Psychiatric Comorbidity, Health-Related Quality of Life, and Mental Health Service Utilization Among Patients Awaiting Liver Transplant

Liver transplantation for alcohol-associated liver disease

Alcohol-associated liver disease (ALD) is a major cause of morbidity and mortality worldwide, and a leading indication for liver transplantation (LT) in many countries, including the United States. However, LT for ALD is a complex and evolving field with ethical, social, and medical challenges. Thus, it requires a multidisciplinary approach and individualized decision-making. Short-term and long-term patient and graft survival of patients undergoing LT for ALD are comparable to other indications, but there is a continued need to develop better tools to identify patients who may benefit from LT, improve the pretransplant and posttransplant management of ALD, and evaluate the impact of LT for ALD on the organ donation and transplantation systems. In this review, we summarize the current evidence on LT for ALD, from alcohol-associated hepatitis to decompensated alcohol-associated cirrhosis. We discuss the indications, criteria, outcomes, and controversies of LT for these conditions and highlight the knowledge gaps and research priorities in this field.

Genetic Variation, Stress, and Physiological Stress Response in Adults With Food Allergy or Celiac Disease

BACKGROUND

Persistently high chronic stress can lead to maladaptive psychological, behavioral, and physiological stress responses and poor mental and physical health, highlighting the importance of identifying individuals at increased risk. Chronic health condition diagnosis and genetics are 2 characteristics that can influence stress, stress response, and health outcomes.

PURPOSE

Food allergy (FA) and celiac disease (CD) require constant vigilance in daily life and can lead to increased stress. The purpose of this exploratory analysis was to examine the association of variants in selected stress-related genes with stress exposures, stress, clinical measures of physiological stress response, and mental health symptoms in adults with and without FA or CD.

METHODS

We compared stress exposures, symptoms of PTSD, depression, anxiety, and stress, BMI, and waist-hip ratio between cases and controls. We analyzed the association of SNPs in genes with known or hypothesized associations with stress-related measures in 124 cases and 124 matched controls: CRHBP (rs7718461, rs10474485), CRHR1 (rs242940) and OXTR (rs2268490). For this exploratory study, p-values ≤ 0.10 were considered suggestive.

RESULTS

For cases and controls, rs7718461 was associated with stress symptoms, rs2268490 with symptoms of stress and PTSD, and rs242940 with symptoms of stress, PTSD, anxiety, and depression. Further analyses found that stress-related outcomes in individuals with FA or CD may be influenced by SNP genotype.

CONCLUSIONS

Given these suggestive findings, larger prospective studies should examine similar relationships in individuals with other chronic health conditions, incorporating factors such as environmental exposures, individual experiences, and epigenetic modifications.

Palliative Care for Patients with End-Stage Liver Disease

End-stage liver disease (ESLD) is the culmination of progression of chronic liver disease to cirrhosis, decompensation, and chronic liver failure, featuring portal hypertension or hepatocellular failure-related complications. Liver transplantation offers improved long-term survival for these patients but is negatively influenced by donor availability, financial constraints in developing countries, active substance abuse, progression of disease or malignancy on wait-list, sepsis and extrahepatic organ involvement. In this context, palliative care (PC), an interdisciplinary medical practice that aim to prevent and relieve suffering, offers best possible quality of life and is not limited to end-of-life care. It also encompasses achievable goals such as symptom control and aggressive disease-modifying treatments or interventions that beneficially alter the natural course of the disease to offer curative intend. In this narrative review, we discuss the prognostic factors that define disease course in ESLD, various indications and challenges in PC for advanced cirrhosis and management options for major symptom burden in patients with ESLD based on evidence-based best practice.

MENTAL DISORDERS AND LIVER TRANSPLANTATION: A 2-YEAR COHORT STUDY

BACKGROUND

Psychosocial assessment is a key component in evaluation for liver transplantation and may affect survival rates and outcomes.

OBJECTIVE

The primary aim of this study was to investigate the impact of previous mental disorders and impulsivity on the 2-year surviving rate after liver transplantation.

METHODS

We performed a prospective cohort study assessing end-stage liver disease individuals with and without psychiatric comorbidities for 2 years post-transplant. Psychiatric diagnosis was carried out through Mini-Plus 5.0.0 and impulsivity by using Barratt Impulsiveness Scale in the pre-transplant phase. We followed patient's status for 2 years after transplantation. The main outcome was death. We used a logistic regression to evaluate the association of psychiatric comorbidities with death and performed a survival analysis with Kaplan-Meier and Cox regression models.

