Uncertainty and Communication Preferences Among Patients Undergoing Lung Transplant Evaluation: A Mixed-Methods Study.

OBJECTIVE: Higher uncertainty is associated with poorer quality of life and may be impacted by clinician communication about the future. We determined how patients undergoing lung transplant evaluation experience uncertainty and communication about the future from clinicians. METHODS: We performed a convergent parallel mixed-methods study using a cross-sectional survey and semistructured interviews. Patients undergoing lung transplant evaluation at the University of Colorado and the University of Washington answered questions about future communication and completed the Mishel Uncertainty in Illness Scale-Adult (MUIS-A; range 33-165, higher scores indicate more uncertainty). Interviews were analyzed using content analysis. Integration of survey and interview results occurred during data interpretation. RESULTS: A total of 101 patients completed the survey (response rate: 47%). Twelve survey participants completed interviews. In the survey, most patients identified changing family roles as important (76%), which was infrequently discussed with clinicians (31%). Most patients (86%) worried about the quality of their life in the future, and 74% said that not knowing what to expect in the future prevented them from making plans. The mean MUIS-A score was 85.5 (standard deviation 15.3). Interviews revealed three themes: (1) uncertainty of the future distresses participants; (2) participants want practical information from clinicians; and (3) communication preferences vary among participants. CONCLUSION: Participants experienced distressing uncertainty and wanted information about the future. Communication topics that were important to participants were not always addressed by physicians. Clinicians should address how chronic lung disease and lung transplant can directly impact patients' lives and support patients to cope with uncertainty.

Lung transplant recipients' experiences of and attitudes towards self-management: a qualitative systematic review.

OBJECTIVE: The objective of this review was to identify lung transplant recipients' experiences of and attitudes towards self-management. INTRODUCTION: Lung transplantation is an established treatment to improve the survival of patients with end-stage lung diseases and has been performed on more than 40,000 patients worldwide. The current focus of care for lung transplant recipients is long-term management. Patients need to adapt and adhere to complex self-management tasks to prevent complications and to enable them to keep the transplanted graft as long as possible. However, to date, there are no qualitative systematic reviews that identify lung transplant recipients' experiences of and attitudes towards self-management. INCLUSION CRITERIA: This review included studies of adults over 18 years of age who had received a lung transplant and were able to perform their self-management tasks independently. All studies that investigated lung transplant recipients' experiences of and attitudes towards self-management in any setting were eligible for inclusion. All types of studies that focused on qualitative data, including, but not limited to, phenomenology, grounded theory, ethnography, action research, and feminist research, were considered for inclusion. Mixed methods studies were included only when qualitative data could be extracted separately, and if they reported results relating to the phenomenon of interest. Studies published in English or German were considered for inclusion in this review. METHODS: The search strategy aimed to find published studies using the databases Web of Science Core Collection, PsycINFO (Ovid), MEDLINE (Ovid), Embase (Ovid), Emcare (Ovid), and CINAHL (EBSCOhost). The search for unpublished studies included ProQuest Dissertations and Theses Database, EThOS, and OpenGrey. Databases were searched from inception to March 2022. Methodological quality of studies was independently assessed by 2 independent reviewers using the JBI checklist for qualitative research. A standardized data extraction tool from JBI was used by 2 reviewers for data collection. Meta-aggregation was undertaken to synthesize the data, and the final synthesis of the findings was reached through discussion. Results were graded according to ConQual. RESULTS: Ten studies with a sample size from 8 to 73 participants from North America and Central/Northern Europe were included in the review. The critical appraisal scores of the included studies ranged from 3 to 9 out of 10. A total of 137 findings were extracted and aggregated to form 19 categories and the following 4 aggregated syntheses: i) Changes in routines, beliefs, and sense of responsibility are essential for better adaptation and self-management after lung transplantation; ii) Life after transplantation is characterized by both positive and negative feelings and experiences; iii) Better adjustment and self-management after a lung transplant require dealing with one's own feelings and beliefs; iv) After transplantation, engaging with relatives, friends, medical team, and donors is essential to improve experiences and adapt to being a transplant recipient. Based on the ConQual scores, 2 synthesized findings were graded as moderate and 2 were graded as low. CONCLUSIONS: Nuanced emotional, social, relational, and psychological adjustment is required of lung transplant recipients to be able to successfully self-manage. Loved ones and health professionals contribute significantly to this process, but psychosocial or peer support may further facilitate this transition. SUPPLEMENTAL DIGITAL CONTENT: A German-language version of the abstract of this review is available as Supplemental Digital Content [ http://links.lww.com/SRX/A46 ].

