Group Psychotherapy Could Improve Depression in Cirrhotic Patients on the Liver Transplant Waiting List

Depression and anxiety management in cirrhosis

Depressive and anxiety symptoms are more prevalent in patients with cirrhosis compared to the general population. Between 2009 and 2019, the prevalence of depression in cirrhosis increased by 80%, while the prevalence of generalized anxiety disorder increased by over 400%. When present, anxiety and depression are linked to lower health-related quality of life, more severe symptoms (eg, fatigue), and poorer response to medical treatment. Screening instruments for depression and anxiety have shown acceptable validity in patients with cirrhosis. However, the diagnosis of depression and anxiety disorder remains challenging in this population and should follow the established criteria for general populations. Treatment interventions are numerous and include patient education and support around liver disease, pharmacological agents, and psychotherapy. Antidepressants are the treatment of choice for patients with depressive or anxiety disorder and cirrhosis. However, consideration must be given to dose adjustment and choice of agent due to changes in their metabolism in patients with liver disease. Psychotherapy may be used as a stand-alone therapy or concomitantly with pharmacotherapy. The high prevalence and complexity of depressive and anxiety symptoms in patients with cirrhosis support the integrated care approach in which patients are cared for by multidisciplinary teams.

Metabolic Disorders in Liver Transplant Recipients: The State of the Art

Liver transplantation represents a chief therapeutic approach for acute liver failure, end-stage liver disease and hepatocellular carcinoma. Despite witnessing advancements in short- and medium-term survival over recent decades, attributed to refinements in surgical techniques and immunosuppressive protocols, long-term mortality remains impervious to modification. Notably, cardiovascular disease emerges as a predominant cause of mortality among liver transplant recipients. This trend is accentuated by the increasing prominence of non-alcoholic steatohepatitis-related cirrhosis as an indication for liver transplantation. Moreover, the administration of immunosuppressive agents is intricately linked to the degradation of the metabolic profile in liver transplant recipients, thereby contributing to the initiation or exacerbation of cardiovascular risk factors, such as hypertension, diabetes, and dyslipidaemia. In addition, the post-liver transplantation period is marked by a decline in lifestyle quality and a failure to acknowledge the psychological distress experienced by patients throughout the transplant process. These factors can precipitate a deterioration in the patient's metabolic profile, exacerbated by suboptimal therapeutic compliance. This narrative review aims to comprehensively address the principal metabolic disorders intricately associated with liver transplantation.

Benefit and harm of waiting time in liver transplantation for HCC

Liver transplantation is the most successful treatment for limited-stage HCC. The waiting time for liver transplantation (LT) can be a critical factor affecting the oncological prognosis and outcome of patients with HCC. Efficient strategies to optimize waiting time are essential to maximize the benefits of LT and to reduce the harm of delay in transplantation. The ever-increasing demand for donor livers emphasizes the need to improve the organization of the waiting list for transplantation and to optimize organ availability for patients with and without HCC. Current progress in innovations to expand the donor pool includes the implementation of living donor LT and the use of grafts from extended donors. By expanding selection criteria, an increased number of patients are eligible for transplantation, which necessitates criteria to prevent futile transplantations. Thus, the selection criteria for LT have evolved to include not only tumor characteristics but biomarkers as well. Enhancing our understanding of HCC tumor biology through the analysis of subtypes and molecular genetics holds significant promise in advancing the personalized approach for patients. In this review, the effect of waiting time duration on outcome in patients with HCC enlisted for LT is discussed.

