Evidence-Based Reviews

The psychiatrist’s role in liver transplantation

Current Psychiatry. 2019 December;18(12):9-16,26

References

1. Meirelles Júnior RF, Salvalaggio P, Rezende MB, et al. Liver transplantation: history, outcomes and perspectives [Article in English, Portuguese]. Einstein (São Paulo). 2015;13(1):149-152.
2. Martin P, DiMartini A, Feng S, et al. Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. Hepatology. 2014;59(3):1144-1165.
3. Centers for Disease Control and Prevention. QuickStats: number of deaths from 10 leading causes,* by sex—National Vital Statistics System, United States, 2015. MMWR Morb Mortal Wkly Rep. 2017;66(15):413.
4. Trieu JA, Bilal M, Hmoud B. Factors associated with waiting time on the liver transplant list: an analysis of the United Network for Organ Sharing (UNOS) database. Ann Gastroenterol. 2018;31(1):84-89.
5. Neuberger J. An update on liver transplantation: a critical review. J Autoimmun. 2016;66:51-59.
6. Maldonado JR, Dubois HC, David EE, et al. The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT): a new tool for the psychosocial evaluation of pre-transplant candidates. Psychosomatics. 2012;53(2):123-132.
7. Grover S, Sarkar S. Liver transplant—psychiatric and psychosocial aspects. J Clin Exp Hepatol. 2012;2(4):382-392.
8. Burra P, Germani G, Gnoato F, et al. Adherence in liver transplant recipients. Liver Transpl. 2011;17(7):760-770.
9. Lieber SR, Volk ML. Non-adherence and graft failure in adult liver transplant recipients. Dig Dis Sci. 2013;58(3):824-834.
10. Dobbels F, Vanhaecke J, Dupont L, et al. Pretransplant predictors of posttransplant adherence and clinical outcome: an evidence base for pretransplant psychosocial screening. Transplantation. 2009;87(10):1497-1504.
11. De Geest S, Sabaté E. Adherence to long-term therapies: evidence for action. Eur J Cardiovasc Nurs. 2003;2(4):323.
12. Park DC, Hertzog C, Leventhal H, et al. Medication adherence in rheumatoid arthritis patients: older is wiser. J Am Geriatr Soc. 1999;47(2):172-183.
13. Greenstein S, Siegal B. Compliance and noncompliance in patients with a functioning renal transplant: a multicenter study. Transplantation. 1998;66(12):1718-1726.
14. Graziadei I, Zoller H, Fickert P, et al. Indications for liver transplantation in adults: Recommendations of the Austrian Society for Gastroenterology and Hepatology (ÖGGH) in cooperation with the Austrian Society for Transplantation, Transfusion and Genetics (ATX). Wien Klin Wochenschr. 2016;128(19):679-690.
15. Addolorato G, Bataller R, Burra P, et al. Liver transplantation for alcoholic liver disease. Transplantation. 2016;100(5):981-987.
16. Lee MR, Leggio L. Management of alcohol use disorder in patients requiring liver transplant. Am J Psychiatry. 2015;172(12):1182-1189.
17. Lee BP, Vittinghoff E, Hsu C, et al. Predicting low risk for sustained alcohol use after early liver transplant for acute alcoholic hepatitis: the Sustained Alcohol Use Post-Liver Transplant score. Hepatology. 2019;69(4):1477-1487.
18. DiMartini A, Crone C, Dew MA. Alcohol and substance use in liver transplant patients. Clinics in Liver Disease. 2011;15(4):727-751.
19. Pungpapong S, Manzarbeitia C, Ortiz J, et al. Cigarette smoking is associated with an increased incidence of vascular complications after liver transplantation. Liver Transpl. 2002;8(7):582-587.
20. Kreek MJ. Pharmacotherapy of opioid dependence: rationale and update. Regulatory Peptides. 1994;53(suppl 1):S255-S256.
21. Jiao M, Greanya ED, Haque M, et al. Methadone maintenance therapy in liver transplantation. Prog Transplant. 2010;20(3):209-214; quiz 215.
22. Rai HS, Winder GS. Marijuana use and organ transplantation: a review and implications for clinical practice. Curr Psychiatry Rep. 2017;19(11):91.
23. Hézode C, Roudot-Thoraval F, Nguyen S, et al. Daily cannabis smoking as a risk factor for progression of fibrosis in chronic hepatitis C. Hepatology. 2005;42(1):63-71.
24. Kotwani P, Saxena V, Dodge JL, et al. History of marijuana use does not affect outcomes on the liver transplant waitlist. Transplantation. 2018;102(5):794-802.
25. Fineberg SK, West A, Na PJ, et al. Utility of pretransplant psychological measures to predict posttransplant outcomes in liver transplant patients: a systematic review. Gen Hospl Psychiatry. 2016;40:4-11.
26. Satapathy S, Sanyal A. Epidemiology and natural history of nonalcoholic fatty liver disease. Semin Liver Dis. 2015;35(3):221-235.
27. Olbrisch ME, Levenson JL, Hamer R. The PACT: a rating scale for the study of clinical decision making in psychosocial screening of organ transplant candidates. Clin Transplant. 1989;3:164-169.
28. Twillman RK, Manetto C, Wellisch DK, et al. Transplant Evaluation Rating Scale: a revision of the psychosocial levels system for evaluating organ transplant candidates. Psychosomatics. 1993;34(2):144-153.
29. Goodier J. Evaluating Stress:97496. In: Zalaquett CP, Wood RJ, eds. Evaluating stress: a book of resources. Lanham, MD: Scarecrow Press; 1997:29-29.
30. Beck AT, Steer RA, Carbin, MG. Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation. Clinical Psychology Review. 1998;8(1):77-100.
31. Trzepacz PT, Mittal D, Torres R, et al. Validation of the Delirium Rating Scale-Revised-98: comparison with the Delirium Rating Scale and the Cognitive Test for Delirium. J Neuropsychiatry Clin Neurosci. 2001;13(2):229-242.
32. Cottle WC. The MMPI: a review. Lawrence, KS: University of Kansas; 1953.
33. Addison CC, Campbell-Jenkins BW, Sarpong DF, et al. Psychometric Evaluation of a Coping Strategies Inventory Short-Form (CSI-SF) in the Jackson Heart Study Cohort. Int J Environ Res Public Health. 2007;4(4):289-295.
34. Mooney S, Hasssanein T, Hilsabeck R, et al. Utility of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) in patients with end-stage liver disease awaiting liver transplant. Arch Clin Neuropsychol. 2007;22(2):175-186.
35. De Bona M, Ponton P, Ermani M, et al. The impact of liver disease and medical complications on quality of life and psychological distress before and after liver transplantation. J Hepatol. 2000;33(4):609-615.
36. Fukunishi I, Sugawara Y, Takayama T, et al. Psychiatric disorders before and after living-related transplantation. Psychosomatics. 2001;42(4):337-343.
37. Landefeld CS, Palme, RM, Kresevic DM, et al. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med. 1995;332(20):1338-1344.
38. Fukunishi I, Sugawara Y, Takayama T, et al. Psychiatric problems in living-related transplantation (II): the association between paradoxical psychiatric syndrome and guilt feelings in adult recipients after living donor liver transplantation. Transplantation Proceedings. 2002;34(7):2632-2633.
39. Campana C, Regazzi MB, Buggia I, et al. Clinically significant drug interactions with cyclosporin. An update. Clin Pharmacokinet. 1996;30(2):141-179.
40. Ozkanlar Y, Nishijima Y, Cunha DD, et al. Acute effects of tacrolimus (FK506) on left ventricular mechanics. Pharmacol Res. 2005;52(4):307-312.
41. Karvellas CJ, Safinia N, Auzinger G, et al. Medical and psychiatric outcomes for patients transplanted for acetaminophen-induced acute liver failure: a case-control study. Liver Int. 2010;30(6):826-833.
42. Maldonado J R. I have been asked to work up a patient who requires a liver transplant how should I proceed? FOCUS. 2009;7(3):332-335.
43. Mccallum S, Masterton G. Liver transplantation for alcoholic liver disease: a systematic review of psychosocial selection criteria. Alcohol and Alcoholism. 2006;41(4):358-363.
44. Nickels M, Jain A, Sharma R, et al. Polysubstance abuse in liver transplant patients and its impact on survival outcome. Exp Clin Transplant. 2007;5(2):680-685.
45. Coffman KL, Hoffman A, Sher L, et al. Treatment of the postoperative alcoholic liver transplant recipient with other addictions. Liver Transpl Surg. 1997;3(3):322-327.

