Post-liver transplantation patient experience

Burden, stress and depression in caregivers of cirrhosis patients before and after liver transplantation

BACKGROUND

Family caregivers of cirrhosis patients (CPs) often experience burden, stress, and depression. Investigating whether these conditions improve following the patient undergoing liver transplantation (LT) is crucial, as it would elucidate the comprehensive benefits of the procedure and demonstrate the positive impacts not only on the patients but also on their caregivers and society.

AIM

To compare the levels of burden, stress and depression among family caregivers of cirrhotic and liver transplant patients.

METHODS

This cross-sectional observational study evaluated caregivers of CPs and LT recipients at a quaternary Brazilian hospital. Instruments included identification cards, interview scripts, the caregiver burden scale Inventory, Lipp’s Stress Symptom Inventory, and the Beck Depression Inventory-Second Edition. Psychometric analyses involved confirmatory factor analysis and calculation of McDonald’s omega and composite reliability. Factor scores were compared with the Mann-Whitney U test, with effect size as the rank-biserial correlation coefficient (r). Statistical analysis was performed with R software (P < 0.05).

RESULTS

Seventy-seven CP caregivers and 65 LT recipient caregivers were included. Most were female (CP: 85.7% vs LT: 84.6%) and the patients’ spouses (76.6% vs 63.1%). The median age and caregiving duration were 55.4 (23.3-76.3) vs 54.6 (25.7-82.1) and 3.9 (1-20) vs 8 (1.5-24) years, respectively (P = 0.001). LT caregivers were less likely to be at risk of overload (21.5% vs 49.4%), to be under stress (33.8% vs 36.4%) and to show symptoms of depression (15.4% vs 35.1%). Compared with LT caregivers, CP caregivers had greater median factor scores for burden (general tension, P = 0.012; isolation, P = 0.014; disappointment, P = 0.004), depression (P = 0.008), and stress (P = 0.047), with small to moderate effect sizes. The disappointment (r = 0.240) and depression (r = 0.225) dimensions had the largest effect sizes.

CONCLUSION

Family caregivers of LT recipients are less likely to exhibit symptoms of burden, stress, and depression, suggesting that the benefits of LT extend to the patients’ family members.

''Two People in One Body": Qualitative Study on the Family Perceptions of Recipients with a Family Member as Their Donor Using a Projective Method

The aim was to examine the family perceptions of recipients with a family member as their donor using a projective method. In this qualitative study, an arts-based narrative method was employed. The study was completed with 16 recipients through the drawing test, observation, and interviews. The recorded data for each participant were analysed projectively by creating a coding list related to family perception. Each participant's drawings were analysed in alignment with data obtained from other data collection tools and the categories were identified. And then categories were evaluated thematically, main themes identified. There were numerous inconsistencies between the recipients' consciously expressed statements and their unconscious projections. The significant changes in the life of another family member after organ transplantation have placed a dual responsibility on the recipient, both for their own life and for the donor's sacrifice, alongside feelings of gratitude. Another finding is the sorrow of lost time within family roles due to illness and its associated treatment processes. Organ transplant recipients tend to view themselves as different from others in society, experience guilt, and engage in self-directed negative attributions. The findings provide transplant and mental health nurses with a new perspective on assessing the psychosocial difficulties of transplant recipients and understanding family dynamics.

Mastering the narrative: Precision reporting of risk and outcomes in liver transplantation

Liver transplantation is associated with a high risk of postoperative complications due to the complexity of the surgical procedure, recipient disease severity and the wide range of graft quality, which remains somewhat unpredictable. However, survival rates after transplantation continue to improve and the focus has thus turned to other clinically relevant endpoints including post-transplant complications, patient quality of life and costs. Procedures like liver transplantation offer the entire spectrum of post-surgical events, even in donor-recipient constellations deemed of low risk within recently defined benchmark criteria. The Clavien-Dindo classification and the CCI (comprehensive complication index) were established to assess postoperative morbidity and are widely utilised across surgical specialties. These scores depend on the number and grade of complications, which reflect the interventions required, and are frequently used to assess specific donor-recipient risk profiles and new approaches, such as machine perfusion. However, these scores are associated with inter-observer variability when used in practice, mainly due to the lack of uniform definitions. The concept of benchmarking was recently introduced in surgery and transplantation as a mechanism of standardising expected donor/recipient risk with outcomes within the first year after surgery. However, the management of complications differs significantly worldwide, as does the rating scale assigned to various complications. This may lead to inhomogeneous interpretation of study results, leading to difficulty in assessing the clinical effects of novel preservation technologies and other therapeutics in liver transplantation. This article critically discusses frequent challenges associated with risk and outcome assessment following liver transplantation.

