Psychosocial Evaluation of Living Kidney Donors: A Survey of Current Practices in the United States.

BACKGROUND: Best practices in psychosocial evaluation and care of living donor candidates and donors are not well established. METHODS: We surveyed 195 living kidney donor (LKD) transplant centers in United States from October 2021 to April 2022 querying (1) composition of psychosocial teams, (2) evaluation processes including clinical tools and domains assessed, (3) selection criteria, and (4) psychosocial follow-up post-donation. RESULTS: We received 161 responses from 104 programs, representing 53% of active LKD programs and 67% of LKD transplant volume in 2019. Most respondents (63%) were social workers/independent living donor advocates. Over 90% of respondents indicated donor candidates with known mental health or substance use disorders were initially evaluated by the psychosocial team. Validated psychometric or transplant-specific tools were rarely utilized but domains assessed were consistent. Active suicidality, self-harm, and psychosis were considered absolute contraindications in >90% of programs. Active depression was absolute contraindication in 50% of programs; active anxiety disorder was excluded 27%. Conditions not contraindicated to donation include those in remission: anxiety (56%), depression (53%), and posttraumatic stress disorder (41%). There was acceptance of donor candidates using alcohol, tobacco, or cannabis recreationally, but not if pattern met criteria for active use disorder. Seventy-one percent of programs conducted post-donation psychosocial assessment and use local resources to support donors. CONCLUSIONS: There was variation in acceptance of donor candidates with mental health or substance use disorders. Although most programs conducted psychosocial screening post-donation, support is not standardized and unclear if adequate. Future studies are needed for consensus building among transplant centers to form guidelines for donor evaluation, acceptance, and support.

"But I didn't drink!": What to do with discordant phosphatidylethanol results.

Liver transplantation (LT) teams must be adept at detecting, evaluating, and treating patients' alcohol use, given its prominence among psychological and behavioral phenomena which cause and contribute to liver diseases. Phosphatidylethanol (PEth) is a highly useful alcohol biomarker increasingly recommended for routine use in hepatology and LT. PEth is unique among alcohol biomarkers because of its wide detection window, high sensitivity and specificity, and the correlation of its numerical value with different patterns of alcohol use. Alongside myriad clinical opportunities in hepatology and LT, PEth also confers numerous challenges: little guidance exists about its clinical use; fearing loss of LT access and the reactions of their clinicians and families, candidates and recipients are incentivized to conceal their alcohol use; and liver clinicians report lack of expertise diagnosing and treating substance-related challenges. Discordance between patient self-reported alcohol use and toxicology is yet another common and particularly difficult circumstance. This article discusses the general toxicological properties of PEth; explores possible scenarios of concordance and discordance among PEth results, patient history, and self-reported drinking; and provides detailed clinical communication strategies to explore discordance with liver patients, a key aspect of its use.

Reexamining "psychosocial clearance": A procedural framework for psychosocial evaluation in liver transplantation.

Psychosocial and "nonmedical" phenomena are commonly encountered in liver transplantation (LT) evaluations. They are simultaneously crucial decision-making factors and some of the most difficult and controversial clinical matters clinicians confront. Epidemiology, societal trends, and the preponderance of psychological and behavioral factors underpinning common end-stage liver diseases ensure that LT teams will continue to encounter highly complex psychosocial patient presentations. Psychosocial policies, practices, and opinions vary widely among clinicians and LT centers. Liver clinicians already report insufficient psychosocial expertise, which creates a large gap between the stark need for psychosocial expansion, improvement, and innovation in LT and the lack of accompanying guidance on how to achieve it. While the clinical domains of an LT psychosocial evaluation have been well-described, few articles analyze the procedures by which teams determine candidates' "psychosocial clearance" and no conceptual frameworks exist. This article proposes a framework of core domains of psychosocial evaluation procedures, common pitfalls, and practical improvement strategies.

Psychosocial evaluation of living liver donors-State of current practices in the United States.

