Journal Article Annotations
2024, 2nd Quarter

Transplant Psychiatry

Annotations by Sarah R. Andrews, MD and Gregory Nikogosyan, DO
July, 2024

Weight Loss Surgery Increases Kidney Transplant Rates in Patients With Renal Failure and Obesity.
Psychosocial Evaluation of Living Kidney Donors: A Survey of Current Practices in the United States.

PUBLICATION #1 — Transplant Psychiatry

Weight Loss Surgery Increases Kidney Transplant Rates in Patients With Renal Failure and Obesity.

Aleksandra Kukla, Sukhdeep S Sahi, Pavel Navratil, Roberto P Benzo, Byron H Smith, Dustin Duffy, Walter D Park, Meera Shah, Pankaj Shah, Matthew M Clark, David C Fipps, Aleksandar Denic, Carrie A Schinstock, Patrick G Dean, Mark D Stegall, Yogish C Kudva, Tayyab S Diwan.

Abstract: Mayo Clin Proc. 2024 May;99(5):705-715. doi: 10.1016/j.mayocp.2024.01.017.

Objective:
To describe the outcomes of kidney transplant (KT) candidates with obesity undergoing sleeve gastrectomy (SG) to meet the criteria for KT.

Methods:
Retrospective analysis was conducted of electronic medical records of KT candidates with obesity (body mass index >35 kg/m²) who underwent SG in our institution. Weight loss, adverse health events, and the listing and transplant rates were abstracted and compared with the nonsurgical cohort.

Results:
The SG was performed in 54 patients; 50 patients did not have surgery. Baseline demographic characteristics were comparable at the time of evaluation. Mean body mass index ± SD of the SG group was 41.7±3.6 kg/m² at baseline (vs 41.5±4.3 kg/m² for nonsurgical controls); at 2 and 12 months after SG, it was 36.4±4.1 kg/m² and 32.6±4.0 kg/m² (P<.01 for both). In the median follow-up time of 15.5 months (interquartile range, 6.4 to 23.9 months), SG was followed by active listing (37/54 people), and 20 of 54 received KT during a median follow-up time of 20.9 months (interquartile range, 14.7 to 28.3 months) after SG. In contrast, 14 of 50 patients in the nonsurgical cohort were listed, and 5 received a KT (P<.01). Three patients (5.6%) experienced surgical complications. There was no difference in overall hospitalization rates and adverse health outcomes, but the SG cohort experienced a higher risk of clinically significant functional decline.

Conclusion:
In KT candidates with obesity, SG appears to be effective, with 37% of patients undergoing KT during the next 18 months (P<.01). Further research is needed to confirm and to improve the safety and efficacy of SG for patients with obesity seeking a KT.

Annotation

The finding:
Patients who underwent sleeve gastrectomy had a significantly higher likelihood of being listed for a kidney transplant. Post-surgical complication risks were consistently low and did not show significant differences between the sleeve gastrectomy group and non-surgical group. While not statistically significant between the groups, there was a noticeable trend indicating a decline in functional status post sleeve gastrectomy, with increased rates of sarcopenia and decline in cardiorespiratory fitness.

Strengths and weaknesses:
This study is the first to demonstrate an increase in listing rates for transplants and post-surgical functional changes in patients who underwent sleeve gastrectomy compared to those who did not. Weaknesses of this study include a lack of statistical power, as there was an observed trend towards poorer functional outcomes in patients who had sleeve gastrectomy. Additionally, longer-term follow-up would be beneficial to ascertain if there are significant differences in mortality rates among three groups: individuals who underwent kidney transplant after sleeve gastrectomy, those who underwent kidney transplant without sleeve gastrectomy, and those who remained on dialysis without sleeve gastrectomy.

Relevance:
The transplant multidisciplinary team evaluates various factors for listing, including body mass index as a determinant of surgical outcomes. It is essential to engage in a risk-benefit discussion when considering the advantages of bariatric surgery in enhancing an individual’s eligibility for listing, balanced against the documented decline in functional capacity described in this study. This article underscores that sleeve gastrectomy poses risks for the pre-transplant patient population, specifically highlighting the heightened incidence of sarcopenia resulting from muscle breakdown due to calorie restriction and the decrease in cardiorespiratory fitness that warrants further investigation.