Integrating Palliative Care Consultation Into Inpatient Liver Transplant Evaluations: A Quality Improvement Study

Palliative care (PC) consultation in high-risk patients with liver disease who are undergoing liver transplant (LT) evaluation is underused due to common beliefs that PC would negatively impact a patient's desire for transplant. This population is at risk due to high morbidity, mortality, and negative impact to overall quality of life. A 4-week pilot study was conducted in a transplant surgical intensive care unit at a single academic center to increase PC consultation during inpatient LT evaluation and improve transitions in care. Two Plan, Do, Study, Act quality improvement cycles were subsequently led by the PC nurse practitioner and social worker to increase the effectiveness of this intervention. The first cycle (November 29, 2018, to September 30, 2019) identified the need to increase PC education of intensive care unit nurses and promote interdisciplinary collaboration. The second cycle (October 1, 2019, to June 13, 2022) modified the study protocol to prioritize high-risk patients undergoing inpatient LT evaluation. Palliative care consultation increased by 262.5% from 2018 to 2019, with consults completed on 19% of all patients admitted for inpatient LT evaluations throughout the duration of the quality improvement study. Palliative care consultation on high-risk patients undergoing inpatient LT evaluation is a promising targeted strategy to increase utilization of PC in this population.

Optimization of surgical evaluation algorithms for living donor liver transplantation

BACKGROUND

Living donor liver transplantation (LDLT) is an established and endorsed alternative for deceased donor liver transplantation with better recipient outcomes. Nevertheless, while extensive evaluation of potential donors is crucial, evaluation algorithms differ between transplant centres and guidelines.

METHODS

We included 317 individuals evaluated for LDLT between 07/2007-07/2022 in a retrospective analysis. The evaluation process was analysed to identify the key reasons for declining 77 potential donors. Additionally, 146 donors that underwent LDLT were analysed regarding risk factors for complications.

RESULTS

The main reasons for donor refusal were liver volumetry (40.3 %) and metabolic factors including obesity or steatotic liver disease (20.8 %). Contrast-enhanced computed tomography (CECT) identified 63.6 % of all declined donors; CECT combined with assessment of medical history, physical examination, blood testing and ultrasonography, identified 87.0 % of declined potential donors. Associated with this selection, complication rates in donors were low (≥II in 17.1 %; none with ≥IVb). Notably, higher age was a risk factor for developing a complication ≥II after hemi-hepatectomy (p = 0.0373).

CONCLUSIONS

We propose a progressive 4-step evaluation algorithm that begins with a very basic assessment combined with up-front CECT. This early phase of testing is expected to identify nearly 90 % of ineligible donors, thereby conserving critical resources, time and money, as well as minimising burden for potential donors.

FUNDING

J.M.W. received funding by grant We-4675/6-1 from the Deutsche Forschungsgemeinschaft (DFG) in Bonn, Germany.

Ethical challenges in organ transplantation for Syrian refugees in Türkiye

BACKGROUND

There is limited information on the ethical issues encountered in living donor organ transplants performed on refugees and asylum seekers. This study investigates the ethical challenges faced by Syrian refugees under temporary protection in Türkiye who engage in living donor organ transplants.

METHODS

From April to July 2022 in Istanbul, the research employed a qualitative design involving semi-structured, in-depth interviews with 27 participants, including organ donors and recipients. The analysis utilized a thematic analytic method.

