Journal Article Annotations
2022, 4th Quarter

Transplant Psychiatry

Annotations by Sarah Andrews, MD and Gregory Nikogosyan, DO
January, 2023

Functional comorbidities and brain tissue changes before and after lung transplant in adults.
Vascularized composite allotransplantation: emerging psychosocial issue in hand, face, and uterine transplant.
Effect of an Integrated Transplantation Mental Health Program on Alcohol Relapse After Liver Transplantation for Severe Alcoholic Hepatitis: A Single-Center Prospective Study.

PUBLICATION #1 — Transplant Psychiatry

Functional comorbidities and brain tissue changes before and after lung transplant in adults.

Matthew Scott Vandiver, Bhaswati Roy, Fahim Mahmud, Helen Lavretsky, Rajesh Kumar

Abstract: Front Cell Neurosci. 2022 Dec 2;16:1015568. doi: 10.3389/fncel.2022.1015568. eCollection 2022.

Background:
Adults undergoing lung transplant, as a lifesaving treatment for end stage lung disease, exhibit high levels of peri-operative neurocognitive dysfunction in multiple domains, including delirium, cognition, and autonomic deficits. These complications impact healthcare costs, quality of life, and patient outcomes. Post-operative symptoms likely result from loss of brain tissue integrity in sites mediating such regulatory functions. Our aim in this study was to examine peri-operative neurocognitive dysfunction and brain tissue changes after lung transplant in adults.

Methods:

We retrospectively examined the UCLA lung transplant database to identify 114 lung transplant patients with pre-operative clinical and neurocognitive data. Of 114 patients, 9 lung transplant patients had pre- and post-transplant brain magnetic resonance imaging. Clinical and neurocognitive data were summarized for all subjects, and brain tissue volume changes, using T1-weighted images, before and after transplant were examined. T1-weighted images were partitioned into gray matter (GM)-tissue type, normalized to a common space, smoothed, and the smoothed GM-volume maps were compared between pre- and post-transplant (paired t-tests; covariate, age; SPM12, p < 0.005).

Results:

Increased comorbidities, including the diabetes mellitus (DM), hypertension, kidney disease, and sleep disordered breathing, as well as higher rates of neurocognitive dysfunction were observed in the lung transplant patients, with 41% experiencing post-operative delirium, 49% diagnosed with a mood disorder, and 25% of patients diagnosed with cognitive deficits, despite incomplete documentation. Similarly, high levels of delirium, cognitive dysfunction, and mood disorder were noted in a subset of patients used for brain MRI evaluation. Significantly decreased GM volumes emerged in multiple brain regions, including the frontal and prefrontal, parietal, temporal, bilateral anterior cingulate and insula, putamen, and cerebellar cortices.

Conclusion:

Adults undergoing lung transplant often show significant pre-operative comorbidities, including diabetes mellitus, hypertension, and chronic kidney disease, as well as neurocognitive dysfunction. In addition, patients with lung transplant show significant brain tissue changes in regions that mediate cognition, autonomic, and mood functions. The findings indicate a brain structural basis for many enhanced post-operative symptoms and suggest a need for brain tissue protection in adults undergoing lung transplant to improve health outcomes.

Annotation

The finding:
Postoperative functional deficits may be related to reduced regional gray matter volume in brain regions including the putamen, insula, anterior cingulate, frontal, parietal and temporal cortices, para-hippocampal gyrus, and cerebellum.

Strength and weaknesses:
Strengths of this study include having the before and after MRI scans on the same lung transplant recipients to better find brain structural changes. The sample size is small for the MRI data set decreasing the ability for multiple comparisons. There is an increased likelihood of having false positive findings due to different MRI scanners at various resolutions and non-standardized scanning times being utilized due to the retrospective nature of the study. Although they statistically correct for this and decrease the resolution for the voxel, this limits the ability to decern specific causes of brain volume loss.

Relevance:
This study highlights the need for presurgical neurocognitive assessment to mitigate risk factors prior to surgery given the presence of both functional and structural post-operative changes for lung transplant recipients.

PUBLICATION #2 — Transplant Psychiatry

Vascularized composite allotransplantation: emerging psychosocial issue in hand, face, and uterine transplant.

Martin Kumnig, Stina Järvholm.

Abstract: Curr Opin Organ Transplant. 2022 Dec 1;27(6):501-507. doi: 10.1097/MOT.0000000000001028. Epub 2022 Oct 13.

Purpose of review:
Currently, several research approaches warrant further attention, given the influence of psychosocial and bioethical issues on the success of upper extremity (UETx), face (FTx), and uterine transplantation (UTx). This review will highlight recent results of psychosocial and bioethical research in the field of vascularized composite allotransplantation (VCA), discuss most recent findings, provide information to guide future research approaches, and address the importance of a multicenter research approach to develop international standards.

Recent findings:

Previously published reports have tried to identify psychosocial factors that are essential to predict psychosocial outcomes and guide posttransplant treatment after VCA procedures. These issues in VCA are receiving more attention but we are still at the beginning of a systematic investigation of these domains. This review article summarizes the emerging psychosocial issues in UeTx, FTx, and UTx by including recent literature and current clinical practice.