RESULTS

Between June 2010 and July 2014, 93 out of 191 transplant candidates received transplants. From the 93 transplant patients, 21 had psychiatric comorbidities and 72 had not. 25 patients died during the study. The presence of psychiatric comorbidities (P=0.353) and high impulsivity (P=0.272) were not associated to 2-year post transplant death.

CONCLUSION

This study found no evidence that the presence of mental disorders and impulsivity worsened prognosis in post-liver transplantation.

Post-liver transplant outcomes in patients with major psychiatric diagnosis in the United States

INTRODUCTION AND OBJECTIVES

Higher rates of psychiatric disorders are reported among cirrhotic patients. This study examines the demographic and clinical outcomes post-liver transplant (LT) among cirrhotic patients with a major psychiatric diagnosis (cases) compared to those without psychiatric diagnosis (controls).

MATERIALS AND METHODS

Retrospective case control design was used among 189 cirrhotic patients who had undergone LT at Methodist University Hospital Transplant Institute, Memphis, TN between January 2006 and December 2014. Multivariable regression and Cox proportional hazard regression were conducted to compare allograft loss and all-cause mortality.

RESULTS

The study sample consisted of a matched cohort of 95 cases and 94 controls with LT. Females and those with Hepatic Encephalopathy (HE) were more likely to have psychiatric diagnosis. Patients with hepatocellular carcinoma (HCC) were twice as likely to have allograft loss. Psychiatric patients with HCC had two and a half times (HR 2.54; 95% CI: 1.20-5.37; p = 0.015) likelihood of all-cause mortality. Data censored at 1-year post-LT revealed that patients with psychiatric diagnosis have a three to four times higher hazard for allograft loss and all-cause mortality compared to controls after adjusting for covariates, whereas when the data is censored at 5 year, allograft loss and all-cause mortality have two times higher hazard ratio.

CONCLUSIONS

The Cox proportional hazard regression analysis of censored data at 1 and 5 year indicate higher allograft loss and all-cause mortality among LT patients with psychiatric diagnosis. Patients with well-controlled psychiatric disorders who undergo LT need close monitoring and medication adherence.

Impact of biliary complications on quality of life in live-donor liver transplant recipients

BACKGROUND

Despite significant advancements in liver transplantation (LT) surgical procedures and perioperative care, post-LT biliary complications (BCs) remain a significant source of morbidity, mortality, and graft failure. In addition, data are conflicting regarding the health-related quality of life (HRQoL) of LT recipients. Thus, the success of LT should be considered in terms of both the survival and recovery of HRQoL.

AIM

To assess the impact of BCs on the HRQoL of live-donor LT recipients (LDLT-Rs).

METHODS

We retrospectively analysed data for 25 LDLT-Rs who developed BCs post-LT between January 2011 and December 2016 at our institution. The Short Form 12 version 2 (SF 12v2) health survey was used to assess their HRQoL. We also included 25 LDLT-Rs without any post-LT complications as a control group.

RESULTS

The scores for HRQoL of LDLT-Rs who developed BCs were significantly higher than the norm-based scores in the domains of physical functioning (P = 0.003), role-physical (P < 0.001), bodily pain (P = 0.003), general health (P = 0.004), social functioning (P = 0.005), role-emotional (P < 0.001), and mental health (P < 0.001). No significant difference between the two groups regarding vitality was detected (P = 1.000). The LDLT-Rs with BCs had significantly lower scores than LDLT-Rs without BCs in all HRQoL domains (P < 0.001) and the mental (P < 0.001) and physical (P = 0.0002) component summary scores.

CONCLUSION

The development of BCs in LDLT-Rs causes a lower range of improvement in HRQoL.

Practice variation in the immediate postoperative care of pediatric liver transplant patients: Framework for a national consensus

Advancements in critical care management have led to improvement in pediatric LT outcomes. However, there are no specific guidelines for many aspects of immediate post-LT care. This survey examines practice variations in the immediate postoperative care of pediatric LT patients at a large number of active US centers. This study is a cross-sectional survey of medical directors at PALISI-affiliated PICU in the United States. Centers performing pediatric LT were analyzed. Study measures included PICU practices regarding staffing, composition of the multidisciplinary team, early post-LT graft and patient monitoring, and anticoagulation. Of the thirty-five responding centers, twenty-five had a LT program which accounted for one-half of all US pediatric LTs. For analysis, centers were categorized by volume: high (7), medium (11), and low (7). The majority of PICU teams included an intensivist (80%) and hepatologist (84%). High-volume centers were less likely to have 24-hour in-house attending coverage (29%, compared to 64% (medium) and 100% (low)). High-volume centers were most likely to have pre-printed orders, but least likely to have written PICU management protocols. Most centers utilize routine daily liver ultrasound. Routine prophylactic anticoagulation, and the agent of choice, was variable. There is marked inconsistency in post-LT practice across PALISI centers in regards to team composition and immediate post-LT management. A national US consensus for post-LT PICU practices would facilitate outcomes research and would establish a platform for multicenter studies.