We surveyed living donor liver transplant programs in the United States to describe practices in the psychosocial evaluation of living donors focused on (1) composition of psychosocial team; (2) domains, workflow, and tools of the psychosocial assessment; (3) absolute and relative mental health-related contraindications to donation; and (4) postdonation psychosocial follow-up. We received 52 unique responses, representing 33 of 50 (66%) of active living donor liver transplant programs. Thirty-one (93.9%) provider teams included social workers, 22 (66.7%) psychiatrists, and 14 (42.4%) psychologists. Validated tools were rarely used, but domains assessed were consistent. Respondents rated active alcohol (93.8%), cocaine (96.8%), and opioid (96.8%) use disorder, as absolute contraindications to donation. Active suicidality (97%), self-injurious behavior (90.9%), eating disorders (87.9%), psychosis (84.8%), nonadherence (71.9%), and inability to cooperate with the evaluation team (78.1%) were absolute contraindications to donation. There were no statistically significant differences in absolute psychosocial contraindications to liver donation between geographical areas or between large and small programs. Programs conduct postdonation psychosocial follow-up (57.6%) or screening (39.4%), but routine follow-up of declined donors is rarely conducted (15.8%). Psychosocial evaluation of donor candidates is a multidisciplinary process. The structure of the psychosocial evaluation of donors is not uniform among programs though the domains assessed are consistent. Psychosocial contraindications to living liver donation vary among the transplant programs. Mental health follow-up of donor candidates is not standardized.

Definition and measurement of alcohol-associated insight in early liver transplantation for acute alcohol-associated hepatitis: A systematic review.

BACKGROUND: Alcohol accounts for a large disease burden in hepatology and liver transplantation (LT) and across the globe. Clinical evaluations and decisions about LT candidacy are challenging because they rely on detailed psychosocial assessments and interpretations of psychiatric and substance use disorder data, which often must occur rapidly according to the acuity of end-stage liver disease. Such difficulties commonly occur during the process of candidate selection and liver allocation, particularly during early LT (eLT) in patients with acute alcohol-associated hepatitis (AAH). Patients with AAH commonly have very recent or active substance use, high short-term mortality, psychiatric comorbidities, and compressed evaluation and treatment timetables. LT clinicians report that patients' alcohol-associated insight (AAI) is among the most relevant psychosocial data in this population, yet no studies exist examining how LT teams define and use AAI in eLT or its effect on clinical outcomes. In April 2022, we searched Ovid MEDLINE, Elsevier Embase, EBSCOhost PsycInfo and CINAHL, and Wiley Cochrane Central Register of Controlled Trials for reports describing AAH populations who underwent eLT, which also described psychosocial evaluation parameters. The searches retrieved 1603 unique reports. After eligibility screening, 8 were included in the qualitative analysis. This systematic review reveals that AAI is a poorly defined construct that is not measured in a standardized way. Yet it is a commonly cited parameter in articles that describe the psychosocial evaluation and decision-making of patients undergoing eLT for AAH. This article also discusses the general challenges of assessing AAI during eLT for AAH, existing AAI definitions and rating scales, how AAI has been used to date in the broader hepatology and LT literature, and future areas for clinical and research progress.

The art of interprofessional psychosocial communication: Optimizing patient interfaces with psychiatric specialists in liver transplantation.

Psychiatric and substance use disorders (SUD) commonly cause and contribute to advanced liver diseases and psychosocial phenomena remain some of the most challenging matters that liver transplantation (LT) teams encounter. Patients are often most focused on biomedical aspects of their treatment and LT course rather than subtler psychosocial factors which must be addressed alongside medical and surgical problems. This means that patients may not accept teams' recommendations for psychiatric and SUD treatment despite their primary role in treating liver disease and promoting successful LT. Alcohol-related liver disease is the archetype of these challenges. A crucial, actionable, and rarely discussed factor in creating a therapeutic interface between liver patients and psychiatric and SUD specialists is medical and surgical clinicians' interprofessional psychosocial communication (IPC; i.e., a clinician's personal ability to communicate effectively with patients about psychiatric and substance-related matters). In this article, we describe three crucial IPC timepoints during a typical ALD transplantation timeline, briefly review and synthesize diverse literature and perspectives into an overview of potential IPC pitfalls, propose practical IPC strategies for institutions and clinicians, and indicate future areas of study.

Substance use disorders in organ transplantation: perennial challenges and interprofessional opportunities.