Elements of Post-Transplant Recovery in Lung Transplant Recipients: A Scoping Review.

To clarify and refine the specific elements of post-transplant recovery in lung transplant recipients, we explored the four dimensions of recovery: physiological, psychological, social, and habitual. This study is a scoping review. Two authors conducted a comprehensive electronic literature search to identify studies published from the establishment of the database to August 2022. Deductive coding was utilized to identify and categorize elements using a predefined list of the four components (physiological, psychological, social, and habitual recovery) based on the framework of post-transplant recovery proposed by Lundmark et al. Inductive coding was applied for concepts requiring further classification. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guideline. Systematic searching identified 8,616 potential records, of which 51 studies met the inclusion criteria. Ten subdimensions and their corresponding elements were identified and categorized into four dimensions of recovery following lung transplantation. The subdimensions included physiological recovery (including symptom experience, complications, physical function, and energy reserve), psychological recovery (encompassing affective distress, psychological adaptation, and transition from illness to health), social recovery (involving family adaptation and social adaptation), and habit recovery (focusing on health behavior).

Quality of life and its association with predictors in lung transplant recipients: a latent profile analysis.

Backgrounds: Improving quality of life (QOL) is one of the main aims of lung transplantation (LTx). There is a need to identify those who have poor quality of life early. However, research addressing inter individual quality of life variability among them is lacking. This study aims to identify group patterns in quality of life among lung transplant recipients and examine the predictors associated with quality of life subgroups. Methods: In total, 173 lung transplant recipients were recruited from one hospital in Guangdong Province between September 2022 and August 2023. They were assessed using the Lung Transplant Quality of Life scale (LT-QOL), Mindful Attention Awareness Scale (MAAS), Life Orientation Test-Revised scale (LOT-R), and Positive and Negative Affect Scale (PANAS). Latent profile analysis was used to identify QOL subtypes, and logistic regression analysis was used to examine the associations between latent profiles and sociodemographic and psychosocial characteristics. Results: Two distinct QOL profiles were identified: "low HRQOL" profile [N = 53 (30.94%)] and "high HRQOL" profile [N = 120 (69.06%)]. Single lung transplant recipients, and patients who reported post-transplant infection, high levels of negative emotion or low levels of mindfulness and optimism were significantly correlated with the low QOL subgroup. Conclusion: Using the domains of the LT-QOL scale, two profiles were identified among the lung transplant recipients. Our findings highlighted that targeted intervention should be developed based on the characteristics of each latent class, and timely attention must be paid to patients who have undergone single lung transplantation, have had a hospital readmission due to infection, exhibit low levels of optimism, low levels of mindfulness or high negative emotions.

Health-Related Quality of Life Long-Term Study in Lung Transplant Patients: A Single-Center Experience.