Factors Affecting Quality of Life in Liver Transplant Candidates: An Observational Study

Health-related quality of life (HRQOL) before and after liver transplant (LT) is an important outcome in LT candidates as, in these patients, HRQOL is commonly impaired. However, evidence regarding factors that influence HRQOL in patients with end-stage liver disease is inconclusive. The aim of the present study was to identify factors associated with poor HRQOL. An observational study was conducted over LT candidates. The 36-item Short Form Health Survey (widely used to assess HRQOL) and the Hospital Anxiety and Depression Scale were administered to 211 patients during the pre-transplant assessment. Baseline demographic and clinical data were also collected. Multiple regression analysis was performed to investigate risk factors for poor HRQOL. Female sex (lower B = 7.99 95%C = 0.07–15.92, higher B = 18.09 95%CI = 7.56–28.62), encephalopathy (lower B = −9.45, 95%CI = −14.59–−4.31, higher B = −6.69, 95%CI = −13.13 to −0.25), higher MELD scores (lower B = −1.14, 95%CI = −1.67 to −0.61, higher B = −0.33, 95%CI = −0.65 to −0.12), anxiety (lower B = −3.04 95%C = −4.71 to −1.36, higher B = −1.93 95%CI = −3.39 to −0.47)and depression (lower B = −3.27 95%C = −4.46 to −2.08, higher B = −1.02 95%CI = −1.90 to −0.13) symptoms were associated to poorer HRQOL. Psychosocial interventions should be addressed to liver transplant candidates, especially to women, patients with anxiety, depression or episodes of encephalopathy, in order to prevent the impact that these conditions can have on HRQOL.

An exploratory study of the experiences of deceased-donor liver transplant recipients and their need for psychotherapeutic support

AIMS AND OBJECTIVES

This study aimed to explore the experiences of liver transplant recipients during their journey through the treatment and their need for psychotherapeutic support related to this process.

BACKGROUND

Over time, measures of survival and quality of life in liver transplant recipients have continued to improve but their emotional needs remain under explored. In the longer-term recovery from transplantation, the focus shifts from physical health to psychological health. In the UK, there are no known embedded adult psychological services in liver transplant centres to react to this need.

DESIGN

A qualitative descriptive design was used.

METHODS

Grounded theory analysis was used to study the narratives of six adult liver transplant recipients. Through a process of coding, conceptual categories were established to describe the participant experiences. The study adhered to the EQUATOR checklist, SRQR.

RESULTS

Four categories emerged that were related to the experience of liver transplantation for the recipients. These were a process of adjustment, the phenomenon of waiting, liver transplant as a transformative experience and on the value of support. The participants identified a lack of psychotherapeutic support provided by the liver transplant service and felt that an embedded psychotherapeutic service would promote accessing such support during challenging times.

CONCLUSION

Through the process of liver transplantation, recipients experience challenges with adjustment, waiting, feeling transformed and they value support with these feelings. In correlation with other studies, the findings of this study highlight the need for providing psychotherapeutic support within liver transplant services.

RELEVANCE TO CLINICAL PRACTICE

The study provides evidence to support recommendations for a conjoined psychotherapy service within liver transplant services to support patients with their holistic needs.

Integrated Model for Patient-Centered Advanced Liver Disease Care

Advanced liver disease (AdvLD) is a high-risk common condition with a progressive, highly morbid, and often fatal course. Despite effective treatments, there are substantial shortfalls in access to and use of evidence-based supportive and palliative care for AdvLD. Although patient-centered, chronic illness models that integrate early supportive and palliative care with curative treatments hold promise, there are several knowledge gaps that hinder development of an integrated model for AdvLD. We review these evidence gaps. We also describe a conceptual framework for a patient-centered approach that explicates key elements needed to improve integrated care. An integrated model of AdvLD would allow clinicians, patients, and caregivers to work collaboratively to identify treatments and other healthcare that best align with patients' priorities.

