ACLP Best Practice Guidance: Evaluation and Treatment of Depression in Solid Organ Transplant Recipients.

We present Academy of Consultation Liaison Psychiatry best practice guidance on depression in solid organ transplant (SOT) recipients, which resulted from the collaboration of Academy of Consultation Liaison Psychiatry's transplant psychiatry special interest group and Guidelines and Evidence-Based Medicine Subcommittee. Depression (which in the transplant setting may designate depressive symptoms or depressive disorders) is a frequent problem among SOT recipients. Following a structured literature review and consensus process, the Academy of Consultation Liaison Psychiatry transplant psychiatry special interest group proposes recommendations for practice: all organ transplant recipients should be screened routinely for depression. When applicable, positive screening should prompt communication with the mental health treating provider or a clinical evaluation. If the evaluation leads to a diagnosis of depressive disorder, treatment should be recommended and offered. The recommendation for psychotherapy should consider the physical and cognitive ability of the patient to maximize benefit. The first-line antidepressants of choice are escitalopram, sertraline, and mirtazapine. Treating depressive disorders prior to transplantation is recommended to prevent posttransplant depression. Future research should address the mechanism by which transplant patients develop depressive disorders, the efficacy and feasibility of treatment interventions (both pharmacological and psychotherapeutic, in person and via telemedicine), and the resources available to transplant patients for mental health care.

Adherence in transplantation.

PURPOSE OF REVIEW: Adequately managing a complex medical regimen is paramount to the success of organ transplants. When patients stray from their prescribed medical regimen posttransplant, graft rejection, and death can occur. Predictors of adherence have been studied for many years, and various factors have been identified as contributing to adequate or poor adherence. Both demographic and personal characteristics have been associated with adherence behavior. However, recent developments, such as the COVID-19 pandemic, increased use of mobile health interventions, and use of medical biomarkers have affected the way adherence is measured and applied. RECENT FINDINGS: The COVID-19 pandemic affected patients' comfort with accessing outpatient care and created a wider use of telehealth services. Measurement of adherence through serum lab levels continues to be reviewed as a potential objective assessment of adherence. Psychosocial factors continue to be identified as major contributors to nonadherence. SUMMARY: Adherence to antirejection medication, lab work, appointments, and exercise and dietary instructions remains critical to the health of the transplant patient. It is critical that providers involved in the selection process and posttransplant treatment of these patients remain well informed of potential new factors affecting adherence.

Cannabinoids and solid organ transplantation: Psychiatric perspectives and recommendations.

Cannabinoid use in patients seeking solid organ transplantation (SOT) is an important and unsettled matter which all transplantation clinicians regularly encounter. It is also a multifaceted, interprofessional issue, difficult for any specialty alone to adequately address in a research article or during clinical care. Such uncertainty lends itself to bias for or against cannabinoid use accompanied by inconsistent policies and procedures. Scientific literature in SOT regarding cannabinoids often narrowly examines the issue and exists mostly in liver and kidney transplantation. Published recommendations from professional societies are mosaics of vagueness and specificity mirroring the ongoing dilemma. The cannabinoid information SOT clinicians need for clinical care may require data and perspectives from diverse medical literature which are rarely synthesized. SOT teams may not be adequately staffed or trained to address various neuropsychiatric cannabinoid effects and risks in patients. In this article, authors from US transplantation centers conduct a systematized review of the few existing studies regarding clinician perceptions, use rates, and clinical impact of cannabinoid use in SOT patients; collate representative professional society guidance on the topic; draw from diverse medical literature bases to detail facets of cannabinoid use in psychiatry and addiction pertinent to all transplantation clinicians; provide basic clinical and policy recommendations; and indicate areas of future study.

Substance use screening in transplant populations: Recommendations from a consensus workgroup.