PUBLICATION #2 — Transplant Psychiatry

Psychosocial Evaluation of Living Kidney Donors: A Survey of Current Practices in the United States.

Erin Clifton, Gerald Scott Winder, Krista L Lentine, Paula C Zimbrean, Anju Yadav, Susan Rubman, Roberto Kalil, Vineeta Kumar, Rohini Prashar, Geliang Gan, Yanhong Deng, Michael Joyce, Rachel Holmes, Jennie Laflen, Darsh Bakhai, AnnMarie Liapakis, Mona D Doshi.

Abstract: Transplantation. 2024 Jun 13. doi: 10.1097/TP.0000000000005095. Online ahead of print.

Background:
Best practices in psychosocial evaluation and care of living donor candidates and donors are not well established. Methods: We surveyed 195 living kidney donor (LKD) transplant centers in United States from October 2021 to April 2022 querying (1) composition of psychosocial teams, (2) evaluation processes including clinical tools and domains assessed, (3) selection criteria, and (4) psychosocial follow-up post-donation.

Results:
We received 161 responses from 104 programs, representing 53% of active LKD programs and 67% of LKD transplant volume in 2019. Most respondents (63%) were social workers/independent living donor advocates. Over 90% of respondents indicated donor candidates with known mental health or substance use disorders were initially evaluated by the psychosocial team. Validated psychometric or transplant-specific tools were rarely utilized but domains assessed were consistent. Active suicidality, self-harm, and psychosis were considered absolute contraindications in >90% of programs. Active depression was absolute contraindication in 50% of programs; active anxiety disorder was excluded 27%. Conditions not contraindicated to donation include those in remission: anxiety (56%), depression (53%), and posttraumatic stress disorder (41%). There was acceptance of donor candidates using alcohol, tobacco, or cannabis recreationally, but not if pattern met criteria for active use disorder. Seventy-one percent of programs conducted post-donation psychosocial assessment and use local resources to support donors.

Conclusions:
There was variation in acceptance of donor candidates with mental health or substance use disorders. Although most programs conducted psychosocial screening post-donation, support is not standardized and unclear if adequate. Future studies are needed for consensus building among transplant centers to form guidelines for donor evaluation, acceptance, and support.

Annotation

The finding:
Findings from the survey of living kidney donor (LKD) transplant centers in the United States revealed significant variability in the acceptance of donor candidates with mental health or substance use disorders. The majority of programs conducted psychosocial screenings post-donation, but there was inconsistency in the utilization of psychometric tools and support services for donors, indicating a need for standardized guidelines in this area. Despite some established contraindications—such as active suicidality, self-harm, and psychosis—other conditions like anxiety and depression in remission were not universally considered barriers to donation, illustrating the complexity of psychosocial evaluations in the living donor process.

Strengths and weaknesses:
Strengths of the study include the high response rate from a significant portion of active LKD programs, providing a comprehensive overview of current practices. The detailed survey queried a range of aspects, including the composition of psychosocial teams, the evaluation processes, selection criteria, and post-donation psychosocial follow-up. However, weaknesses include the study’s reliance on self-reported data, which may introduce bias or inaccuracies, and the absence of qualitative insights into the decision-making processes within transplant centers, which could have provided a deeper understanding of the challenges and considerations involved in psychosocial evaluations of living kidney donors.

Relevance:
The relevance of these findings to Consultation-Liaison (CL) psychiatrists lies in the importance of understanding the nuanced psychosocial considerations for living kidney donors. It highlights the need for CL psychiatrists to be actively engaged in the multidisciplinary evaluation and follow-up care of living donor candidates, particularly in assessing mental health conditions and substance use disorders that may impact donor eligibility and the support required post-donation. This study underscores the critical role that CL psychiatrists can play in ensuring comprehensive and holistic care for living kidney donors and emphasizes the necessity of their involvement in developing best practices for psychosocial evaluation within transplant programs.