recipients died had increased levels of psychosocial burden, including increased rates of anxiety and depression. These donors also experienced increased regret and hopelessness.

Strength and weaknesses:
The study focuses on the importance of evaluating the psychosocial stressors associated with living donation, specifically the long-term consequences based on recipient survival. One of the weaknesses was that the participation rate was only 25% in donors, which raises the concern of selection bias.

Relevance:
This study is relevant for C-L psychiatrists who evaluate or manage the transplant population. Living donors should be well-educated on the potential negative effects of donation, specifically if the recipient does not survive. Living donors should be made aware of the possible regret that can occur based on recipient outcome.

Type of study (EBM guide):
Cross-section study

PUBLICATION #2 — Transplant psychiatry

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

Becker JH, Shemesh E, Shenoy A, Posillico A, Knight CS, Kim SK, Florman SS, Schiano T, Annunziato RA.

Abstract: Prog Transplant. 2020 Dec 4;1526924820978605. doi: 10.1177/1526924820978605. Online ahead of print.

Background:
There is insufficient evidence about the ability of pretransplant psychosocial evaluations to predict posttransplant outcomes. While standardized assessments were developed to increase predictive validity, it is unclear whether the risk scores they yield predict outcomes. We investigated if the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT), a scaling approach to those assessments, would have been a superior predictor than the standard psychosocial evaluation.

Methods:
In this retrospective study, medical records of 182 adult liver transplant recipients who were at least 1 year posttransplant and prescribed tacrolimus for immunosuppression were analyzed. Regression analyses predicted outcomes of interest, including immunosuppressant nonadherence and biopsy-proven rejection, obtained 1-year posttransplant to time of data collection. Nonadherence was determined using the medication level variability index (MLVI).

Results:
Approximately 49% of patients had MLVI > 2.5, suggestive of nonadherence, and 15% experienced rejection. SIPAT total score did not predict adherence either using the continuous (P = .70), or dichotimized score, above or below > 2.5 (P = .14), or rejection (P = 0.87). Using a SIPAT threshold (total score > 69) did not predict adherence (p = .16) nor was a superior predictor of the continuous adherence score (P = .45), MLVI > 2.5 (P = .42), or rejection (P = 0.49), than the standard evaluation.

Conclusion:
Our findings suggest that the SIPAT is unable to predict 2 of the most important outcomes in this population, immunosuppressant adherence and rejection. Research efforts should attempt to evaluate the best manner to use psychosocial evaluations.

Keywords:
liver transplantation; nonadherence; psychosocial assessment; psychosocial risk; transplant evaluation; transplant outcomes.

Annotation

The finding:
This retrospective study analyzed 182 adult liver transplant recipients at least one year post-transplant, comparing their results from the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) with outcomes post-transplant. Nonadherence was evaluated through biopsy-proven rejection. SIPAT was ineffective in predicting nonadherence in patients post-transplant.

Strength and weaknesses:
The strength of this study was appropriate regression analyses predicting outcomes and comparing pre-transplant assessments with post-transplant adherence. One weakness is that only transplanted patients were included in the analyses, and thus skewing results. Further, raters for the SIPAT may have not accurately identified all risks.

Relevance:
This study is relevant for C-L psychiatrists as we complete psychosocial evaluations for patients pre-transplant. Part of the evaluation process is a psychosocial evaluation and attempting to predict adherence post-transplant, however patients may present differently pre-transplant as compared to reality of behaviors post-transplant. We need to continue assessing psychosocial risk and to further explore how to predict outcomes.

Type of study (EBM guide):
Retrospective study

PUBLICATION #3 — Transplant psychiatry

The Stanford Integrated Psychosocial Assessment for Transplant is Associated with Outcomes Before and After Liver Transplantation

Deutsch-Link S, Weinberg EM, Bitterman T, McDougal M, Dhariwal A, Jones LS, Weinrieb RM, Banerjee AG, Addis S, Serper M.

Abstract: Liver Transpl. 2020 Dec 15. doi: 10.1002/lt.25975. Online ahead of print.

Background:
The Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) is a standardized psychosocial evaluation tool used in liver transplant (LT) evaluation. Study aims were to assess the impact of the SIPAT score and sub-score domains on transplant waitlisting decisions and post-LT outcomes including immunosuppression (IS) non-adherence, biopsy-proven rejection, and mortality/graft failure.

Methods:
We conducted a single center observational cohort study of 1430 patients evaluated for LT. Patients were divided in two groups based on a SIPAT cutoff of score < or ≥ 21 (higher SIPAT scores indicate higher psychosocial risk). Tacrolimus coefficient of variation (CoV) was used to measure IS non-adherence. Regression models assessed the relationship between total SIPAT score and domain scores and waitlisting decisions, IS non-adherence, allograft rejection, and patient death/graft failure.

Results:
Patients with elevated total SIPAT and SIPAT domain scores were at higher risk of not being waitlisted for LT (total SIPAT ≥21 aOR=1.78, CI 1.36-2.33, readiness ≥5 aOR=2.01, CI 1.36-2.76, social support ≥4 aOR=1.50, CI 1.15-1.94, psychopathology ≥7 aOR=1.45, CI 1.07-1.94, and lifestyle/substance abuse ≥12 aOR=1.72, CI 1.23-2.39), and were more likely to experience IS non-adherence as measured by the tacrolimus CoV (total SIPAT ≥21 aOR=2.92, CI 1.69-5.03, readiness ≥5 aOR=3.26, CI 1.63-6.52, psychopathology ≥7 aOR=1.88, CI 1.00-3.50, and lifestyle substance abuse ≥ 12 aOR=3.03, CI 1.56-5.86). Patients with a SIPAT readiness score ≥5 were more likely to experience biopsy-proven allograft rejection (aOR=2.66, CI 1.20-5.91).

Conclusion:
The SIPAT score was independently associated with LT listing decisions and IS non-adherence, and the readiness domain was associated with risk of allograft rejection. These findings offer insights into higher risk recipients that may require additional support prior to and after transplantation.

Keywords:
behaviour changes; children; dexmedetomidine; emergence delirium; paediatrics.

Annotation

The finding:
Authors of this study demonstrate that patients with higher risk SIPAT score, using a cut-off of 21, were less likely to be waitlisted for transplant. Patients with 21 or higher SIPAT scores were also less likely to adhere with immunosuppressant medications post-transplant. Additionally, the study subjects with higher scores in readiness domain of SIPAT were at a higher risk of graft rejection.

Strength and weaknesses:
Even though this study was conducted at a single center, yet the study cohort is relatively diverse and large. Transplant team evaluated 1430 patients and of those the researchers analyzed 384 recipients for post-transplant outcomes. Only the clinical social workers assigned SIPAT scores, and transplant psychiatrists did not assign scores independently. Authors performed appropriate statistical analyses and conclusions are supported by the study findings. Study’s duration does allow authors to study outcomes beyond 1-year post transplant in some patients but further longitudinal follow up may provide additional information regarding SIPAT-score and transplant outcomes. An additional strength is that authors do explore gender, education and community health scores related covariates and their impact on scores, likelihood for listing and outcomes as social determinants of health and issues of equity remain important and active areas of study.

Relevance:
Transplant team has to carefully evaluate all potential transplant candidates. Transplant psychiatrists and social workers play a key role in assessing these patients to identify any relevant psychosocial factors that can increase the risk of poorer outcomes after transplant. However, such evaluations need to be individualized and standardized where possible. Tools such as SIPAT are used to inform psychosocial evaluations. This study contributes to the accumulating evidence base to support the utility and validity of SIPAT.

Type of study (EBM guide):
Retrospective case-control study