Psychopathology, quality of life, and related factors in pediatric liver transplantation candidates and recipients

BACKGROUND

Liver transplantation (LT) has been accepted as a standard treatment of pediatric liver diseases that can progress to end-stage liver disease or lead to acute liver failure. However, there is a lack of studies clarifying quality of life (QoL) and the characteristics and the prevalence of common psychiatric disorders in children before and/or after LT. Thus, this study aimed to investigate QoL and the prevalence of anxiety, depression, and post-traumatic stress disorder (PTSD) in children and adolescents before and after LT and to compare them with healthy controls.

METHODS

The study included 30 children aged 5-18 years who were waiting for LT (pTx group) or had undergone LT (Tx group) as the study groups and 20 children for the control group. The PedsQL was used to evaluate QoL, and SCARED, CDI, and the CPTSD-RI were used to evaluate psychopathology.

RESULTS

The QoL scores were higher in the control group compared with the study groups in all or most of the dimensions, depending on the reporter. The mean scores of anxiety, depression, and PTSD of the control group were significantly lower than those of the Tx and pTx groups. A significant positive correlation was found between depression, anxiety, and PTSD scores, and a negative correlation was observed between depression, anxiety, and PTSD scores and QoL.

CONCLUSION

Waiting for LT and the transplantation process itself seem to be psychologically traumatic for children. Healthcare providers need to be trained to recognize the symptoms of the main psychiatric disorders.

MENTAL DISORDERS AND QUALITY OF LIFE IN PATIENTS AWAITING LIVER TRANSPLANTATION

BACKGROUND

Liver transplantation is the main therapeutic alternative for patients with advanced liver disease. These patients have high prevalence of psychiatric comorbidities that may negatively interfere in clinical outcomes and quality of life. It is not clear in the literature whether the different etiologies of hepatic disease have the same prevalence of psychiatric disorders.

OBJECTIVE

The aim of this study was to investigate whether patients in the liver transplant list showed differences in psychiatric characteristics, medical variables and quality of life among different etiological groups.

METHODS

This is a cross-sectional study that evaluates quality of life, psychiatric and clinical comorbidities through the application of validated questionnaires and instruments in 248 patients who were on transplant waiting list from 2010 to 2014, assisted in a University Hospital and in a Private Hospital in Salvador/Bahia, Brazil. The patients were evaluated through the Mini International Neuropsychiatric Interview (M.I.N.I. PLUS 5.0) and Medical Outcomes Short-Form Health Survey (SF-36).

RESULTS

The etiology of the most prevalent liver disease was hepatitis C virus. A prevalence of 50.8% of at least one mental disorder was identified. When alcohol abuse/dependence was excluded, the prevalence was 25.8%. Mental health did not show a statistically significant difference in the diverse etiological groups, but a higher prevalence of psychiatric comorbidities was detected among women and younger than 40 years. No cases of psychotic disorders were detected, possibly by exclusion prior to listing. There was no difference in the quality of life domains in the different liver etiological groups.

CONCLUSION

A high-prevalence of psychiatric disorders was found among all clinical conditions most associated with indication for liver transplantation. Attention is drawn to the absence of patients with psychotic disorders, which suggests that transplantation may not have been indicated for this group of patients. For these reasons, professionals caring for liver transplant candidates should be highly vigilant for the presence of mental disorders, regardless of the etiology of liver disease. Specialized care is recommended to minimize the early exclusion of patients with no other therapeutic possibilities, as well as care of all people with mental disorders.

Multicultural Awareness and a Comprehensive Team Approach to Liver Transplantation: A Case Report

Patients being considered for a liver transplant undergo a rigorous evaluation process to identify the medical and psychosocial factors that may impact transplant success. The American Association for the Study of Liver Disease outlines recommendations for medical factors, but guidelines for psychosocial factors, such as multiculturalism, are less clear. The aim of this unique case study was to highlight the importance of multicultural awareness in the context of liver transplantation. More specifically, the report follows an American Indian man from initial diagnosis through psychological assessment and transplantation in order to illustrate the benefits of a comprehensive, multicultural team approach. Various components of multiculturalism are discussed, including the patient's ethnicity, intellectual functioning, socioeconomic status, and mental health history. Consideration of these factors by the patient's treatment team ultimately led to the patient's candidacy for transplant, as well as effective psychosocial support throughout the transplant process and recovery. Incorporation more specific psychosocial recommendations into national liver transplantation guidelines would likely improve the evaluation process and outcomes.