RESULTS

The findings elucidate two principal themes related to ethical concerns: justice and autonomy. Under the justice theme, several sub-themes emerged, highlighting the multifaceted challenges Syrian refugees face in accessing healthcare services. These include migration and language barriers, significantly impeding their ability to understand medical procedures and rights. Financial difficulties and restricted movement within the country further complicate their access to necessary healthcare. Despite these hurdles, refugees benefit from free access to organ transplantation services and medications, a policy underscoring Türkiye's commitment to healthcare equity for protected populations. The autonomy theme addresses the ethical handling of donor consent and motivation. The results indicate that Syrian refugees undergo a transplantation process free from coercion, with rigorous oversight by organ transplant ethics committees ensuring the prevention of donor abuse. However, despite these protective measures, challenges persist in the informed consent process, primarily due to language barriers that hinder effective communication between healthcare providers and patients. While the efforts of healthcare professionals to assist are recognized as alleviating some difficulties, the broader issues of access to comprehensive health services remain a significant concern. These barriers suggest a need for enhanced linguistic and financial support to improve healthcare accessibility for refugees.

CONCLUSIONS

This study posits that the healthcare framework provided by Türkiye to Syrians under temporary protection can serve as a model for international human rights and social justice. However, it also emphasizes the importance of addressing the persistent obstacles that limit healthcare access for asylum seekers. Recommendations for policy enhancements focus on improving language services, increasing financial support, and expanding the accessibility of comprehensive health services to ensure equitable health outcomes for refugees.

Financial burden following adult liver transplantation is common and associated with adverse recipient outcomes

The financial impact of liver transplantation has been underexplored. We aimed to identify associations between high financial burden (≥10% annual income spent on out-of-pocket medical costs) and work productivity, financial distress (coping behaviors in response to the financial burden), and financial toxicity (health-related quality of life, HRQOL) among adult recipients of liver transplant. Between June 2021 and May 2022, we surveyed 207 adult recipients of liver transplant across 5 US transplant centers. Financial burden and distress were measured by 25 items adapted from national surveys of cancer survivors. Participants also completed the Work Productivity and Activity Impairment and EQ-5D-5L HRQOL questionnaires. In total, 23% of recipients reported high financial burden which was significantly associated with higher daily activity impairment (32.9% vs. 23.3%, p =0.048). In adjusted analyses, the high financial burden was significantly and independently associated with delayed or foregone medical care (adjusted odds ratio, 3.95; 95% CI, 1.85-8.42) and being unable to afford basic necessities (adjusted odds ratio, 5.12; 95% CI: 1.61-16.37). Recipients experiencing high financial burden had significantly lower self-reported HRQOL as measured by the EQ-5D-5L compared to recipients with low financial burden (67.8 vs. 76.1, p =0.008) and an age-matched and sex-matched US general population (67.8 vs. 79.1, p <0.001). In this multicenter cohort study, nearly 1 in 4 adult recipients of liver transplant experienced a high financial burden, which was significantly associated with delayed or foregone medical care and lower self-reported HRQOL. These findings underscore the need to evaluate and address the financial burden in this population before and after transplantation.

Risk Factors for Non-Adherence to Medication for Liver Transplant Patients: An Umbrella Review

Background/Objectives: Liver Transplantation (LT) is the second most common solid organ transplantation. Medication adherence on LT patients is key to avoiding graft failure, mortality, and important quality of life losses. The aim of this study is to identify risk-factors for non-adherence to treatment of liver transplant patients according to reliable published evidence. Methods: An umbrella review within the context of adherence to immunosuppressant medication of LT patients, was conducted. The review was performed in accordance with the principles of the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Results: A total of 11 articles were finally included for the review. Non-adherence factors were identified and allocated using the WHO classification of factors for non-adherence. Each of these groups contains a subset of factors that have been shown to influence adherence to medication, directly or indirectly, according to literature findings. Conclusions: The results of the review indicate that sociodemographic factors, factors related to the patient, factors related to the treatment, condition-related and health system-related factors are good categories of predictors for both adherence and non-adherence to immunosuppressive medication in LT patients. This list of factors may help physicians in the treating and recognizing of patients with a potential risk of non-adherence and it could help in the designing of new tools to better understand non-adherence after LT and targeted interventions to promote adherence of LT patients.