INTRODUCTION: Health-related quality of life (HRQL) assessment plays a crucial role in the follow-up care of lung transplanted (LTx) patients. Previous reports have indicated that the HRQL achieved by these patients is often poorer compared to that of healthy individuals. However, the factors contributing to this lower HRQL remain unclear. This prospective study aimed to assess the effectiveness of using both a generic and a disease-specific HRQL instrument in evaluating the outcomes of patients who have undergone LTx. METHODS: A total of 111 LTx patients were enrolled in the study, with 88 survivors completing the 5-year follow-up and 23 nonsurvivors identified within the first 3 y. Among the participants, 84 underwent double LTx, while 27 received a single LTx. Patients were interviewed before LTx, at 6 mo post-transplantation, and annually thereafter. Two validated instruments were utilized: the Euro quality of life five dimensions, a generic measure, and the St. George's Respiratory Questionnaire (SGRQ), a disease-specific questionnaire. RESULTS: The study showed significant improvements in Euro Quality of Life five Dimensions scores from 6 mo after LTx. Specifically, the percentage of patients without Mobility problems increased from 23% before LTx to 71% at 5 y (P = <0.001), while the ability to self-care improved from 48% to 100% (P = <0.001). The ability to carry out usual activities improved from 13% to 86% (P = <0.001), and the proportion of patients without anxiety and depression increased from 50% to 86% (P > 0.004). However, there was no significant improvement observed in Pain, with only a slight reduction from 57% to 42.8% (P = 0.22). The SGRQ also showed improvements in all dimensions (symptoms, impact, activities) (P < 0.001). However, by the fifth year, the HRQL scores remained below normal reference values. Chronic graft dysfunction was associated with a decline in SGRQ scores. Bilateral LTx patients exhibited better SGRQ scores compared to unilateral LTx patients from the first year post-transplantation. Notably, there were no differences in scores between nonsurvivors and survivors. CONCLUSIONS: The study highlights the long-term improvement in HRQL among LTx patients, with greater improvements observed in physical dimensions compared to psychological dimensions. Bilateral LTx was associated with better SGRQ scores than unilateral LTx, and chronic graft dysfunction primarily affected SGRQ scores. These findings underscore the importance of utilizing both generic and specific HRQL instruments in assessing LTx outcomes.

Qualitative Analysis of Perspectives on Lung Transplant among People with Cystic Fibrosis.

Rationale: Lung transplant (LTx) is a potentially lifesaving treatment option for individuals with advanced cystic fibrosis (CF), but more people with CF (PwCF) and advanced lung disease die each year than undergo transplant in the United States. Little is known about these individuals' LTx information needs and factors influencing their decision-making process related to transplant. Objectives: To examine PwCF's experiences with and preferences for provision of LTx information and to identify transplant information needs that CF clinicians are well positioned to address. Methods: We performed semistructured qualitative interviews in two separate cohorts: PwCF without LTx and PwCF with LTx between July 2019 and June 2020. Questions focused on awareness and knowledge about LTx, perspectives related to communication about transplant in the CF clinic, and experiences with LTx. Thematic analysis was used to organize the qualitative data. Exemplar quotes were chosen to llustrate domains that emerged pertaining to the research objectives. Results: Fifty-five PwCF, including 35 without LTx and 20 with LTx, participated. One-third of PwCF without LTx had normal or near-normal lung function. Key common domains among PwCF with and without LTx were identified, including information needs, connections with LTx recipients, and conversations with CF clinicians. For PwCF with and without transplant, concrete information needs were identified: success or survival, social support, surgery, recovery/pain, and quality of life post-transplant. The importance of connecting with LTx recipients to hear their stories and experiences was emphasized by both PwCF with and without transplant. Important considerations for timing and content of discussions with CF clinicians were identified, including having information presented early (before LTx referral is needed) and in limited detail at first. PwCF without LTx wanted to understand how LTx was relevant to them, with a focus on the unique experience of CF. PwCF with LTx emphasized the need for a centralized resource for LTx information. Conclusions: The findings provide content areas for CF clinicians to focus on as they proactively initiate conversations about LTx and support the development of tools to aid in discussions about LTx for PwCF.

Expectations of patients awaiting lung transplantation: A qualitative study.

