Early Survivorship After Liver Transplantation: A Qualitative Study Identifying Challenges in Recovery From the Patient and Caregiver Perspective.

Survivorship after liver transplantation (LT) is a novel concept providing a holistic view of the arduous recovery experienced after transplantation. We explored components of early survivorship including physical, emotional, and psychological challenges to identify intervention targets for improving the recovery process of LT recipients and caregivers. A total of 20 in-person interviews were conducted among adults 3 to 6 months after LT. Trained qualitative research experts conducted interviews, coded, and analyzed transcripts to identify relevant themes and representative quotes. Early survivorship comprises overcoming (1) physical challenges, with the most challenging experiences involving mobility, driving, dietary modifications, and medication adherence, and (2) emotional and psychological challenges, including new health concerns, financial worries, body image/identity struggles, social isolation, dependency issues, and concerns about never returning to normal. Etiology of liver disease informed survivorship experiences including some patients with hepatocellular carcinoma expressing decisional regret or uncertainty in light of their post-LT experiences. Important topics were identified that framed LT recovery including setting expectations about waitlist experiences, hospital recovery, and ongoing medication requirements. Early survivorship after LT within the first 6 months involves a wide array of physical, emotional, and psychological challenges. Patients and caregivers identified what they wish they had known prior to LT and strategies for recovery, which can inform targeted LT survivorship interventions.

What Survivorship Means to Liver Transplant Recipients: Qualitative Groundwork for a Survivorship Conceptual Model.

Survivorship is a well-established concept in the cancer care continuum with a focus on disease recurrence, quality of life, and the minimization of competing risks for mortality; however, survivorship has not been well studied in liver transplantation (LT). We investigated what survivorship means to LT patients and identified motivations and coping strategies for overcoming challenges after LT. A total of 20 in-depth home interviews were conducted among adults 3 to 6 months after LT. Interviews were conducted by trained qualitative research experts and coded and analyzed using an inductive approach. A majority of LT recipients (75%) identified themselves as survivors. Integral to the definition of survivorship was overcoming hardship (including experiences on the waiting list) and the unique experience of being given a "second chance" at life. Motivations to survive included a new chance at life (55%), family (40%), spirituality/faith (30%), and fear of rejection (15%). LT recipients and caregivers identified multiple strategies to cope with post-LT challenges, including relying on a large network of community, spiritual, and virtual support. These findings informed a conceptual model of LT survivorship based on socioecological theory, which identified the following variables influencing survivorship: (1) pretransplant experiences, (2) individual attributes and challenges, (3) interpersonal relationships with caregivers and other social support, (4) community relationships, and (5) large-scale factors including neighborhood and financial issues. LT recipients identified themselves as survivors, and post-LT identities were greatly influenced by pre-LT experiences. These perspectives informed an in-depth conceptual model of survivorship after transplantation. We identified sources of motivation and coping strategies used in LT recovery that could be targets of survivorship interventions aimed at improving post-LT outcomes.

The relationship between marijuana use and psychosocial variables in living kidney donor candidates.

BACKGROUND: We investigate whether marijuana use in living kidney donor candidates is associated with psychosocial risk factors that place donors at higher risk for adverse outcomes and the unique associations between marijuana use and donor candidacy. METHODS: Medical records of 757 living kidney donor candidates were reviewed. Patients were grouped into marijuana users/abstainers; demographic, psychiatric, and substance use variables were compared. Multivariate logistic regression assessed the independent association of marijuana use on committee approval for donation. RESULTS: Marijuana use was associated with lack of health insurance, legal history, lower education level, active and history of substance use disorder, active psychiatric disorder, history of multiple psychiatric diagnoses, and history of suicidality. Marijuana users were also more likely to be young, male, unmarried, and less likely to be approved for donation by the multidisciplinary selection committee. This latter association persisted in multivariate models. CONCLUSIONS: This is the first study to show that marijuana use is associated with psychosocial factors that could impact behavioral adherence following kidney donation, while reducing chances of committee approval for kidney donation. Special attention to potential overlay between psychosocial risk factors and marijuana use should be considered when evaluating kidney donors, particularly in context of increasingly legal use.

Post-Traumatic Stress Disorder and Post-Traumatic Growth following Kidney Transplantation.

Background: Kidney transplantation (KT) is a life-saving therapy for kidney failure. However, KT recipients can suffer from debilitating depression, post-traumatic stress disorder (PTSD), and suicide. In contrast to PTSD, post-traumatic growth (PTG) is a positive psychologic change in response to a challenging situation. PTG has been studied in other chronic diseases, but less is known about its role in the setting of KT. We sought to elucidate the prevalence, predictors, and the effect of PTSD and PTG on post-KT outcomes. We also considered the roles of benefit finding and resilience. Methods: In a literature review, we identified publications that examined PTSD, PTG, benefit finding, and/or resilience in KT recipients. We excluded case reports and first-person narratives. Publications meeting the specified criteria after full text review underwent data abstraction and descriptive analysis. Results: Of the 1013 unique citations identified, 39 publications met our criteria. PTSD was the most common construct evaluated (16 publications). Resilience was studied in 11 publications, PTG in nine, and benefit finding in five. Up to 21% of adult and 42% of pediatric KT recipients may experience PTSD, which is associated with lower quality of life (QOL), impaired sleep, and other psychiatric comorbidity. PTG was associated with improved QOL, kidney function, and reduced risk of organ rejection. Although benefit finding tended to increase post KT, resilience remained stable post KT. Like PTG, resilience was associated with lower psychologic distress and increased treatment adherence and confidence in the health care team. Conclusions: PTG, resilience, and benefit finding appear to reduce the risk of PTSD, promote well-being, and reduce risk of graft failure in KT recipients. Future research to understand these relationships better will allow clinicians and researchers to develop interventions to promote PTG, resilience, and benefit finding, and potentially improve post-transplant outcomes such as adherence and reducing risk of organ rejection.

