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Ethical and psychosocial challenges in liver transplantation
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Symposium abstracts / Journal of Psychosomatic Research 55 (2003) 111–129
have stimulated controversy regarding liver transplantation for alcoholic liver disease. They include the poor prognosis for the treatment of addictions, in general, with high rates of relapse, the presence of comorbid medical and psychiatric conditions, and moral attributions associated with alcohol use. The attitude regarding liver transplantation for alcoholic liver disease changed in 1988, when Starzl et al. demonstrated that the survival of patients transplanted for alcoholic cirrhosis was not different from the survival of other transplant recipients. Since that report alcoholic liver disease has become the most common indication for liver transplantation. Concerns regarding relapse have also fueled the controversy. There is clear consensus that patients with alcoholic cirrhosis should be considered for liver transplantation. Survival rates are comparable to patients receiving transplants for other conditions, and the relapse rate averages 15%. No nationally accepted selection criteria have been established for predicting long-term sobriety and compliance. This paper will address the criteria we have found important in maximizing the outcome of liver transplantation for alcoholic liver disease. An approach to the selection of candidates is outlined.
Neuropsychiatric changes after liver transplantation Hilsabeck RC, Withers NW, Wetter S One year survival rates following adult liver transplantation have been reported to range from 80% to 90% at most centers worldwide. Given the high likelihood of survival following this surgery, patients and clinicians have become more interested in posttransplant quality of life. Research has shown significant improvements in physical health, sexual functioning, ability to perform daily activities, social functioning, and general health-related quality of life, but improvements in neuropsychiatric functioning have been less well characterized. Pretransplant candidates often demonstrate impaired neurocognition, including complex attention, visuomotor, visuospatial, and memory deficits, and significant psychiatric symptoms, such as depression and anxiety. Preliminary data show that patients evaluated pre- and postliver transplant show significant improvements in all areas of neurocognitive functioning, albeit not to premorbid levels of functioning. In contrast, psychiatric symptoms do not necessarily improve and may become increased by posttransplant stressors, such as managing and paying for multiple antirejection medications, pressure to return to work, and loss of social support. Case presentations will be used to illustrate changes in neuropsychiatric symptomatology.
Ethical and psychosocial challenges in liver transplantation Withers NW, Hilsabeck RC, Maldonado JR The number of patients on the U.S. liver transplant waiting list is 18,000 and will double in 10 years. The number of transplants completed is limited by organ availability. Thirteen thousand patients die each year while waiting for orthotopic liver transplantation (OLT). One challenge is timing of OLT. The present allocation scheme gives priority to the most severely ill patients, who unfortunately have the poorest transplant survival with the highest costs. Another challenge is the selection of candidates. Fewer than 10% of the patients dying from alcoholic liver disease have received transplants partly due to fear that patients will relapse. The period of time of abstinence remains controversial. Subacute encephalopathy can delay transplant. The appropriateness of OLT as therapy for patients with hepatitis C is controversial since the virus recurs. Inadequate social support is a relative contraindication. Individuals who lack social support may receive an OLT while in prison. Patients may lose the ability to work after OLT and not have coverage for treatment. The true risks and outcomes of both donors and recipients of living donor transplants are not known; this impacts informed consent for this procedure. Case histories reflecting the ethical and psychosocial challenges for patients facing OLT are reviewed.
Safety of psychotropic medications in liver disease Dishman B, Withers NW Safety of psychotropic medications in liver disease, the need to treat interferon-induced depression, has resulted in studies assessing the safety of antidepressants on hepatic function. The Canadian Adverse Reaction Monitoring Program recorded 32 cases of nefazodone induced liver injury, 29 of which were severe. In the United States, the reported rate of liver failure leading to transplant and/or death temporally associated with nefazodone is estimated to be one case per 250,000 – 300,000 patient years of use. Most practitioners are aware of the hepatotoxic potential of the phenothiazine class of neuroleptics and that the buterophenones are the preferred agents in liver patients; but what is our experience with the new atypical agents? Numerous antiseizure mood stabilizers exist today. We have always been cautious using valproic acid in the treatment of bipolar disorder but recent literature suggests that valproic acid is safe for use in hepatitis C patients. That is our experience with newer anticonvulsants also. Even herbal agent kava – kava has been associated with endstage liver disease. In this age, the safety of psychotropic agents in liver disease is an important concept to master and only with an understanding of the risks associated with each agent can a rational treatment plan be formulated.