PURPOSE OF REVIEW: The current article examines recent publications regarding ongoing clinical and ethical challenges and opportunities related to substance use disorders (SUD) in solid organ transplantation (SOT) utilizing a lens of interprofessional clinical models and care delivery. RECENT FINDINGS: Innovative interprofessional clinician skillsets and care models are increasingly emphasized in the SOT literature as the standard of care for common, complex psychosocial problems like substance use and SUD. Cannabinoids are common among candidates and recipients and present several unique quandaries to SOT teams. Opioid use disorder treatment can often be definitively treated with medications that SOT teams may find unfamiliar, controversial, or aversive. Arguably the quintessential example of SUD in SOT, early liver transplantation for patients with alcohol-related liver disease and short periods of sobriety has become increasingly common and accepted in recent years requiring liver teams to rapidly acquire significant interprofessional psychiatric awareness and expertise. The question of retransplantation in patients who have experienced recurrent SUD remains unsettled. SUMMARY: Regardless of substances used or organs transplanted, interprofessional care continues to emerge as a foundational aspect of clinical care and research in SOT.

The 21st Century Cures Act and psychosocial electronic documentation in solid organ transplantation: Potential harms and practical strategies.

Recent health system initiatives and government legislation have enhanced electronic health information (EHI) sharing in the healthcare technology environment. These measures are favorably viewed by most patients and clinicians. The 21st Century Cures Act, whose final rules went into effect in the United States in 2021, prohibits information blocking practices except in the case of potential harm. The definition of such harm, particularly regarding psychosocial EHI, is unclear and little guidance has been published. No articles address the matter in solid organ transplantation (SOT) despite the crucial role of psychosocial data in organ allocation. This article describes the implications of patient and family access to psychosocial EHI in SOT, discusses potential mechanisms of harm, and suggests practical communication strategies relevant to clinicians of all disciplines to promote high quality care and favorable interactions with patients and families.

Prerenal Transplant Education and Evaluation Positively Impacts Outcomes.

Introduction: An outstanding question in kidney transplantation is how to prepare candidates and their social supports for optimal posttransplant outcomes. Project Aims: This program evaluation assessed whether a pretransplant quality improvement clinic improved clinical outcomes in the year posttransplant compared to recipients receiving standard of care. Design: The Countdown to Transplant Clinic was implemented with kidney transplant candidates expected to receive a transplant within the next few months. The clinic included an enhanced education session on posttransplant lifestyle management, confirmation of support (≥2 adults), and evaluations by transplant social work, psychology, and nephrology. Results: Seventy-five patients participated in the clinic and underwent a transplant. A retrospective chart review of posttransplant laboratory values, rehospitalizations (within 3-months posttransplant), biopsy-confirmed graft failure, and mortality (within 1-year posttransplant) were collected from both groups. Univariate and multivariate propensity score-weighted linear or logistic regression models were used to evaluate the association between clinic participation and outcomes. In models adjusting for relevant covariates, participation in The Countdown to Transplant Clinic (vs standard care) was associated with a lower coefficient of variation of serum tacrolimus (all values collected 3-12 months posttransplant), 30-day posttransplant white blood cell counts (but not 90-day), 90-day posttransplant potassium, and 30 and 31 to 90 days rehospitalizations. Clinic participation did not predict serum glucose levels at 30- or 90-days posttransplant. Due to low rates of rejection and mortality, meaningful comparisons were not possible. Conclusion: Participation in a pretransplant, multicomponent clinic may improve certain outcomes of interest posttransplantation. Pilot testing for feasibility for randomized controlled trials is a necessary next step.

Interprofessional teamwork is the foundation of effective psychosocial work in organ transplantation.

Interprofessional teamwork (IPT) is a well-established idea spanning multiple professional fields and supported by decades of literature. IPT is underemphasized in the medical literature despite its known impact on patient safety and care delivery. While many transplant teams adeptly work together, little has been written about team dynamics in organ transplantation and less on how IPT principles apply to transplant psychosocial clinicians. This editorial summarizes IPT principles, extrapolates key elements to psychosocial work in organ transplantation, flags potential barriers, collates practical strategies for teamwork enhancement, and identifies areas for future study.

An empirical review of potential mediators and mechanisms of prolonged exposure therapy.