AIM: The main aim of the present study is to examine the expectations and feelings of people awaiting lung transplantation. BACKGROUND: The assessment of the benefits of lung transplant should consider, among other things, the subjective perceptions of patients about the procedure, especially in relation to the context and to their values, goals and expectations. This is an issue that has not been studied in depth, especially in Spain. DESIGN: Exploratory qualitative study. METHODS: Data were collected through semi-structured interviews during the period of being on the waiting list for transplantation. Thematic analysis of the data was supported by the Atlas.ti software. RESULTS: The study population comprised 16 patients awaiting lung transplant, a number sufficient to reach data saturation. Four categories were identified to describe patients' feelings and expectations: (1) reasons for undergoing the transplant, (2) expectations about life post-transplant, (3) emotional state, and (4) relationship with the healthcare team. CONCLUSIONS: Patients have high expectations of lung transplantation. They see it as offering them a second chance at life, although the future creates uncertainty. The healthcare professionals are identified as key actors, providing essential support and information throughout the various stages of the process. Future research should explore recipients' experiences of lung transplant at later stages. RELEVANCE TO CLINICAL PRACTICE: It is important to adapt care through all the lung transplant process, which is accompanied by intense and complex emotions since the beginning. Thus, providing social and psychological support from the beginning may contribute to their health status, helping them deal with all the emotions and feelings experienced, and find balance between expectations and reality. PATIENT OR PUBLIC CONTRIBUTION: Sixteen patients awaiting lung transplant were interviewed. Interview transcripts were returned to participants to check for accuracy with their experiences.

Health-related quality of life and psychological indicators of thriving 15-19 years after heart or lung transplantation.

BACKGROUND: Survival into the second decade after cardiothoracic transplantation (CTX) is no longer uncommon. Few data exist on any health-related quality of life (HRQOL) impairments survivors face, or whether they may even experience positive psychological outcomes indicative of "thriving" (e.g., personal growth). We provide such data in a long-term survivor cohort. METHODS: Among 304 patients prospectively studied across the first 2 years post-CTX, we re-interviewed patients ≥15 years post-CTX. We (a) examined levels of HRQOL and positive psychological outcomes (posttraumatic growth related to CTX, purpose in life, life satisfaction) at follow-up, (b) evaluated change since transplant with mixed-effects models, and (c) identified psychosocial and clinical correlates of study outcomes with multivariable regression. RESULTS: Of 77 survivors, 64 (83%) were assessed (35 heart, 29 lung recipients; 15-19 years post-CTX). Physical HRQOL was poorer than the general population norm and earlier post-transplant levels (P's < .001). Mental HRQOL exceeded the norm (P < .001), with little temporal change (P = .070). Mean positive psychological outcome scores exceeded scales' midpoints at follow-up. Life satisfaction, assessed longitudinally, declined over time (P < .001) but remained similar to the norm at follow-up. Recent hospitalization and dyspnea increased patients' likelihood of poor physical HRQOL at follow-up (P's ≤ .022). Lower sense of mastery and poorer caregiver support lessened patients' likelihood of positive psychological outcomes (P's ≤ .049). Medical comorbidities and type of CTX were not associated with study outcomes at follow-up. CONCLUSIONS: Despite physical HRQOL impairment, long-term CTX survivors otherwise showed favorable outcomes. Clinical attention to correlates of HRQOL and positive psychological outcomes may help maximize survivors' well-being.

Vaccination and their importance for lung transplant recipients in a COVID-19 world.

INTRODUCTION: Lung transplant patients are immunocompromised because of the medication they receive to prevent rejection, and as a consequence are susceptible to (respiratory) infections. Adequate vaccination strategies, including COVID-19 vaccination, are therefore needed to minimize infection risks. AREAS COVERED: The international vaccination guidelines for lung transplant patients are reviewed, including the data on immunogenicity and effectivity of the vaccines. The impact on response to vaccination of the various categories of immunosuppressive drugs, used in the posttransplant period, on response to vaccination is described. A number of immunosuppressive and/or anti-inflammatory drugs also is used for controlling the immunopathology of severe COVID-19. Current available COVID-19 vaccines, both mRNA or adenovirus based are recommended for lung transplant patients. EXPERT OPINION: In order to improve survival and quality of life, infections of lung transplant patients should be prevented by vaccination. When possible, vaccination should start already during the pre-transplantation period when the patient is on the waiting list. Booster vaccinations should be given post-transplantation, but only when immunosuppression has been tapered. Vaccine design based on mRNA technology could allow the design of an array of vaccines against other respiratory viruses, offering a better protection for lung transplant patients.

