Journal Article Annotations
2023, 2nd Quarter

Transplant Psychiatry

Annotations by Sarah R. Andrews, MD
July, 2023

Comorbid psychiatric disorders and long-term survival after liver transplantation in transplant facilities with a psychiatric consultation-liaison team: a multicenter retrospective study.

PUBLICATION #1 — Transplant Psychiatry

Comorbid psychiatric disorders and long-term survival after liver transplantation in transplant facilities with a psychiatric consultation-liaison team: a multicenter retrospective study.

Hiroyuki Kimura, Shinichi Kishi, Hisashi Narita, Teruaki Tanaka, Tsuyoshi Okada, Daisuke Fujisawa, Naoko Sugita, Shun’ichi Noma, Yosuke Matsumoto, Ayako Ohashi, Hiroshi Mitsuyasu, Keizo Yoshida, Hiroaki Kawasaki, Katsuji Nishimura, Yasuhiro Ogura, Norio Ozaki.

Abstract: BMC Gastroenterol. 2023 Apr 5;23(1):106. doi: 10.1186/s12876-023-02735-1.

Objective:
Comorbid psychiatric disorders negatively affect the survival rate of patients with some physical disorders. In liver transplant recipients, various psychiatric disorders have been identified as worsening prognosis. However, little is known about how the presence of any comorbid (overall) disorders affect the survival rate of transplant recipients. In this study, we examined the effect of overall comorbid psychiatric disorders on survival rate in liver transplant recipients.

Methods:
A total of 1006 recipients who underwent liver transplantation between September 1997 and July 2017 across eight transplant facilities with a psychiatric consultation-liaison team were identified consecutively. Recipients were categorized into those with comorbid psychiatric disorders and those without comorbid psychiatric disorders. In the comorbid psychiatric disorder group, psychiatric disorder diagnosis and time of diagnosis were investigated retrospectively.

Results:
Of the 1006 recipients, 294 (29.2%) had comorbid psychiatric disorders. Comorbid psychiatric disorders in the 1006 recipients were insomnia (N = 107, 10.6%), delirium (N = 103, 10.2%), major depressive disorder (N = 41, 4.1%), adjustment disorder (N = 19, 1.9%), anxiety disorder (N = 17, 1.7%), intellectual disability (N = 11, 1.1%), autism spectrum disorder (N = 7, 0.7%), somatic symptom disorder (N = 4, 0.4%) schizophrenia (N = 4, 0.4%), substance use disorder (N = 24, 2.4%) and personality disorder (N = 2, 0.2%). The most common time of psychiatric disorder diagnosis was within the first 3 months after liver transplantation (51.6%). The final mortality in patients with comorbid psychiatric disorder diagnosis during the five periods (pretransplant, transplant to 3 months, months to 1 year, 1 to 3 years, and over 3 years posttransplant) was 16.2%, 18.8%, 39.1%, 28.6%, and 16.2% respectively, and there were no significant differences between the five periods (χ2 = 8.05, df = 4, p = 0.09). Overall comorbid psychiatric disorders were significantly associated with shorter survival time (log-rank test: p = 0.01, hazard ratio: 1.59 [95% confidence interval: 1.14-2.21], survival rate at the endpoint [%]: 62.0 vs. 83.3). However, after adjusting for confounding variables using Cox proportional hazards regression, there was no significant effect of overall comorbid psychiatric disorders on prognosis.

Conclusion:
Comorbid psychiatric disorders did not affect the survival rate of liver transplant recipients in this study.

Keywords:
Consultation-liaison psychiatry; Liver transplant recipient; Psychiatric disorder; Survival rate.

Annotation

The finding:
Psychiatric illness has been associated with increased mortality in patients with certain physical disorders, including liver transplant recipients. However, there has been minimal evidence to describe how comorbid psychiatric illness affects survival of these transplant recipients. This retrospective study examined 1006 recipients across eight institutions who underwent liver transplantation for 20 years starting in 1997. Recipients were divided by whether they had a comorbid psychiatric disorder, which included major groups (schizophrenia, major depressive disorder, mild intellectual disability, and autism spectrum disorder), minor groups (insomnia, adjustment disorder, and anxiety disorder), and other groups (substance use or personality disorder). Nearly 30% of the recipients met criteria for a comorbid psychiatric condition. Recipients were followed for over three years posttransplant. Even though recipients who had a comorbid psychiatric condition had significantly shorter survival time, this effect was no longer significant after adjusting for confounding variables, whereas age and length of hospitalization remained significant.

Strength and weaknesses:
This study had several strengths. Consultation-liaison psychiatrists directly evaluated patient for comorbid psychiatric conditions, particularly within the first three months of transplantation. There were also limitations: first, only patients referred by the transplant team were evaluated for psychiatric conditions. Another potential confounder was that after patients were identified to have a comorbid psychiatric condition, they were not monitored to determine if they followed up with treatment. Acute and chronic conditions were not separated, which could have affected results as well.

Relevance:
Even though patients with severe psychiatric illness are often excluded from transplantation, those with mild conditions did not show any significant change in survival outcome. This article is relevant to consultation-liaison psychiatrists who evaluate patients for transplant with mild psychiatric conditions. Future research should focusing on how to best monitor recipients after transplantation and how management and treatment may affect outcomes.