Liver cirrhosis due to chronic hepatitis C virus (HCV) infection is one of the leading causes for LT. In the United States, HCV is commonly transmitted during injection drug use. According to the 2013 AASLD guideline, ongoing illicit substance use is a relative contraindication to LT.² It is important to note, however, that methadone maintenance therapy (MMT) is not a contraindication to LT. In fact, the 2013 AASLD guideline recommends that patients receiving MMT should not be required to reduce or stop therapy in order to be listed for transplant.² Studies have shown that in 80% of patients, tapering MMT leads to illicit opiate relapse.²⁰ Currently, there is no evidence that patients receiving MMT have poorer post-transplant outcomes compared with patients not receiving MMT.²¹

Whether cannabis use is a relative contraindication to LT remains controversial.²² Possible adverse effects of cannabis use in transplant patients include drug–drug interactions and infections. Hézode et al²³ reported that daily cannabis use is significantly associated with an increased fibrosis progression rate in patients with chronic HCV infection. Another recent study found that a history of cannabis use was not associated with worse outcomes among patients on the LT waitlist.²⁴ With the increased legalization of cannabis, more studies are needed to assess ongoing cannabis use in patients on the LT waitlist and post-LT outcomes.

Psychiatric history. When assessing a patient for possible LT, no psychiatric disorder is considered an absolute contraindication. Patients with a serious mental illness, such as schizophrenia, and those with intellectual disability can have successful, long-term outcomes with proper evaluation and preparation, including social support. However, empirical literature regarding transplant outcomes and predictive factors in patients with serious mental illness is scarce.²

Studies examining the predictive value of pre-transplant depression on post-transplant outcomes have had mixed results.²⁵ Depression may predict lower post-transplant quality of life. Pre-LT suicidal thoughts (as noted on the Beck Depression Inventory, for example) are associated with post-LT depression.²⁵In contrast, available data show no significant effect of pre-transplant anxiety on post-LT outcomes. Similarly, pre-transplant cognitive performance appears not to predict survival or other post-transplant outcomes, but may predict poorer quality of life after transplant.²⁵

A few psychiatric factors are considered relative contraindications for LT. These include severe personality disorders, active substance use with no motivation for treatment or abstinence, active psychosis, severe neurocognitive disorders, suicidality, and factitious disorder.⁷

Continue to: Social support

The psychiatrist’s role in liver transplantation

References

Pages

Recommended Reading