The Effect of Psychiatric History on Pain and Related Outcomes Among Living Kidney Donors.

INTRODUCTION: Living donor transplantation of kidneys accounts for one quarter of transplants performed in the United States. Careful screening of psychiatric history is a standard part of the donor evaluation. Little is known about the impact of psychiatric history on post-donation course and pain experience. RESEARCH QUESTION: This study investigated whether psychiatric history was associated with pain and related outcomes among living kidney donors. DESIGN: A retrospective medical record review was conducted of 75 living kidney donors who underwent laparoscopic donor nephrectomy. All donor candidates completed a psychological evaluation and were approved for donation by a multidisciplinary committee. History of psychiatric diagnosis and psychiatric medication use were obtained from donors' psychological evaluation reports. Data on pain and related outcomes (ie, history of prescribed pain medication, post-donation pain, opioid use, length of hospital stay, post-donation emergency department visits), as well as demographic and donation-related characteristics were also abstracted from medical records. RESULTS: Psychiatric history, including current or historical psychiatric diagnosis or psychiatric medication use, in living kidney donors who were evaluated and approved for donation by a transplant psychologist was not associated with greater perceived pain, greater use of opioid pain medication in the post-operative period, longer hospital stays, or more frequent post-donation emergency department visits. DISCUSSION: The findings demonstrate that carefully screened donors with a psychiatric history have comparable pain-related outcomes as donors without a psychiatric history. This study highlights the importance of the pre-donation psychological evaluation in promoting positive postdonation outcomes through careful selection of donor candidates.

Depression in primary caregivers of patients listed for liver or kidney transplantation.

BACKGROUND: No studies have examined depression in primary caregivers of adult patients listed for liver or kidney transplantation. OBJECTIVE: To determine the prevalence of depression among primary caregivers of patients listed for liver or kidney transplantation and to compare these 2 groups. DESIGN: A cross-sectional survey was conducted. The Center for Epidemiologic Studies Depression Scale and a demographic questionnaire were sent out and returned by mail. RESULTS: Of 72 eligible primary caregivers, 42 (58%) participated; the participation rate was similar for caregivers of kidney and liver failure patients (21/32 [66%)] vs 21/40 [53%], P = .3). Mean caregiver age was 54.7 +/- 13.6 years. Twenty-three caregivers (54.8%) were spouses, 15 (35.7%) were first-degree relatives, and 26 (62%) were women. Median depression scale score was 5.5 (0-36). Three (7%), 2 (5%), and 3 (7%) participants reported mild, moderate, and severe depression, respectively. Median Center for Epidemiologic Studies Depression Scale score was higher among caregivers of liver versus kidney patients, but the difference was not statistically significant (9 vs 4, P = .2). Depression scale scores did not correlate with age, sex, time listed, or nature or length of relationship with the patient. The prevalence of depression in primary caregivers was 19%; of these caregivers, one third may have had severe depression. CONCLUSIONS: The prevalence of moderate to severe depression in primary caregivers of liver and kidney transplant candidates is significant. The impact of depression on caregivers as well as patients, both before and after transplantation, deserves study. Screening for depression in caregivers could lead to clinical interventions that benefit caregivers and indirectly improve patient outcomes.

Relationship between coping and depression in heart transplant candidates and their spouses.

CONTEXT: Survival rates for heart transplantation are encouraging, but the pretransplant period can be extremely stressful for patients and their spouses. Although a relationship between patients' depression levels and the coping strategies employed by their spouses has been demonstrated, this association has not been examined in heart transplant candidates and their spouses. Depression in this group of patients is important because heart transplant patients with preoperative depression have been found to have a higher mortality rate after transplantation. OBJECTIVE: To determine if a relationship exists between spousal coping strategies and heart transplant candidates' depression. METHODS: A descriptive, exploratory pilot study. PARTICIPANTS: Twenty-two individuals with end-stage heart disease who were undergoing an inpatient evaluation for heart transplantation, plus their spouses. Design-Heart transplant candidates were assessed via the Structured Interview Guide for the Hamilton Depression Scale. Spouses completed the COPE Inventory and the Center for Epidemiological Studies Depression Scale. RESULTS: Spousal behavioral disengagement was positively associated with heart transplant candidates' depression. CONCLUSIONS: Heart transplant candidate depression may follow spousal disengagement, or, conversely, a spouse may disengage in response to the patient becoming depressed. Identification during the pretransplant evaluation of those spouses who cope using behavioral disengagement might be a first step in the process of assessment and intervention. Clinical interventions may need to focus on the spouse as well as on the transplant candidate.