Prolonged exposure (PE) is an empirically-supported treatment for posttraumatic stress disorder (PTSD), but the precise mechanism(s) by which PE promotes symptom change are not well established. Understanding how PE works is critical to improving clinical outcomes, advancing dissemination efforts, and enhancing transdiagnostic models of psychopathology. However, mechanisms research conducted in clinical treatment settings is complex, and findings may be difficult to interpret without appropriate context. This is the first review of potential mechanisms of PE to provide such context, by rigorously evaluating empirical findings in line with essential criteria for effective research on mechanisms (or mediators). We begin by describing six putative mechanisms identified by emotional processing theory and contemporary models of fear extinction, before thoroughly reviewing empirical findings from clinical research on PE and similar PTSD treatments. We provide a detailed description of each study and mechanism test, as well as ratings of strength of evidence and quality of evaluation based on a novel rating scheme. We highlight variables with strong evidence (belief change and between-session habituation), intermediate evidence (inhibitory learning and emotional engagement), and minimal support (narrative organization and within-session habituation). After discussing limitations of the extant literature and this review, we summarize specific challenges for research on PE mechanisms and highlight directions for future study based on clinical and research implications.

Anger and guilt in treatment for chronic posttraumatic stress disorder.

BACKGROUND AND OBJECTIVES: Feelings of anger and guilt are important to consider when treating PTSD as they are related to higher PTSD severity and may be related to avoidance during treatment. Avoidance may impede emotional engagement, the process of connecting with distressing, fear-related emotions during imaginal exposure, which is considered an important mechanism for successful PTSD treatment in prolonged exposure (PE). Yet, little research has examined possible complications in achieving emotional engagement, such as anger and guilt. METHODS: The present study utilized data from 116 individuals with PTSD who received PE to investigate whether anger and guilt were associated with poorer emotional engagement, as captured by pre, peak, post, and mean subjective units of distress (SUDs), during the initial imaginal exposure, and whether anger and guilt predicted worse treatment outcome generally and as a result of lessened emotional engagement. RESULTS: Neither initial anger nor guilt hindered engagement nor predicted worse outcome. Contrary to hypotheses, higher guilt was predictive of greater anticipatory distress and slightly better PTSD outcome. The relationship between pre-treatment guilt cognitions and post-treatment PTSD severity was not mediated by engagement. LIMITATIONS: This study used a trauma-specific measure of guilt and general measure for anger, however both are commonly used. In addition, this study examined emotional engagement during imaginal exposure to the exclusion of engagement with other therapy components, such as in vivo exposure. CONCLUSIONS: These findings help dispel concerns that those with higher anger and guilt will avoid emotionally engaging during the initial imaginal exposure due to feeling distressed by intense negative emotionality.

Biological and symptom changes in posttraumatic stress disorder treatment: a randomized clinical trial.

BACKGROUND: Understanding cognitive and biological mechanisms of PTSD treatment can help refine treatments and increase rates of response. METHODS: Thirty-six veterans with PTSD were randomly assigned to receive Prolonged exposure therapy (PE) or Present-Centered therapy (PCT). We examined symptoms, trauma-related cognitions, and two indices of HPA axis function (cortisol awakening response and cortisol response to a script-driven imagery task). RESULTS: Thirty veterans started treatment and 26 completed. PE resulted in significantly more symptom reduction than PCT (P = .008). High treatment responders collapsed across treatments showed nominally higher cortisol levels measured at pretreatment 30 min after trauma script exposure compared to low responders (P = .08). At midtreatment, high treatment responders showed higher cortisol levels throughout the imagery task (Ps = .03-.04). There were no differences between high and low treatment responders at posttreatment. Thoughts of incompetence (F (1.6, 35.8) = 16.8, P = .000) and a dangerous world (F (1.3, 29.9) = 8.2, P = .004) significantly improved over time in high treatment responders but showed no change in low responders. Script-associated cortisol response prior to treatment and reductions in thoughts of incompetence accounted for 83% of the variance in reductions in PTSD severity with PE. CONCLUSIONS: Both increased cortisol response to personal trauma script prior to PTSD therapy and reductions in cognitive symptoms of PTSD were significantly and uniquely related to reductions in the core symptoms of PTSD in PE. However, contrary to our hypotheses, cortisol measures were not related to cognitive changes.