Journal Article Annotations
2022, 2nd Quarter

Transplant Psychiatry

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

Suicide amongst transplant recipients: Trends and unique risk factors.
Psychosocial Assessment Rather Than Severity of Liver Failure Dominates Selection for Liver Transplantation in Patients With Alcohol-Related Liver Disease

PUBLICATION #1 — Transplant Psychiatry

Suicide amongst transplant recipients: Trends and unique risk factors.

Scott Serpico, Afshin Parsikia, Alireza Goodarzi, Rosy Manikath James, Naoru Koizumi, Jorge Ortiz

Abstract: Clin Transplant. 2022 Jun;36(6):e14669. doi: 10.1111/ctr.14669. Epub 2022 Apr 17.

Introduction:
There are higher rates of depression and suicidal ideation among those with chronic diseases, including end-stage renal disease, diabetes mellitus and liver disease. Suicide is the tenth leading cause of death worldwide and is more prevalent among transplant recipients. Although transplantation has the potential to improve quality of life, many transplant recipients commit suicide each year. The extent to which sex, race, age, type of insurance coverage, time on waitlist, comorbidities, immunosuppressive regimen and graft loss contribute to suicide risk in this population remains understudied.

Methods:
We queried UNOS data collected between 1990 and 2019 to determine what risk factors contribute to suicide in the transplant population. Suicide mortality rate was calculated by determining the fraction of organ recipients who died by suicide since 1990 and was expressed as deaths per 100 000. Two groups (suicide and all other cause mortality) were compared via univariate and multivariate statistical analysis. Time to graft loss was estimated using a Kaplan Meier Product Limit method. A propensity score analysis was performed to match patients who committed suicide to those who did not, allowing us to balance the relatively small sample of size of the suicide cohort with the larger all other cause mortality group to minimize the effect of confounding variables. We estimated years of organ life lost using the restricted mean. Statistical significance was defined by p < .05.

Results:
The data included 135 432 transplant deaths in total; the majority were kidney recipients-82 305 (61%). We determined suicide rates of .28%, .31%, and .44% for kidney, liver and pancreas, respectively, with an overall rate of .3%. Across all three organs the most significant risk factor was male sex. Non-Hispanic whites were also at elevated risk (OR = 2.16, p < .003). In the liver and kidney transplant groups, the odds of committing suicide were reduced by 4% with advancing age. The odds of taking one’s own life was inversely related to BMI in the kidney and pancreas groups. We observed a doubling of suicide rates from .3% in 2014 to .6% in 2018. There were no other statistically significant correlations.

Conclusion:
Suicide is more prevalent among transplant recipients than in the general population. White males in particular are most at risk. The highest rate of suicide was in pancreas recipients. Advancing age and increasing BMI conferred some protective effect. There were no significant associations between suicide incidence and glucocorticoid use, type of insurance coverage, time on waitlist or graft loss. The phenomenon has become more prevalent in recent years.

Annotation

The finding:
This retrospective study described suicide rates for patients who underwent kidney, liver, or pancreas transplants between 1990 and 2019 using UNOS data. The overall incidence of suicide was 0.3% per year—far higher than in the general population. Those patients at highest risk included non-Hispanic white, male sex, and pancreas transplants.

Strength and weaknesses:
This study is the first of its kind to evaluate suicide rates using a large database of transplant patients (over 135,000 patients). This work provides a starting point to develop further studies to better examine suicide rates in the transplant population and relevant risk factors. One weakness was the exclusion of lung and heart patients, who often also have high rates of psychiatric illness.

Relevance:
Suicide is the tenth leading cause of death worldwide, and transplant patients die by suicide at a higher rate than the general population. C-L psychiatrists must inquire about suicide risk for all patients and address that risk accordingly. Transplantation is not a protective factor against suicide.

PUBLICATION #2 — Transplant Psychiatry

Psychosocial Assessment Rather Than Severity of Liver Failure Dominates Selection for Liver Transplantation in Patients With Alcohol-Related Liver Disease

Kimberly E Daniel, Lindsay A Matthews, Nimrod Deiss-Yehiely, Jaime Myers, Maureen Garvey, John P Rice, Jens Eickhoff, Michael R Lucey

Abstract: Liver Transpl. 2022 Jun;28(6):936-944. doi: 10.1002/lt.26324. Epub 2021 Nov 25.

The Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) is a validated interview tool to assess psychosocial well-being in candidates for solid organ transplants, with higher scores indicating greater vulnerability. We hypothesized that patients with alcohol-related liver disease (ALD) undergoing liver transplantation (LT) evaluation would have higher SIPAT scores than candidates with non-ALD, but that only patients with ALD who have low scores would be selected. We analyzed retrospectively consecutive adults undergoing LT evaluation from June 2018 to December 2019. Comparisons between patients with ALD and patients with non-ALD were made using the nonparametric Wilcoxon rank sum test plus a multivariate analysis to determine independent predictors for approval. In the study cohort of 358 patients, there were 199 (56%) patients with ALD with a mean age of 55 years, and 133 (67%) were men. There were 159 (44%) patients with non-ALD with a mean age of 57 years, and 95 (60%) were men. Mean Model for End-Stage Liver Disease-sodium scores were similar for selected versus not selected patients with ALD (25 versus 25.6) and selected versus not selected patients with non-ALD (18.3 versus 17.4), although the ALD group had substantially higher Model for End-Stage Liver Disease scores. Patients with ALD had higher mean SIPAT composite and individual domain scores compared with their non-ALD counterparts. SIPAT scores were not affected by age or sex. Proportionately more candidates with non-ALD were selected compared to candidates with ALD (68% versus 42%; P < 0.001; odds ratio for approval of non-ALD versus ALD, 2.9; 95% confidence interval, 1.8-4.7; P < 0.001). Composite SIPAT scores were lower in the selected versus nonselected in both ALD and non-ALD groups, although the SIPAT scores were significantly higher in selected patients with ALD (median, 39) than selected patients with non-ALD (median, 23; P = 0.001). Psychosocial assessment has a greater influence than acuity of liver failure on the selection of patients with ALD for LT listing, whereas psychosocial assessment has a minor influence on the selection of non-ALD candidates.

Annotation

The findings:
Daniel and colleagues compared 199 study subjects with alcoholic liver disease (ALD) with 159 subjects who suffered from non-alcohol liver disease. They found that psychosocial status assessed by using the Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) greatly influenced listing for patients with ALC but had only a minor influence on listing for those with non-alcoholic pathology of liver failure.

Strengths & Weakness:
The SIPAT does not distinguish between active and remitted psychosocial problems. Indeed, the developers of SIPAT have advised interpreting SIPAT scores based on active and current issues affecting patients’ score and, by extension, their listing.

Relevance:
The SIPAT was developed to ensure a consistent and standardized psychosocial assessment of transplant candidates. Though SIPAT scores should not be used exclusively to decide who to list for transplant, there is at least one study where a cut-off was used to assess outcomes, and in practice, it appears that SIPAT scores are disproportionately limiting access to transplantation among patients with ALD. ALD patients are likely to experience psychosocial distress and thereby score higher on the SIPAT than do patients with liver failure of other causes. Trained transplant mental health professionals should perform a comprehensive and nuanced psychosocial evaluation on more than one occasion and supplement this assessment with collateral information. In such an evaluation, SIPAT plays a role in identifying areas of concern that a transplant mental health professional can further explore and address. This approach ensures that patients’ candidacy can evolve, and even those not listed initially will have an opportunity to be re-evaluated as their risk profile changes over time with targeted interventions.