Summary:

Even though different VCA procedures address different domains leading to specific psychosocial issues, common aspects impacting all forms of VCA would benefit of further coordination. These domains include clinical resources, public attitude and perception, bioethical considerations, adherence and rehabilitation, motives for VCA, information needs and multidisciplinary communication, body image, domains of quality of life, coping strategies, and follow-up care.

Annotation

The finding:
Authors highlight nine psychosocial areas of focus for vascularized composite allotransplantation (VCA). The clinical resource investment raises the question of which subset of patients is such an undertaking justifiable for and what are the alternative treatments. The public perception of such a procedure may be perceived as positive and extraordinary. This possibly gives less attention to the realities and burdens faced by VCA. Although little data is available, clinical practice has shown overall psychological stability and contentment with the decision to receive allotransplantation. Treatment adherence remains important as in other transplant procedures, but it raises special issues with uterine transplantation given the organ can be removed later. Appears recipients’ quality of life relates to becoming a mother or not. Teams would need to explore if the removal of the transplanted uterus is seen as a positive return to self or a deficit in self-image. There is little research on what knowledge entails informed consent for a vascular compositive allotransplantation procedure. As in other transplants, there are improved psychosocial outcomes and greater long-term success in recipients with a strong social support system to rely on and regular post-transplant follow-up and care.

Strength and weaknesses:
Literature review and current clinical practice review help shape clinical understanding of risks and ethical issues for vascularized composite allotransplantation. Limitations include this being a review and expert opinion given the little research available for the developing allotransplantation field area.

Relevance:
Given the growing field for vascular compositive allotransplantation, psychiatrists may encounter more pre-transplantation evaluations for a procedure with little current clinical research particularly in the psychosocial outcomes. This review points to the current clinical practice and how it can help guide a pre-transplant evaluation.

PUBLICATION #3 — Transplant Psychiatry

Effect of an Integrated Transplantation Mental Health Program on Alcohol Relapse After Liver Transplantation for Severe Alcoholic Hepatitis: A Single-Center Prospective Study.

Stephanie C Zanowski, Jenessa S Price, Motaz A Selim, Vanessa Schumann, Francisco Durazo, Johnny C Hong.

Abstract: Transplant Proc. 2022 Dec;54(10):2627-2633. doi: 10.1016/j.transproceed.2022.09.026. Epub 2022 Nov 19.

Background:
Liver transplantation (LT) for severe alcohol-associated hepatitis (AH) remains controversial due to perceived increased recidivism risk after LT because of a lack of protracted abstinence before LT. Data on risk stratification for alcohol relapse after LT are limited. We sought to evaluate the utility of having a mental health program embedded in a transplantation center in risk assessment for alcohol relapse-free patient survival after LT.

Methods:
We conducted a prospective analysis of all patients with a diagnosis of severe AH hospitalized at a single transplant center from April 2015 to April 2020. After a comprehensive mental health risk stratification, patients were either waitlisted for LT or declined for waitlisting. The primary endpoint was alcohol relapse-free patient survival rate for those who received LT. The secondary endpoint compared survival rates between patients who received LT and those who did not. The median follow-up was 10 months.

Results:
Among the 83 patients included in the study, 54 patients were waitlisted for LT (65%, group 1) and 29 were declined (35%, group 2). Patient characteristics and median Model for End-Stage Liver Disease score on presentation were comparable for both cohorts (36 in group 1, 38 in group 2; P = .8). Group 1 had significantly better Stanford Integrated Psychosocial Assessment for Transplantation total scores (median 40 vs 57; P < .01), presence of social support (100% of patients in group 1 vs 76% in group 2; P < .01), and less prevalence of active tobacco smokers (30% in group 1 vs 66% in group 2; P < .01). For those who were not waitlisted, 72.5% experienced rapid deterioration of hepatic function. Among the 54 patients waitlisted, 29 patients received LT (54%), whereas 19 died while on the waiting list (35%). One- and 3-year patient survival after LT were 92.5% and 92.5%, respectively. The overall and sustained alcohol relapse rates after LT were 10.3% and 3.5%, respectively.

Conclusion:
Severe AH is a complex medical and mental health disease and requires an intense risk assessment for recidivism after LT. Our study shows that an integrated transplantation mental health program provides an accurate risk stratification for alcohol relapse after LT, a successful intervention to mitigate recidivism risk, and optimal short-term alcohol relapse-free patient survival. Future studies should focus on enhancing the guidelines for broader application.

Annotation

The finding:
The single-center prospective study studied the usefulness of an integrated mental health program within the liver transplantation program for those with alcohol-related hepatitis. Of the 83 patients included in the study, 65% were waitlisted for liver transplantation and had stronger social supports and were less likely to be active tobacco users as compared to the control group of 29 patients who had been declined for transplantation. Of those who were transplanted and received integrated mental health services, the survival rate was high at 92.5% at both the one-year and three-year marks. The alcohol relapse rates were also low.

Strength and weaknesses:
The strength of the study including the attempt to integrate mental health treatment into the liver transplantation program. A weakness of the study was that there was not an objective way to measure relapse from alcohol, such as a biomarker. Also, there was not a comparison group of those transplanted who did not receive integrated treatment to truly understand the benefits integrating mental health treatment within the program.

Relevance:
There has been much data about the benefits of integrating mental health treatment into medical practices, which is much of the basis of consultation-liaison psychiatrist. As providers who care for medically complex patients, there is a benefit of integrating mental health services in order to be more accessible for the patient population.