Characteristics of Liver Transplant Candidates Referred for Psychological Evaluation

1
Characteristics of Liver Transplant Candidates
Referred for Psychological Evaluation

• Marvin W. Acklin Ph.D.
• Psychological Consultant
• Hawaii Medical Center-East Transplant Institute
• Honolulu, Hawaii

2
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.

3
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).

4
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.

5
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

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Survival

• National Survival Liver
• 199577.5 2001 80.3
• 199676.0 2002 82.3
• 199778.3 2003 81.8
• 199879.6 2004 83.0
• 199979.3
• 200080.5

7
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.

8
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

9
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

10
Psychological Evaluation in Liver Disease

• Ethics of psychological evaluationsome 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

11
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

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Gender
Frequency Percent
Males 46 71.9
Females 18 28.1
13
Age Years of Education
N Minimum Maximum Mean Std. Deviation
Age 64 39 68 52.391 6.326


N Minimum Maximum Mean Std. Deviation
Years of Education 64 10 25 13.547 2.423
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DSM-IV Axis I Diagnoses(Clinical Condition)
Axis I Diagnoses Frequency Percent
Delirium due to End Stage Liver Disease 31 48.4
Mood Disorder 29 45.3
Substance Abuse 26 41.6
Sleep Disorder due End Stage Liver Disease 19 29.0
No diagnosis 12 18.8
Anxiety Disorder 9 14.1
15
DSM-IV Axis III Diagnoses(Health/Medical Issues)
Axis III Diagnosis Frequency Percent
End Stage Liver Disease 64 100.0
Hepatitis C 39 60.9
Hepatic Encephalopathy 24 37.5
Diabetes Mellitus 9 14.1
Alcoholic Cirrhosis 7 10.9
Hepatocellular Cancer 6 9.4
Cryptogenic Cirrhosis (unknown origin) 2 3.1
16
DSM-IV Axis V Global Assessment of Functioning
Scale
Mean 54.0169
Median 45.0000
Std. Deviation 14.279
Minimum 20
Maximum 90
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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

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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 lt 45 group (70, chi square,
  .001)
• A lower proportion of Delirium diagnoses were
  found in the GAF gt 45 group (24, chi square,
  .001)

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Findings continued
Syndrome Significance ANOVA
Thought ABCL .026
Attention ABCL .000
Thought ASR .010
Attention ASR .005

• 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

20
Rand -36 Category Mean MIN MAX 25th Quartile
Physical Functioning 60.29 5.00 100.00 35.00
Role Limits Health 34.29 0.00 100.00 0.00
Role Limits Emotional 75.23 0.00 100.00 66.00
Energy / Fatigue 42.05 6.60 85.00 25.00
21
MELD Ammonia
22
Rand -36 Category Mean MIN MAX 25th Quartile
Emotional Well-Being 72.96 48.00 96.00 64.00
Social Functioning 61.06 25.00 100.00 77.50
Pain 61.64 20.00 100.00 45.00
General Health 35.51 5.00 83.00 20.00
23
Sleep Inventory Findings
24
Psychosocial Assessment of Candidates for
Transplant (PACT) Findings
Frequency Percent
Poor 1 1.6
Borderline 7 10.9
Acceptable 19 29.7
Good 21 32.8
Excellent 13 20.3
Total 61 95.3
25
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

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Other Outcomes
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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