Journal Article Annotations
2022, 1st Quarter

Transplant Psychiatry

Annotations by Sarah R. Andrews, MD and Shehzad K. Niazi, MD, FRCPC, FACLP
January, 2022

Associations Between Recipients’ Feelings of Guilt for Donor and Depressive Symptoms Before Living Kidney Transplantation.
Adherence to Immunosuppressive Therapies after Kidney Transplantation from a Biopsychosocial Perspective: A Cross-Sectional Study.

PUBLICATION #1 — Transplant Psychiatry

Associations Between Recipients’ Feelings of Guilt for Donor and Depressive Symptoms Before Living Kidney Transplantation.

Satomi Doi, Mayu Sekiguchi, Ryo Motoya, Junichiro Kanazawa, Masumi Sato, Hiroshi Harada, Nobuyuki Fukuzawa, Yoshiki Wada, Tetsuo Hirano

Abstract: Transplant Proc. 2022 Mar 17;S0041-1345(22)00092-6. doi: 10.1016/j.transproceed.2021.10.033. Online ahead of print.

Background:
Recipient depression before kidney transplantation needs to be treated to reduce poor posttransplant outcomes. For recipients who receive living kidney transplantation, feelings of guilt for potential donors may be factors related to the presence of depressive symptoms. This study aimed to examine the association between recipients’ feelings of guilt for the donor and depressive symptoms before living kidney transplantation.

Methods:
Participants included 178 patients in Sapporo City General Hospital, Hokkaido, Japan, who completed a questionnaire before having living kidney transplantation from April 2009 to May 2016. Feelings of guilt for the donor, depressive symptoms using the Beck Depression Inventory-II (BDI-II), relationship to the donor, dialysis period, and socio-demographic characteristics were assessed via a questionnaire. Multivariate regression analyses were performed to examine the association between feelings of guilt for the donor and BDI-II score after multiple imputations.

Results:
The results showed that feelings of guilt for donors were associated with depressive symptoms, especially cognitive factors.

Conclusions:
These findings indicate that medical staff needs to address recipients’ feelings of guilt for donors before living kidney transplantation.

Annotation

The finding:
This cross-sectional study included 178 patients from Japan who were undergoing living kidney transplantation from April 2009 to May 2016. Participants completed questionnaires prior to transplantation regarding depressive symptoms assessed through the Beck Depression Inventory-II and feelings of guilt for the donor. Multivariate regression analyses examined the association between depression scores and feelings of guilt. Results demonstrated that feelings of guilt were associated with depressive symptoms. Even after adjusting for participants’ clinical and background data, the association between feelings of guilt and depression scores remained significant. Kidney transplant recipients who expressed feelings of guilt were more likely to have elevated levels of depressive symptoms, specifically anhedonia, guilt, and sadness.

Strength and weaknesses:
This study had limitations, specifically the sample population was from one hospital and predominately one global region. Depressive symptoms or prior psychiatric illness were not assessed prior to the cross-sectional study. As such, the level of depression prior to the transplant process could influence feelings of guilt. The strength of this study was that it was the first to explore the relationship between feelings of guilt for donor and its association with depressive symptoms.

Relevance:
Depression in kidney transplant recipients has been associated with poor post transplant outcomes, which can include graft failure and mortality. Transplant recipients’ mental health is a vital aspect of the transplant process and must be appropriately managed prior to and following transplant. Guilt in kidney transplant recipients is common in those who received a living donor transplant due to concerns about the donor’s health that may arise following donation. This study indicated that feelings of guilt for donors were associated with depressive symptoms in the transplant population. Given that depression can worsen post transplant outcomes, we must help identify and discuss potential guilt and the impact of guilt on mental health pre and post transplant. These findings suggest a role for pre transplant psychological interventions to reduce guilt and depression among living kidney donor recipients.

PUBLICATION #2 — Transplant Psychiatry

Adherence to Immunosuppressive Therapies after Kidney Transplantation from a Biopsychosocial Perspective: A Cross-Sectional Study.

Justyna Zachciał, Izabella Uchmanowicz, Magdalena Krajewska, Mirosław Banasik

Abstract: J Clin Med. 2022 Mar 2;11(5):1381. doi: 10.3390/jcm11051381.

Kidney transplantation (KT) is the best method for kidney replacement therapy (KRT) because of patient survival rates and quality of life (QoL). Nowadays, the main cause of graft loss is antibody-mediated rejection. The treatment of humoral injury is difficult with uncertain results and still not firmly established. Therefore, appropriate adherence is crucial to prolong graft and patient survival. This study aims to evaluate the association of transplant patients’ acceptance of illness, symptoms of anxiety and depression, frailty, and QoL with medication adherence in KT recipients. A total of 210 patients after KT completed the surveys. The instruments were distributed during patients’ admission at the clinic by a qualified nurse, who assisted the patients’ in completing the questionnaires. A cross-sectional study of KT recipients 9.45 ± 7.26 years after KT was performed. Patient adherence with medications was assessed using the Adherence to Refills and Medications Scale (ARMS). Explanatory variables were examined with validated instruments, such as the World Health Organization Quality of Life (WHOQoL-BREF) questionnaire, The Mini-Mental State Examination (MMSE), the Acceptance of Illness Scale (AIS), the Hospital Anxiety and Depression Scale (HADS), and the Tilburg Frailty Indicator (TFI) scale, respectively. Simple linear and multiple regression analyses demonstrated the positive correlation between acceptance of illness and adherence to immunosuppressive medications in a patient sample of KT recipients. The other important factor facilitating adherence to medications was linked with physical and environmental dimensions. On the other hand, frail kidney transplant patients were more likely to be nonadherent. In conclusion, identifying contributors to better medication adherence in immunosuppressive therapy is crucial in preventing transplant rejection or graft loss. In the kidney transplant population, the acceptance of illness, selected dimensions of QoL, and demographic variables associated with rural living and vocational education favored adherence behaviors.

Annotation

The finding:
In this Polish study, the authors conducted a cross-sectional study to assess the adherence with refilling and taking immunosuppressant medications among 210 kidney transplant recipients. Validated rating scales measured quality of life (QOL), cognition, illness-acceptance, depression, anxiety, and frailty. Patients with higher acceptance of illness as measured by the Polish version of the Acceptance of Illness Scale were more likely to be adherent to immunosuppressant medications after kidney transplants. On the other hand, frail patients; those who had lower cognitive capabilities as measured by Mini-Mental State Examination; and those who had hypercholesteremia were more likely to be nonadherent.

Strength and weaknesses:
The authors used validated scales and robust statistical methodology that considered the issue of collinearity of multiple variables by calculating VIF (Variance Inflation Factor). The observed VIF of 3.53 suggests there was no multicollinearity among variables of interest. Depression and anxiety as measured by HADS had no significant association with adherence. The study was cross-sectional and hence subject to recall bias; the results cannot be used to infer causality. Additionally, it is difficult to comment on the temporal relationship among variables such as frailty, hypercholesteremia, cognitive status, and non-adherence or acceptance of illness and improved adherence. This is a single-center study in a country where the Polish National Health System pays the cost of immunosuppressant medications, and the out-of-pocket cost is only $1.00/medication pack. As a result, the authors did not explore associations between socioeconomic factors on compliance. Hence, generalizability to patient populations to other healthcare systems, such as the USA, is limited.

Relevance:
Findings of the study are clinically relevant to the clinicians as adherence to immunosuppressant medications is critical to achieve graft survival after kidney transplant. These findings suggest that the clinicians may even more closely monitor adherence in higher risk patients who are frail or cognitively impaired.