Ethical and clinical implications of liver transplantation in patients on methadone maintenance therapy Maldonado JR The lifetime heroin-dependence prevalence increased from 1.7 (1992) to 2.3 (1998) million. The most effective treatment is methadone maintenance (MMT), currently serving almost 180,000 patients in 785 programs. Patients on MMT fare better with respect to social functioning, job rates, incarceration, and human immunodeficiency virus infection compared with patients denied methadone after rehabilitation from heroin use. Although patients fully rehabilitated from previous drug use are considered for orthotopic liver transplant (OLT) candidates, there is a paucity of data regarding OLT in MMT. Hepatitis C is the leading cause of liver transplantation (46%) followed by alcoholic liver disease (25%); both are primarily substance abuse-related diagnoses. The prevalence of HCV in intravenous drug users in MMT is 84 – 90%. Recipient selection, a critical aspect of OLT, involves a multidisciplinary approach. Patients undergo a psychosocial and medical evaluation. Currently, patients actively using illicit drugs are excluded from consideration for OLT. Many programs consider pretransplant use of methadone and other narcotics a contraindication for OLT. To date, no one has addressed the ethical and moral issues surrounding OLT for MMT patients with end-stage liver disease. Arguments for and against the inclusion of MMT patients as candidates for liver transplantation are reviewed.
Life cycle of the Japanese ESRD patients: psychosocial/psychiatric issues (Chair) Haruki S, Ohira S, Watanabe T, Kamo T, Saito N, (Co-chair) Kurihara Y, (Discussant) Levy N In 2001, the number of patients on dialysis reached 220,000 in Japan, showing 4% increase over the previous year. The number also reflects the aging society; the average age of patients receiving hemodialysis (HD) treatment was 61.6, and the mean age of the patients who started dialysis was 64.3. At this symposium, 4 Japanese physicians will present various psychosocial aspects on the ‘‘life cycle of the Japanese dialysis patients’’ including the following issues: (1) factors influencing the preference of dialysis treatment time and frequency for the elderly patients; (2) problems relating to long-term chronic ambulatory peritoneal dialysis (CAPD) when sclerosing encapsulating peritonitis (SEP) forces the patients face the transition from CAPD to HD; (3) the cognitive function and emotional state as the prognostication factors for the elderly dialysis patients; and (4)
Symposium abstracts / Journal of Psychosomatic Research 55 (2003) 111–129
have stimulated controversy regarding liver transplantation for alcoholic liver disease. They include the poor prognosis for the treatment of addictions, in general, with high rates of relapse, the presence of comorbid medical and psychiatric conditions, and moral attributions associated with alcohol use. The attitude regarding liver transplantation for alcoholic liver disease changed in 1988, when Starzl et al. demonstrated that the survival of patients transplanted for alcoholic cirrhosis was not different from the survival of other transplant recipients. Since that report alcoholic liver disease has become the most common indication for liver transplantation. Concerns regarding relapse have also fueled the controversy. There is clear consensus that patients with alcoholic cirrhosis should be considered for liver transplantation. Survival rates are comparable to patients receiving transplants for other conditions, and the relapse rate averages 15%. No nationally accepted selection criteria have been established for predicting long-term sobriety and compliance. This paper will address the criteria we have found important in maximizing the outcome of liver transplantation for alcoholic liver disease. An approach to the selection of candidates is outlined.
Neuropsychiatric changes after liver transplantation Hilsabeck RC, Withers NW, Wetter S One year survival rates following adult liver transplantation have been reported to range from 80% to 90% at most centers worldwide. Given the high likelihood of survival following this surgery, patients and clinicians have become more interested in posttransplant quality of life. Research has shown significant improvements in physical health, sexual functioning, ability to perform daily activities, social functioning, and general health-related quality of life, but improvements in neuropsychiatric functioning have been less well characterized. Pretransplant candidates often demonstrate impaired neurocognition, including complex attention, visuomotor, visuospatial, and memory deficits, and significant psychiatric symptoms, such as depression and anxiety. Preliminary data show that patients evaluated pre- and postliver transplant show significant improvements in all areas of neurocognitive functioning, albeit not to premorbid levels of functioning. In contrast, psychiatric symptoms do not necessarily improve and may become increased by posttransplant stressors, such as managing and paying for multiple antirejection medications, pressure to return to work, and loss of social support. Case presentations will be used to illustrate changes in neuropsychiatric symptomatology.
