Journal Article Annotations
2023, 1st Quarter

Transplant Psychiatry

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

Long-term cognitive impairments in kidney transplant recipients: impact on participation and quality of life.
Racial and ethnic disparities in psychosocial evaluation and liver transplant waitlisting.

PUBLICATION #1 — Transplant Psychiatry

Long-term cognitive impairments in kidney transplant recipients: impact on participation and quality of life.

Aaltje L Ziengs, Anne M Buunk, Lisanne van Sonderen, Michele F Eisenga, Antonio W Gomes Neto, Coby Annema, Thialda Vlagsma, Gerjan J Navis, Stefan P Berger, Stephan J L Bakker, Jacoba M Spikman

Abstract: Nephrol Dial Transplant. 2023 Feb 13;38(2):491-498. doi: 10.1093/ndt/gfac035.

Background:
Cognitive impairment is often present shortly after transplantation in kidney transplant recipients (KTR). To date, it is unknown whether these impairments persist in thelong term, to what extent they are associated with disease-related variables and whether they affect societal participation and quality of life (QoL) of KTR.

Method:
This study was part of the TransplantLines Biobank & Cohort Study in the University Medical Center Groningen. A total of 131 KTR, with a mean age of 53.6 years (SD = 13.5) transplanted ≥1 year ago (M = 11.2 years, range 1-41.7 years), were included and compared with 306 healthy controls (HC). KTR and HC were well matched; there were no significant differences regarding age, sex and education. All participants were assessed with neuropsychological tests measuring memory, mental speed, attention and executive functioning, and with questionnaires examining societal participation and QoL.

Results:
Compared with HC, KTR performed significantly worse on memory, mental speed and measures of executive functioning (all P-values <0.05). Moreover, 16% of KTR met the criteria for mild cognitive impairment (MCI), compared with 2.6% of the HC. MCI in KTR was not significantly correlated with age- and disease-related variables. Poorer cognitive functioning was significantly related to lower levels of societal participation and to lower QoL (all P-values <0.01).

Conclusions:
This study shows long-term cognitive impairments in KTR, which are not related to disease-related variables. Neuropsychological assessment is important to timely signal these impairments, given their serious negative impact on societal participation and QoL.

Annotation

The finding:
Kidney Transplant Recipients (KTR) had significantly lower scores in all cognitive domains at an average 11-year post-transplant measurement point. Furthermore, 16% of KTR met internationally accepted criteria for mild cognitive impairment (MCI), defined as a 1.5 standard deviation decrease from the normative mean on at least two neuropsychological tests within the battery. Decreased cognitive function was also shown to have a serious negative impact on societal participation and quality of life (QoL) measured by Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-P) and Medical Outcomes Study Short-Form 36 (SF-36) respectively.

Strength and weaknesses:
The authors describe cognitive outcomes at a longer time after transplantation compared to other previous studies in this topic area. Cognitive impairment does not improve as expected post-transplantation and the impairment appears to be stable based on these results, but this was implicitly determined by showing no relationship between the time of transplantation and the presence of neuropsychological deficits. It was determined furthermore that there was no significant relation between MCI and other variables (age, duration of dialysis before transplantation, eGFR, pre-transplant health status, and immunosuppressant drugs). It is unclear about the which percentage of invited candidates for the study became participants. To what degree would more cognitively impaired candidates be unable to agree to participate or decide to refuse participation? This study was not able to determine the cognitive status of KTR in the pre-transplantation or sub-acute stage of post-transplantation which would have more reliably determined if cognitive function worsens, improves, or remains the same after surgery.

Relevance:
Routine neurocognitive testing can help identify the pervasive cognitive impairment in KTR. This will allow multidisciplinary treatment teams to provide adequate counselling, management, and efforts to prevent decreased levels of participation and QoL.

PUBLICATION #2 — Transplant Psychiatry

Racial and ethnic disparities in psychosocial evaluation and liver transplant waitlisting.

Sasha Deutsch-Link, Therese Bittermann, Lauren Nephew, Katherine Ross-Driscoll, Ethan M Weinberg, Robert M Weinrieb, Kim M Olthoff, Senayish Addis, Marina Serper.

Abstract: Am J Transplant. 2023 Jan 31;S1600-6135(23)00233-2. doi: 10.1016/j.ajt.2023.01.011. Online ahead of print.

Health disparities have been well-described in all stages of the liver transplantation (LT) process. Using data from psychosocial evaluations and the Stanford Integrated Psychosocial Assessment, our objective was to investigate potential racial and ethnic inequities in overall LT waitlisting and not waitlisting for medical or psychosocial reasons. In a cohort of 2271 candidates evaluated for LT from 2014 to 2021 and with 1-8 years of follow-up, no significant associations were noted between race/ethnicity and overall waitlisting and not waitlisting for medical reasons. However, compared with White race, Black race (odds ratio [OR], 1.65; 95% confidence interval [CI], 1.07-2.56) and Hispanic/Latinx ethnicity (OR, 2.10; 95% CI, 1.16-3.78) were associated with not waitlisting for psychosocial reasons. After adjusting for sociodemographic variables, the relationship persisted in both populations: Black (OR, 1.95; 95% CI, 1.12-3.38) and Hispanic/Latinx (OR, 2.29; 95% CI, 1.08-4.86) (reference group, White). High-risk Stanford Integrated Psychosocial Assessment scores were more prevalent in Black and Hispanic/Latinx patients, likely reflecting upstream factors and structural racism. Health systems and LT centers should design programs to combat these disparities and improve equity in access to LT.

Keywords: Stanford Integrated Psychosocial Assessment for Transplant; liver transplantation (LT); psychosocial evaluation; racial and ethnic disparities; transplant evaluation.

Annotation

The finding:
Health disparities, unfortunately, have been well-documented in different medical environments, including within the liver transplantation (LT) process. The goal of this single-center cohort study was the determine if there are any racial and ethnic inequities for candidates regarding listing for LT. Although the study did not find disparities between race/ethnicity for listing or not listing based on medical reasons, there were disparities when based on psychosocial reasons. Even after adjusting for psychosocial covariates, Black race and Hispanic/Latinx ethnicity were still associated with increased risk of not being listed due to psychosocial reasons. This study suggested that Black patients may be more affected by high-risk total Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) compared to White patients.

Strength and weaknesses:
The strengths of the study included a large sample size of over 2200 patients who were evaluated for LT. The study also included detailed psychosocial data with SIPAT scores. The limitations included that it was only a single-center design study. Even though the study evaluated race inequity in LT waitlist decisions, there was not evaluation of racial inequities with the referral process.

Relevance:
This study demonstrates the importance of evaluating structural racism that is evident in the LT process.