Transplant patients are frequently treated with substances that have dependence potential and/or they may have a history of substance use disorders. The Psychosocial and Ethics Community of Practice of the American Society of Transplantation formed a Drug Testing Workgroup with participation from members of the Pharmacy Community of Practice and members of the Academy of Consultation-Liaison Psychiatry. The workgroup reviewed the literature regarding the following issues: the role of drug testing in patients with substance use disorders, for patients prescribed controlled substances, legal, ethical and prescription drug monitoring issues, financial and insurance issues, and which patients should be tested. We also reviewed current laboratory testing for substances. Group discussions to develop a consensus occurred, and summaries of each topic were reviewed. The workgroup recommends that transplant patients be informed of drug testing and be screened for substances prior to transplant to ensure optimal care and implement ongoing testing if warranted by clinical history. While use of certain substances may not result in the exclusion for transplantation, an awareness of the patient's practices and possible risk from substances is necessary, allowing transplant teams to screen for substance use disorders and ensure the patient is able to manage and minimize risks post-transplant.

Evaluation of the Relationship between Medication Adherence and Tacrolimus Coefficient of Variation.

Introduction: High tacrolimus intrapatient variability is associated with poor outcomes following transplantation. A commonly hypothesized cause of this variability is medication non-adherence, but this has not been conclusively demonstrated. Research Question: The purpose of this study was to evaluate the relationship between medication adherence and tacrolimus intrapatient variability. Design: This was a retrospective cohort study of kidney transplant recipients. Adherence was assessed at the 12-month clinic visit as a composite of patient self-report, pharmacist assessment, and lab monitoring frequency. Tacrolimus intrapatient variability was calculated as the coefficient of variation (CV). Linear regression and receiver operating curve (ROC) analysis were used to assess the relationship between adherence and CV. Results: Nonadherence was identified in 37.5% of patients. The median CV was 27.1% for adherent patients and 29.8% for non-adherent patients (P = 0.051). In the multivariable analysis, the only significant predictor of CV was the incidence of dose changes (P = 0.002). ROC analysis demonstrated poor discriminant power with an AUC of 0.597. Discussion: The results fail to support a clinically meaningful relationship between medication adherence and tacrolimus CV. There is very little evidence at this time that adherence is the primary contributing factor to tacrolimus intrapatient variability and, by extension, that CV can be used as a surrogate for adherence.

Immediate Postoperative Insulin Requirements May Predict Metabolic Outcome after Total Pancreatectomy and Islet Autotransplantation.

Chronic pancreatitis (CP) is a progressive disease that leads to eventual loss of endocrine and exocrine function. Total pancreatectomy and islet autotransplantation (TPIAT) is a treatment option for patients with CP; however, predicting postoperative metabolic outcomes remains elusive. In this single-center retrospective study, we report pre-TPIAT characteristics, beta cell function indices, islet yield, and post-TPIAT glucose management data to further understand their relationship. Islet yield, glucose level, and insulin requirement for 72 hours postoperatively were collected for a total of 13 TPIAT recipients between 9-2013 and 9-2018. In addition, their glucose control and basal insulin requirements at 3, 6, and 12 months post-TPIAT were analyzed. All 13 subjects had normal baseline fasting glucose levels. Median islet yield was 4882 IEq/kg (interquartile range 3412 to 8987). Median postoperative total insulin requirement on day 3 was 0.43 units/kg. Pre-TPIAT baseline glucose, insulin, or c-peptide level did not have a significant correlation with the islet yield. Similarly, there was no correlation between islet yield and insulin requirement at 72-hour postoperatively. However, there was an inverse correlation between the absolute islet yield (IEq) and insulin requirement at 6 months and 12 months following post-TPIAT. Further analysis of the relationship between 72-hour post-op insulin requirement and insulin requirement at discharge, 3, 6, and 12 months showed a positive correlation. Despite the finding of inverse correlation of islet yield with long-term basal insulin requirement, this study was not able to detect a correlation between the preoperative parameters to postoperative short-term or long-term outcome as noted in other studies. The 72-hour postoperative insulin requirement is a helpful postoperative predictor of patients needing long-term insulin management following TPIAT. This observation may identify a high-risk group of patients in need of more intensive diabetes education and insulin treatment prior to hospital discharge.

Total Pancreatectomy and Islet Autotransplantation Following Treated Hepatitis C Infection.