Changes in Health-Related Quality of Life During the First Year in Lung Transplant Recipients.

BACKGROUND: Health-related quality of life (HRQOL) has increasingly been accepted as a supplementary outcome measure for patients before and after lung transplantation (LT). This longitudinal study was conducted to recognize the tracks of HRQOL during the first year after transplantation and the main factors associated with HRQOL of LT recipients. The research was conducted in accordance with the 2000 Declaration of Helsinki and the Declaration of Istanbul 2008. The transplant organs were from volunteer donation, and next of kin provided written informed consents of their own free will. No prisoners were used, and donors were neither paid nor coerced. METHODS: A total of 118 patients were investigated before and 3, 6, 9, and 12 months post-transplantation. The Medical Outcomes SF-36 (Chinese version) was used to measure the HRQOL. The recipients' demographic characteristics and clinical data were evaluated to determine the relative contributions to HRQOL outcomes. RESULTS: Recipients reported a mean physical component summary of 39.62 ± 6.57, 57.90 ± 9.99, 59.15 ± 8.73, 58.79 ± 8.52, and 58.72 ± 8.99 before transplantation and at 3, 6, 9, and 12 months after LT (F = 64.960, P < .001). By 3 months after transplant, patients experienced significant improvement in physical component summary (MD = 18.27, SE = 1.52, P < .001); but between 3 and 12 months, no significant improvement was observed (MD = 0.82, SE = 1.77, P = .645). Patients reported a continuous rise with means of 44.63 ± 5.35, 51.13 ± 10.25, 51.92 ± 9.72, 53.23 ± 10.34, and 55.40 ± 8.83 for the mental component summary before LT and at 3, 6, 9, and 12 months after transplant (F = 13.059, P < .001). By 3 months after transplant, patients experienced significant improvement in mental component summary (MD = 6.50, SE = 1.50, P < .001). Between 3 and 12 months, a continuous significant improvement was observed (MD = 4.27, SE = 1.92, P = .030). The generalized estimated equation showed that age, marital status, residence, disease diagnosis, transplant type, sleep disorders, gastrointestinal complications, and BODE index (body mass index, obstruction, dyspnea, exercise) were all found to be related to HRQOL. CONCLUSION: The HRQOL of LT patients improved significantly at 3 months after transplantation, but between 3 and 12 months after transplantation, the changes were not obvious. Health practitioners should pay more attention to elderly patients, unmarried patients, patients living in urban areas, patients diagnosed with pneumoconiosis, patients with left single-lung transplantation, patients with sleep disorders, patients with high BODE indexes, and patients with gastrointestinal complications.

Assessment of Quality of Life Among Patients After Lung Transplantation: A Single-Center Study.

INTRODUCTION: Lung transplantation (LTx) is the only effective method of treatment to improve the health and quality of life (QoL) of patients with end-stage lung diseases. After LTx, medical examination accompanied by quality of life assessment should be performed on routine follow-up visits. The aim of the study was to assess the QoL of patients after LTx. MATERIAL AND METHODS: The study group consisted of 60 patients (29 women and 31 men); 20 patients received single lung transplantation (SLT), and 40 received double lung transplantation (DLT). To determine the patient's QoL, the General Health Questionnaire (GHQ), the World Health Organization Quality of Life Test-BREF (WHOQOL-BREF), and the Saint George Respiratory Questionnaire (SGRQ) were used. Spirometry and the 6-minute walk test were analyzed to examine efficiency of transplanted organs. RESULTS: In SGRQ there are differences between patients with cystic fibrosis and interstitial lung disease in symptom domain (20.28% vs 39.26%, P = .025) and total score (19.38% vs 32.47%, P = .028). As reported in the GHQ, men had worse overall results than women in sten scale (5.22 points vs 4.69 points). Patients after SLT achieved similar scores in every questionnaire. CONCLUSION: Studies assessing QoL should be an important addition to lung function tests and an integral part of control during postoperative follow-up visits. This study is one of the important contributions to understanding of how essential QoL is after LTx. The authors of this study realize that their work does not cover the whole issue, and further studies in this area are warranted.

