Paula C. Zimbrean, MD, FAPA, FACLP
Associate professor of psychiatry and surgery (transplant), Yale University School of Medicine; Chair, Transplant Psychiatry Special Interest Group, Academy of Consultation Psychiatry. New Haven, CT.
Dr. Zimbrean has consulted for Ultragenyx and Vivet Therapeutics, and has consulted and advised for Alexion. Relevant financial relationships listed for the author have been mitigated.
CHPR: Please briefly describe the field of transplant psychiatry and what it encompasses.
Dr. Zimbrean: Transplant psychiatrists provide specialized psychiatric evaluations and care for transplant candidates, transplant recipients, and living organ donors. The need for organs in the US far exceeds the availability, so transplant psychiatrists help select the transplant candidates who are most likely to benefit from these scarce resources. Transplant psychiatrists also evaluate living donors to identify psychopathology that can impact the decision to donate or can be worsened by donation. We also educate patients and families about the mental health challenges that come up during the transplantation process. We mostly focus on organ transplantation and vascularized composite allographs (VCAs), such as faces and arms, and not as much on bone marrow transplantation, as those patients are typically followed by psycho-oncology services.
CHPR: Why is it important for hospital and outpatient psychiatrists to know about transplant psychiatry?
Dr. Zimbrean: The number of transplantations grows every year, and transplant recipients increasingly follow up in community mental health practices. Also, transplant candidates and recipients often have significant psychiatric or addictive disorders that led to the indication for transplantation (eg, alcohol-related liver disease or lithium-induced kidney disease).
CHPR: How many transplants are performed in the US?
Dr. Zimbrean: Last year there were over 40,000 organ transplants performed in the US, and for the last decade the numbers have increased every year. Even with the COVID-19 pandemic, which markedly reduced living donations in 2020 (as they were considered elective procedures), the rate of organ transplants continues to grow. Sadly, the availability of organs falls far short of the demand, and thousands of patients die every year waiting for an organ.
CHPR: How long are the waitlists?
Dr. Zimbrean: There are significant geographical disparities in access to transplantation. In general, waitlists are shorter in the South and Midwest and longer on the coasts and in the North. The United Network for Organ Sharing (UNOS)—the organization that oversees organ allocations—is working to reduce these disparities. Waitlists also vary by organ. In Connecticut, the wait for a kidney can be as long as six or seven years. For a liver transplant, the wait time depends in part on the severity of the liver disease. For a heart, on the other hand, at times there are enough organs available to ensure rapid transplantation. In these cases, the challenge for us transplant psychiatrists is that we don’t have time to evaluate or prepare the patient. We’ve had patients who walked into the emergency room with chest pain and over the next two to three weeks underwent heart transplantation and then were discharged home with their lives completely changed, asking “What just happened?!” In these cases, transplant psychiatrists mostly focus on helping patients adapt to their loss of health and function and to their need for lifelong medical care.
CHPR: What are the success rates of different organ transplants?
Dr. Zimbrean: The medical outcomes of transplantation, which include graft survival and patient survival, continue to improve. A summary of rate of transplantation and posttransplant survival can be found on the Health Resources and Services Administration website (https://srtr.transplant.hrsa.gov/annual_reports/Default.aspx). Programs report one-year and five-year survival rates, and in general, one-year survival rates are close to 90% for liver, heart, and organs. For kidneys, they are even higher, around 95%. Survival rates start decreasing five years posttransplantation, especially for lung and heart recipients.
CHPR: Can you describe a recent case in which you were asked to consult on a transplant patient, so we have a clear sense of some of the typical psychiatric issues?
Dr. Zimbrean: I recently consulted on a woman in her late 30s with a history of major depressive disorder and alcohol use disorder (AUD). She had alcohol-related liver cirrhosis that had progressed to the point of requiring a liver transplantation. She suffered from lower-extremity edema and ascites and was undergoing paracentesis (the removal of fluid from the abdomen) every other week. AUDs are the main indication for liver transplants in the US. This patient struggled to maintain sobriety and had lost confidence that she could stay abstinent and that her health would ever improve. I met with her several times to identify interventions that would help her achieve abstinence and become a transplant candidate. I started her on acamprosate and connected her to an intensive outpatient dual diagnosis program. She has been abstinent now for about three months and hopefully will continue in her recovery so that she can move forward with the transplant and return to a life without physical illness.
CHPR: How long do patients need to maintain sobriety before they can be candidates for liver transplants?
Dr. Zimbrean: Alcohol relapse after transplantation is linked with higher rates of mortality and graft loss, so for many years, a six-month abstinence from alcohol and other illicit substances was a requirement before receiving a transplant (Kodali S et al, Alcohol Alcohol 2018;53(2):166–172). The field is now moving toward considering people who have a shorter abstinence, like three or four months, but who are engaged in counseling and show significant motivation to stay abstinent. Another major change is that patients with acute alcoholic hepatitis—who are typically using alcohol until the day that they are hospitalized with liver failure—can receive a liver transplantation if certain conditions are met, such as committing to lifelong abstinence, having good social support, and agreeing to engage in addiction treatment after the surgery (Jesudian AB et al, Curr Opin Organ Transplant 2016;21(2):107–110).
