Characteristics of Liver Transplant Candidates Referred for Psychological Evaluation

Marvin W. Acklin Ph.D.

Psychological Consultant Hawaii Medical Center-East Transplant Institute Honolulu, Hawaii

The Magnificent Liver

 Weighing about three pounds, the liver is the second largest organ in the body--only the skin takes up more room. The liver is divided into lobes that contain liver cells and passageways for blood circulation, called sinusoids. It is within the lobules that the specialized liver cells transform chemical substances into nutrients the body can use or neutralizes potential toxins to protect the body from damage.

Because the liver plays a major role in the circulation and the composition of blood, its health has an impact on all body systems, from hormone regulation to thinking.

End-Stage Liver Disease

 The six most common causes of chronic liver disease in the United States are alcohol, hepatitis viruses (especially hepatitis B and C), fatty liver, medications and hemochromatosis (too much iron in the liver).

Adult Cadaveric Liver Transplantation

 Adult cadaveric liver transplantation is the original transplant procedure, first performed in 1964. It is still the most common liver transplant procedure performed today. Adult cadaveric liver transplantation involves the removal of the entire recipient's liver and replacement with a whole organ obtained from a cadaveric donor.

Liver Transplants/Survival

 4500 liver transplants per annum  Mostly cadaveric, except for children  One year survival- 81.4%  Five year survival- 66.1%  Hawaii Post-transplant Outcomes (01/01/2004 06/30/2006) One year Adult graft survival (based on 33 transplants) (%)81.82

Survival



National Survival Liver:

1995:77.5% 1996:76.0% 2001: 80.3% 2002: 82.3% 1997:78.3% 1998:79.6% 1999:79.3% 2000:80.5% 2003: 81.8% 2004: 83.0%

California Pacific Medical Center

 Our experience shows that Hepatitis C is the most common indication for transplantation, the current median waiting time is 363 days and the average hospitalization stay at California Pacific Medical Center is 8 days. Most importantly, our one-year patient survival rate from 1995 to 2000 is 92% and graft survival is 91%.

Coping With Liver Disease

 The adaptive tasks of the recipient at various stages of the listing/transplant process: coping with serious debilitating illness, acceptance of patient role, adjustment to losses (occupational, social, physical); waiting for a donor; financial issues; coping with immunosuppressive medications; graft failure; death

Psychological Evaluation in Liver Disease

 Role of psychological evaluation: Assessment of risk factors for noncompliance, motivation, capacity, psychopathology, substance abuse; pre transplant clinical management planning; collateral interviews to assess support system

Psychological Evaluation in Liver Disease

 Ethics of psychological evaluation—some argue that only extreme noncompliance should be the only basis for non-listing, rather than a means for selection or prioritization  Issue of informed consent re: use of information  Instructions and impression management

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Transplant Assessment Protocol

Clinical Interview Caregiver Interview Achenbach Adult Self – Report (ASR) Achenbach Adult Behavior Checklist (ABCL) Beck Depression Inventory – II (BDI-II) Beck Anxiety Inventory (BAI) RAND – 36 Item Health Survey Sleep Inventory Psychological Assessment of Candidates for Transplant (PACT) MELD and Ammonia Data Outcome Data

Gender

25 20 15 10 5 0 50 45 40 35 30

Males Females

Male

Frequency 46 18

Female

Percent 71.9 28.1

Age & Years of Education

Age N 64 Minimum Maximum 39 68 Mean 52.391

Std. Deviation 6.326

Years of Education N 64 Minimum Maximum 10 25 Mean 13.547

Std. Deviation 2.423

DSM-IV Axis I Diagnoses

(Clinical Condition) Axis I Diagnoses Delirium due to End Stage Liver Disease Frequency 31 Percent 48.4

Mood Disorder Substance Abuse Sleep Disorder due End Stage Liver Disease No diagnosis Anxiety Disorder 29 26 19 12 9 45.3