Coping Patterns and Emotional Distress in Patients With Chronic Obstructive Lung Disease Who Are Undergoing Lung Transplant Evaluation.

OBJECTIVES: Living with severe lung disease like chronic obstructive pulmonary disease (COPD) is a very stressful situation. The way patients cope may impact their symptoms of anxiety and depression and physical function as well. We studied how ways of coping are associated with levels of emotional distress and lung function in patients with COPD being evaluated for lung transplantation. METHODS: Sixty-five (mean age 57 years, 46% females) patients completed the General Health Questionnaire-30 (GHQ-30) assessing emotional distress and the Ways of Coping Questionnaire. Measurements of lung function and 6-minute walk test were included. RESULTS: Seventeen (26%) patients had elevated emotional distress. Logistic regression of chronic GHQ score with gender, age, body mass index, lung function, and coping scales as covariates showed that escape avoidance and self-controlling coping and forced vital lung capacity were significantly associated with high emotional distress. Odds ratio of emotional distress increased with 5.2 per tertile (P = .011) in escape avoidance coping score. Moreover, we revealed that emotionally distressed patients cope with their current situation by refusing to believe the current situation and taking their distress out on other people. CONCLUSION: Among patients with COPD, a high level of emotional distress was uniquely associated with escape-avoidance coping and lung function. Future work should ascertain whether coping style predicts distress or whether distress increases the use of escape-avoidance coping. Nevertheless, our findings indicate that if either element is present, health care professionals should be attentive to the need for interventions to improve patients' well-being.

Navigating School Reentry in Lung Transplant Recipients With Cystic Fibrosis.

In addition to medical and psychological support, social support plays a key role in the success of lung transplant recipients, especially in children. An important component of that social support for pediatric lung transplant recipients is school reentry. These children face daily challenges, which often have to be addressed by the transplant team with little existing guidance in the medical literature. In this article, we discuss relevant practice issues for pediatric lung transplant recipients with cystic fibrosis including heightened concern for infection risk, bullying, school performance, and body image concerns. In addition to discussing these important issues, we provide recommendations based on our experiences.

The Need for Psychological Rehabilitation in Lung Transplant Recipients.

Transplant recipients have significant psychosocial stressors due to unique posttransplant sequela that results in an increased incidence of psychopathology. Posttransplant psychological interventions, especially in lung transplant recipients, are understudied, as the focus of prior research has emphasized pretransplant interventions. However, posttransplant psychological stability affects medical outcomes. The importance of posttransplant psychological intervention is highlighted. Recommendations exist which call for attention to specific psychological domains in the posttransplant recovery period and highlight the impact of psychological rehabilitation on overall wellness and success in recovery. A novel psychological rehabilitation intervention is outlined as a response to posttransplant intervention recommendations to demonstrate implementation.

Analysis of Optimal Health-Related Quality of Life Measures in Patients Waitlisted for Lung Transplantation.