Hepatic parenchymal disease, including chronic viral hepatitis, has traditionally been considered a relative contraindication to islet transplantation as the islets are infused into the recipient's liver. We present a case study of a patient with treated chronic hepatitis C infection (HCV) who safely received an autologous islet transplant following total pancreatectomy with excellent clinical outcomes. The patient was a 60-year-old woman diagnosed with debilitating abdominal pain secondary to chronic pancreatitis and with preserved islet function. She had previously been treated >10 years prior to surgical evaluation with interferon monotherapy for 1 year that led to sustained virologic response, including at the time of surgical evaluation for total pancreatectomy and islet autotransplantation (TPIAT). She underwent comprehensive preoperative evaluation of the liver, including liver biopsy, which showed no significant portal inflammation or fibrosis. Following a multidisciplinary meeting and discussion of the potential risks for the patient, the decision was made to proceed with TPIAT. The patient underwent a standard total pancreatectomy, and an autologous islet dose of 6638 islet equivalents/kg body weight was infused into the liver via the portal vein. Portal vein pressure was monitored throughout the infusion with a transient peak pressure of 27 cm H2O (basal pressure of 14 cm H2O) and final pressure of 23 cm H20 at 10 min post-infusion. Aside from a transient transaminitis, liver enzymes were normal at the time of hospital discharge. At greater than 1 year of follow-up, the patient has improved quality of life, with reduction in narcotic analgesia, remains insulin independent (with normal islet function), and has normal liver function. This case illustrates that islet autotransplant into the liver can be safely performed and suggests that carefully selected patients with liver disease may be eligible for TPIAT.

Report from the American Society of Transplantation Psychosocial Community of Practice Adherence Task Force: Real-world options for promoting adherence in adult recipients.

Starting in 2015, the American Society of Transplantation Psychosocial Community of Practice, with representatives of the Transplant Pharmacy Community of Practice, convened a taskforce to develop a white paper that focused on clinically practical, evidenced-based interventions that transplant centers could implement to increase adherence to medication and behavioral recommendations in adult solid organ transplant recipients. The group focused on what centers could do in their daily routines to implement best practices to increase adherence in adult transplant recipients. We developed a list of strategies using available resources, clinically feasible methods of screening and tracking adherence, and activities that ultimately empower patients to improve their own self-management. We limited the target population to adults because they predominate the research, and because adherence issues differ in pediatric patients, given the necessary involvement of parents/guardians. We also examined broader multilevel areas for intervention including provider and transplant program practices. Ultimately, the task force aims to foster greater recognition, discussion, and solutions required for implementing practical interventions targeted at improving adherence.

Quality of life and psychological symptoms in patients with pulmonary hypertension.

BACKGROUND: Pulmonary arterial hypertension (PAH) has a delay in diagnosis that makes time since diagnosis of interest in this population. OBJECTIVES: To assess psychological conditions, perceived stress, QOL, and interpersonal support and to explore whether these factors may correlate with time since diagnosis in patients with PAH. METHODS: Participants at an academic medical center (n = 108) completed psychological questionnaires (Cambridge Pulmonary Hypertension Outcome Review, Patient Health Questionnaire-9, Perceived Stress Scale-10, and Interpersonal Support Evaluation List-Short Form). RESULTS: Prevalence of psychiatric disorder, major depression, and "other depressive disorder" were 29.6%, 15.7%, and 9.3%, respectively. Participants reported adequate social support, high perceived stress, and average quality of life. Time since diagnosis was positively associated with greater perceived social support (ρ = 0.174, p = .075) and greater perceived stress (ρ = 0.191, p = .048), but no other psychological factor. CONCLUSIONS: Routine psychological assessment and timely referral for mental health services are suggested. Social support may buffer patients from stress.

Psychosocial Challenges in Solid Organ Transplantation.

Organ transplantation is often a life-saving surgery for individuals with end-stage organ disease. However, for most types of solid organ transplant, the demand for organs outweighs the supply, resulting in the need to institute a waiting list for suitable patients who cannot immediately receive an organ. Individuals who need transplants must undergo an assessment process that includes medical, surgical, and psychosocial evaluations. The transplant psychosocial evaluation considers whether surgical candidates are able and willing to care for the transplanted organ for many years. The evaluation must also consider a number of psychosocial risk factors that can lead to complications, which may cause premature loss of the graft. Some of these risk factors include a history of poor medical adherence, psychopathology (including substance use disorders), poor social support, and cognitive dysfunction. This article briefly summarizes the assessment of each of these risk factors and how they can be mitigated to ensure the best outcomes for patients and their families.