European Society of Organ Transplantation (ESOT) Consensus Statement on Prehabilitation for Solid Organ Transplantation Candidates

There is increasingly growing evidence and awareness that prehabilitation in waitlisted solid organ transplant candidates may benefit clinical transplant outcomes and improve the patient's overall health and quality of life. Lifestyle changes, consisting of physical training, dietary management, and psychosocial interventions, aim to optimize the patient's physical and mental health before undergoing surgery, so as to enhance their ability to overcome procedure-associated stress, reduce complications, and accelerate post-operative recovery. Clinical data are promising but few, and evidence-based recommendations are scarce. To address the need for clinical guidelines, The European Society of Organ Transplantation (ESOT) convened a dedicated Working Group "Prehabilitation in Solid Organ Transplant Candidates," comprising experts in physical exercise, nutrition and psychosocial interventions, to review the literature on prehabilitation in this population, and develop recommendations. These were discussed and voted upon during the Consensus Conference in Prague, 13-15 November 2022. A high degree of consensus existed amongst all stakeholders including transplant recipients and their representatives. Ten recommendations were formulated that are a balanced representation of current published evidence and real-world practice. The findings and recommendations of the Working Group on Prehabilitation for solid organ transplant candidates are presented in this article.

Psychosocial treatment on psychological symptoms, adherence, and physiological function on transplanted patients: A systematic review and metanalysis

OBJECTIVE

Transplantation represents an important source of hope for the candidates and produces an intense emotional effect. Psychosocial interventions can be helpful in all transplantation stages to better manage this extraordinarily stressful situation. Aim of the work is to verify the effects of the psychosocial interventions on recipients on psychological symptoms, medical adherence and transplanted solid organ functioning.

METHODS

This work adhered to PRISMA, STROBE, Cochrane and New Castle Ottawa bias scales and it is registered in PROSPERO. Inserting "Transplant" and "Psychological intervention" as key words in PubMed, Psycinfo, Cochrane database resulted 977 studies from 2001 to 2021. A systematic review and metanalyses were processed on nineteen randomized controlled trials and observative prospective cohort studies. The difference between pre- and post- psychosocial intervention assessment on the psychological variables, medical adherence, and organ functioning outcome was processed.

RESULTS

Main findings showed that the psychosocial interventions were effective on depression (0.62; CI: 0.32-0.92) and anxiety on kidney recipients (0.49; CI: 0.17-0.81), and on anxiety on heart recipients, mainly when administrated after the surgery (0.68; CI: 0.30-1.06). Moreover, the findings showed a lack of studies on the effectiveness of the psychosocial intervention on organ functioning.

CONCLUSION

The work highlighted the effectiveness of the psychosocial interventions on psychological outcome, particularly after the surgery and the need to address the research on the evaluation of the effectiveness of the psychosocial interventions on the organ functioning. The findings suggest to integrate the transplantation procedures with psychosocial interventions considering the different needs of recipients in relation to the specific transplanted organ.

The psychological burden of waiting for procedures and patient-centred strategies that could support the mental health of wait-listed patients and caregivers during the COVID-19 pandemic: A scoping review

BACKGROUND

Waiting for procedures delayed by COVID-19 may cause anxiety and related adverse consequences.

OBJECTIVE

To synthesize research on the mental health impact of waiting and patient-centred mitigation strategies that could be applied in the COVID-19 context.

METHODS

Using a scoping review approach, we searched 9 databases for studies on waiting lists and mental health and reported study characteristics, impacts and intervention attributes and outcomes.

RESULTS

We included 51 studies that focussed on organ transplant (60.8%), surgery (21.6%) or cancer management (13.7%). Most patients and caregivers reported anxiety, depression and poor quality of life, which deteriorated with increasing wait time. The impact of waiting on mental health was greater among women and new immigrants, and those of younger age, lower socio-economic status, or with less-positive coping ability. Six studies evaluated educational strategies to develop coping skills: 2 reduced depression (2 did not), 1 reduced anxiety (2 did not) and 2 improved quality of life (2 did not). In contrast, patients desired acknowledgement of concerns, peer support, and periodic communication about wait-list position, prioritization criteria and anticipated procedure date.

CONCLUSIONS

Findings revealed patient-centred strategies to alleviate the mental health impact of waiting for procedures. Ongoing research should explore how to optimize the impact of those strategies for diverse patients and caregivers, particularly in the COVID-19 context.

PATIENT OR PUBLIC CONTRIBUTION

Six patients and four caregivers waiting for COVID-19-delayed procedures helped to establish eligibility criteria, plan data extraction and review a draft and final report.