Background: Improving health-related quality of life (HRQL) is an important goal of lung transplantation, and St. George's Respiratory Questionnaire (SGRQ) is frequently used for assessing HRQL in patients waitlisted for lung transplantation. We hypothesized that chronic respiratory failure (CRF)-specific HRQL measures would be more suitable than the SGRQ, considering the underlying disease and its severity in these patients. Methods: We prospectively collected physiological and patient-reported data (HRQL, dyspnea, and psychological status) of 199 patients newly registered in the waiting list of lung transplantation. CRF-specific HRQL measures of the Maugeri Respiratory Failure Questionnaire (MRF) and Severe Respiratory Insufficiency Questionnaire (SRI) were assessed in addition to the SGRQ. Results: Compared to the MRF-26 and SRI, the score distribution of the SGRQ was skewed toward the worse ends of the scale. All domains of the MRF-26 and SRI were significantly correlated with the SGRQ. Multiple regression analyses to investigate factors predicting each HRQL score indicated that dyspnea and psychological status accounted for 12% to 28% of the variance more significantly than physiological measures did. The MRF-26 Total and SRI Summary significantly worsened from the baseline to 1 year (p < 0.001 and p < 0.001 and p < 0.001 and. Conclusions: The MRF-26 and SRI are valid, discriminative, and responsive in patients waitlisted for lung transplantation. In terms of the score distribution and responsiveness, CRF-specific measures may function better in their HRQL assessment than the currently used measures do.

Health-related quality of life of transplant recipients: a comparison between lung, kidney, heart, and liver recipients.

BACKGROUND: Quality of life and psychological responses to transplantation are constructs used to assess various psychosocial aspects after organ transplantation. The purpose of this study is to compare physical, psychological, social, and environmental quality of life between recipients of four organs: liver, lung, heart, and kidney. METHODS: In order to compare the four types of quality of life and emotional responses post-transplant, HRQOL and TxEQ questionnaires were administered to 427 transplant recipients. RESULTS: Heart and liver recipients report significantly higher health-related quality of life than lung and kidney recipients. Heart and lung patients report significantly fewer concerns and worries than liver and kidney patients. New additional variables were explored in our study: psychological connection to the living donor/deceased donor's family and commitment to them. We also found that heart recipients feel their personality traits changed, postoperative. CONCLUSIONS: The contribution of our study was the finding that ethno-religious and psychosocial variables have a positive effect on four dimensions of HRQOL. It may be useful to design psychological support interventions specifically adapted to patients after organ transplantation that aim at enhancing patients' HRQOL and alleviating negative emotional responses.

Depression, Immunosuppressant Levels, and Clinical Outcomes in Postlung Transplant Recipients.

OBJECTIVE: Posttransplant depression has been linked to increased risk for adverse outcomes in lung transplant patients. Maintaining target serum immunosuppressant levels is also essential for optimal lung transplant clinical outcome and may be a crucial predictor of outcomes. Because depression could affect medication nonadherence, resulting in out-of-range immunosuppressant levels, we examined the relationship between posttransplant depression, immunosuppressant medication trough level variability, indexed by out-of-range values on clinical outcomes and coefficient of variability, and clinical outcomes. METHOD: A consecutive series of 236 lung transplant recipients completed the Center for Epidemiological Studies-Depression two-month posttransplant. Immunosuppressant trough levels (i.e., tacrolimus or cyclosporine) within the range of individualized immunosuppressant targets were obtained at three-, six-, nine-month follow-up clinic visits. Clinical outcomes including hospitalizations and mortality were obtained from medical records. RESULTS: Fourteen percent of patients were classified as depressed (Center for Epidemiological Studies-Depression ≥16), 144 (61%) of patients had at least 25% out-of-range immunosuppressant values, and the average coefficient of variability was 36%. Over a median of 2.6 years (interquartile range = 1.2), 32 participants died (14%) and 144 (61%) had at least one unplanned, transplant-related hospitalization. Both depression (hazard ratio = 1.45 (1.19, 1.76), p < . 01) and immunosuppressant variation (immunosuppressant out-of-range: hazard ratio = 1.41 (1.10, 1.81), p < .01) independently predicted more frequent hospitalizations and higher mortality. CONCLUSIONS: Early posttransplant depression was associated with significantly worse clinical outcomes. While immunosuppressant level variability is also related to adverse outcomes, such variability does not account for increased risk observed with depression.