41.6

29.0

18.8

14.1

DSM-IV Axis III Diagnoses

(Health/Medical Issues) Axis III Diagnosis Frequency Percent End Stage Liver Disease 64 100.0

39 60.9

Hepatitis C Hepatic Encephalopathy Diabetes Mellitus Alcoholic Cirrhosis 24 9 7 37.5

14.1

10.9

6 9.4

Hepatocellular Cancer 2 3.1

Cryptogenic Cirrhosis (unknown origin)

DSM-IV Axis V

Global Assessment of Functioning Scale

Mean 54.0169

Median Std. Deviation Minimum Maximum 45.0000

14.279

20 90

Psychosocial Severity Markers

 When comparing individuals with and without Delirium, a higher proportion of Delirium patients reported sleep disturbance (64% vs. 38%, chi square, .09, ns)  The Global Assessment of Functioning Scale appears to be the single most effective predictor of psychosocial severity

Psychosocial Severity Markers

   Median Split analysis of GAFS scores indicated that individuals with low GAFs (45 or less) were unemployed, more depressed, anxious, and had lower physical functioning, role limitations, sleep, and PACT Final Rating A higher proportion of Delirium diagnoses were found in the GAF < 45 group (70%, chi square, .001) A lower proportion of Delirium diagnoses were found in the GAF > 45 group (24%, chi square, .001)

Findings continued

Syndrome  When cases were separated into Delirium vs. No Delirium there were significant between group and within group differences on the following ASR/ABCL syndrome scales   Thought Problems Attention Problems Thought ABCL Attention ABCL Thought ASR Attention ASR Significance ANOVA .026

.000

.010

.005

Rand -36 Category

Physical Functioning Role Limits Health Role Limits Emotional

Mean

60.29

34.29

75.23

Energy / Fatigue 42.05

MIN

5.00

0.00

0.00

6.60

MAX

100.00

85.00

25 th Quartile

100.00

35.00

0.00

100.00

66.00

25.00

MELD & Ammonia

Statistics

N Valid Mis sing Mean Median Std. Deviation Minimum Maximum Percentiles 25 50 75 MELD at Ass es sment 64 0 14.4375

14.0000

5.56028

.00

40.00

11.0000

14.0000

17.0000

Ammonia at Ass es sment 64 0 63.0156

53.0000

52.84523

.00

267.00

25.2500

53.0000

92.2500

Rand -36 Category

Emotional Well Being Social Functioning Pain

Mean MIN MAX 25 th Quartile

72.96

48.00 96.00

64.00

61.06

61.64

25.00 100.00

20.00 100.00

77.50

45.00

General Health 35.51

5.00

83.00

20.00

Sleep Inventory Findings

Valid Mis sing Total no s leep problems Minimal (1-5) Mild (6-10) Moderate (11-15) Severe (16-20) Total Sys tem

Sleep Category

Frequency 1 9 17 14 10 51 13 64 Percent 1.6

14.1

26.6

21.9

15.6

79.7

20.3

100.0

Valid Percent 2.0

17.6

33.3

27.5

19.6

100.0

Cumulative Percent 2.0

19.6

52.9

80.4

100.0

Psychosocial Assessment of Candidates for Transplant (PACT) Findings

Frequency Percent Poor

1 1.6

Borderline Acceptable Good Excellent Total

7 19 21 13 61 10.9

29.7

32.8

20.3

95.3

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Outcomes

Listed and Waiting for Transplant Information not available Doing Well Died waiting on list Died while waiting for evaluation completion Too well for treatment Other  Died after transplant        Using alcohol and IV drugs Medical Evaluation not completed No caregiver Jail Diagnosed with hepatocellular cancer “Not cognizant” Received Treatment in PA

Other Outcomes

Clinical Management : Psychosocial Issues & QOL

 Delirium/Encephalopathy Management  Ammonia control (lactulose, antibiotics)  Nutritional Issues (no red meat; 80 grams/day of protein)  Sleep Disturbance  Antidepressant medications  Sedative hypnotics  Sleep hygiene