CHPR: Besides a patient’s length of sobriety, what other factors do you take into consideration when selecting candidates for liver transplants?
Dr. Zimbrean: First, the patient must have no medical contraindications. In general, patients should have a 50% survival expectation at five years. For instance, someone with active malignancies is not a candidate because their malignancies would be accelerated with the immunosuppression needed after the transplant. We also look at psychiatric comorbidities that could impair a patient’s ability to adhere to the complex posttransplant medical care or could be made worse after transplantation by medications, like steroids, or by the life changes that result from the transplantation. As transplant psychiatrists, we help select candidates who are most likely to benefit from the procedure for the longest time.
CHPR: Are there any psychiatric contraindications to being a transplant donor or recipient?
Dr. Zimbrean: There are no formal guidelines about psychiatric contraindications to transplantation. If there is an acute psychiatric illness that interferes with the patient’s ability to provide informed consent, and if the transplant is not for a life-threatening condition, then we have time to address the psychiatric condition and discuss the transplant decision later. But if the psychiatric disorder interferes with the patient’s ability to participate in the treatment plan, or can be worsened by the transplant, then those patients might not be good candidates. For instance, there are patients with severe bipolar disorder (BPD) who fear a steroid-induced manic episode. Steroids are almost always needed after transplantation, and some patients are so worried about exacerbating their BPD that they decide against kidney transplantation and prefer to continue hemodialysis.
CHPR: What do you do for patients with acute psychiatric illnesses who require a transplant immediately, meaning there’s no time to address the psychiatric condition?
Dr. Zimbrean: In these cases, we collaborate with the transplant team and treat the psychiatric condition postoperatively while patients are recovering after transplantation. There are very rare situations when the psychiatric condition is treatment refractory and interferes with a patient’s safety or ability to participate in care; in these cases, the transplant team may decide not to proceed with transplantation.
CHPR: How about a history of suicidal ideation or suicide attempts—is that a contraindication?
Dr. Zimbrean: It’s an excellent question. If a patient has made multiple suicide attempts despite receiving mental health treatment, and if we feel all interventions have been exhausted and believe the patient is still at high risk for suicide after being discharged from the hospital, then a history of suicidal ideation may be a contraindication. But most commonly we see a different scenario: patients with a remote history of a suicide attempt during a depressive episode who received psychiatric treatment and did well. In these cases, a history of suicide attempt is not a contraindication.
“When prescribing for transplant recipients, try to avoid medications with risks of organ toxicity whenever possible and be mindful of drug interactions with immunosuppressant medications.” Paula C. Zimbrean, MD, FAPA, FACLP
CHPR: What do you look for in evaluations of potential donors?
Dr. Zimbrean: The most common living organ donors are for kidneys, followed by livers. When meeting with the donor candidates, we evaluate for existing psychiatric illnesses that might interfere with the donor’s functioning or with their decision to donate. It is also important to ensure the donor can provide informed consent and has realistic expectations about the donation. Another important point is the donor’s relationship with the recipient. Prior to the transplantation surgery, some donors have a relationship with the recipient, whereas some don’t (so-called “altruistic,” “unrelated,” or “unaffiliated” donors) and might not desire one. And in some cases we might find out that, consciously or unconsciously, the donor’s desire to establish a close relationship is their main motivating drive for offering to donate. In these cases, we help them reach a different resolution for their wishes.
CHPR: What additional information might be helpful for us to know when we encounter transplant patients?
Dr. Zimbrean: Most of the questions I receive from psychiatrists in the community are about what medications are safe to give to transplant recipients. A helpful concept is that if a transplant is successful, the graft works as well as a healthy organ, so usually dose adjustments are not necessary. In addition, we try to avoid medications with risks of organ toxicity (for instance, risk of liver toxicity associated with divalproex) whenever possible and to be mindful of drug interactions with immunosuppressant medications.
CHPR: Finally, can you say something about the new types of transplants you mentioned earlier—VCAs?
Dr. Zimbrean: These transplants improve quality of life, but they are not lifesaving, so the decision process is different. In many cases the need for the transplant is due to a traumatic injury, for example from a gunshot to the head in a suicide attempt. Patients require many procedures before the transplant procedure and almost invariably become dependent on opioids iatrogenically because they need them for pain control. In addition, the typical doses of immunosuppressant medications for VCAs are higher than for organ transplants, so they risk more side effects. Rejection is also different: While organ recipients with rejection become ill and are hospitalized, the rejection of a VCA is more localized, and patients may see their body part literally decaying. Seeing one’s own face going through rejection—changing color, necrotizing—that is another trauma. On the other hand, quality of life can improve so much afterward that I think these types of transplants will become more widespread.
CHPR: Thank you for your time, Dr. Zimbrean.
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