Willingness to Consider Non-Directed Kidney Donation.

The purpose of the study was to determine whether factors, including knowledge about living kidney donation or acquaintance with a donor or recipient, are related to willingness to consider donating a kidney. Participants were randomly assigned to read (n = 78) or not read (n = 71) educational materials regarding living donation. All participants then completed a living donation knowledge quiz, indicated whether they knew a donor or recipient, and indicated their support for living donation. Knowledge was not related to willingness to consider donation. Acquaintance with a living donor predicated greater willingness to act as a non-directed living donor, as did acquaintance with a transplant recipient. Decisions regarding whether to consider acting as a living organ donor may be related to whether a person is acquainted with an organ donor or a recipient. Emphasizing personal connections to transplant may lead to increased acceptance of living donation.

Psychological distress in patients presenting for initial renal transplant evaluation.

The comorbidity of psychological disorders with end-stage renal disease (ESRD) presents challenges for renal transplantation, including increased likelihood of medication noncompliance and poorer quality of life. Estimates of rates and severity of affective and anxiety disorders have varied significantly across studies of renal transplant patients, possibly due in part to variation in the methodology and timing of evaluations. To this point, few researchers have examined the psychological condition of patients who are newly referred for renal transplantation. This study examined rates of psychological distress using the Patient Health Questionnaire (PHQ) in a sample of 518 ESRD patients at the specific time point of first contact with the transplant center. In this sample, 15.1% of patients endorsed symptoms consistent with a depressive condition and 7.6% of patients endorsed an anxiety condition. These rates were lower than expected, which may be due to decreased distress in this sample, selection biases, or underreporting of symptoms due to patients' motivation to present themselves positively.

Decision-making, emotional distress, and quality of life in patients affected by the recall of their implantable cardioverter defibrillator.

AIMS: We sought to investigate whether patients with implantable cardioverter defibrillators (ICDs) were suffering from emotional distress related to the recent United States Food and Drug Administration (FDA) recalls, to better understand their decision process related to device replacement, and to assess any impact of recall on quality of life (QOL). METHODS AND RESULTS: Thirty-one patients experiencing device recalls answered questions regarding their knowledge about the recall and their decision whether to replace the device. Fifty patients whose devices were not recalled reported demographic data. In both groups, psychological factors were assessed. No significant differences were found for psychological factors. Most patients reported being informed of their recall by their physician. Most estimated the risk of device failure to be low or very low, but they overestimated the fail rate. Thirty-six per cent of patients reported feeling anxious about the recall. CONCLUSION: No significant differences existed in psychological factors and QOL between patients whose ICDs were recalled compared with those whose devices were not. The majority of patients whose ICDs are the subject of an FDA advisory/recall have a realistic understanding of the risks of device failure. Prompt information, support, and reassurance provided by healthcare professionals may allay patient distress.

Cardiovascular stress responses among Asian Indian and European American women and men.

Asian Indians have approximately 3 times the rate of coronary artery disease as do age-matched European Americans, but the increased risk cannot be explained by the presence of known physiological and behavioral risk factors. One previous study suggested that Asian Indians have diminished vasoactive responses to isoproterenol, but no published study has examined responses to psychological stressors. The purpose of this study was to test the hypothesis that the vasomotor response to stress, as indexed by hemodynamic measures, would be exaggerated in Asian Indian men and women, relative to European American individuals. Thirty-seven Asian Indian and 43 European American men and women were tested in a standard reactivity protocol, whereas heart rate, blood pressure, and cardiac impedance measures were assessed. Asian Indian men and women had significantly smaller changes in systolic blood pressure and mean arterial pressure during the stressors, relative to European American men and women. Asian Indian women, but not men, had significantly smaller diastolic blood pressure and total peripheral-resistance index changes to the stressors, relative to the other 3 groups. These data are in contrast to our expectation of decreased tendency of Asian Indians to vasodilate during psychological stress but do suggest that sex and Asian Indian ethnicity interact to influence vascular reactivity to stressors.