Ethical and psychosocial challenges in liver transplantation Withers NW, Hilsabeck RC, Maldonado JR The number of patients on the U.S. liver transplant waiting list is 18,000 and will double in 10 years. The number of transplants completed is limited by organ availability. Thirteen thousand patients die each year while waiting for orthotopic liver transplantation (OLT). One challenge is timing of OLT. The present allocation scheme gives priority to the most severely ill patients, who unfortunately have the poorest transplant survival with the highest costs. Another challenge is the selection of candidates. Fewer than 10% of the patients dying from alcoholic liver disease have received transplants partly due to fear that patients will relapse. The period of time of abstinence remains controversial. Subacute encephalopathy can delay transplant. The appropriateness of OLT as therapy for patients with hepatitis C is controversial since the virus recurs. Inadequate social support is a relative contraindication. Individuals who lack social support may receive an OLT while in prison. Patients may lose the ability to work after OLT and not have coverage for treatment. The true risks and outcomes of both donors and recipients of living donor transplants are not known; this impacts informed consent for this procedure. Case histories reflecting the ethical and psychosocial challenges for patients facing OLT are reviewed.
Safety of psychotropic medications in liver disease Dishman B, Withers NW Safety of psychotropic medications in liver disease, the need to treat interferon-induced depression, has resulted in studies assessing the safety of antidepressants on hepatic function. The Canadian Adverse Reaction Monitoring Program recorded 32 cases of nefazodone induced liver injury, 29 of which were severe. In the United States, the reported rate of liver failure leading to transplant and/or death temporally associated with nefazodone is estimated to be one case per 250,000 – 300,000 patient years of use. Most practitioners are aware of the hepatotoxic potential of the phenothiazine class of neuroleptics and that the buterophenones are the preferred agents in liver patients; but what is our experience with the new atypical agents? Numerous antiseizure mood stabilizers exist today. We have always been cautious using valproic acid in the treatment of bipolar disorder but recent literature suggests that valproic acid is safe for use in hepatitis C patients. That is our experience with newer anticonvulsants also. Even herbal agent kava – kava has been associated with endstage liver disease. In this age, the safety of psychotropic agents in liver disease is an important concept to master and only with an understanding of the risks associated with each agent can a rational treatment plan be formulated.
Ethical and clinical implications of liver transplantation in patients on methadone maintenance therapy Maldonado JR The lifetime heroin-dependence prevalence increased from 1.7 (1992) to 2.3 (1998) million. The most effective treatment is methadone maintenance (MMT), currently serving almost 180,000 patients in 785 programs. Patients on MMT fare better with respect to social functioning, job rates, incarceration, and human immunodeficiency virus infection compared with patients denied methadone after rehabilitation from heroin use. Although patients fully rehabilitated from previous drug use are considered for orthotopic liver transplant (OLT) candidates, there is a paucity of data regarding OLT in MMT. Hepatitis C is the leading cause of liver transplantation (46%) followed by alcoholic liver disease (25%); both are primarily substance abuse-related diagnoses. The prevalence of HCV in intravenous drug users in MMT is 84 – 90%. Recipient selection, a critical aspect of OLT, involves a multidisciplinary approach. Patients undergo a psychosocial and medical evaluation. Currently, patients actively using illicit drugs are excluded from consideration for OLT. Many programs consider pretransplant use of methadone and other narcotics a contraindication for OLT. To date, no one has addressed the ethical and moral issues surrounding OLT for MMT patients with end-stage liver disease. Arguments for and against the inclusion of MMT patients as candidates for liver transplantation are reviewed.
Life cycle of the Japanese ESRD patients: psychosocial/psychiatric issues (Chair) Haruki S, Ohira S, Watanabe T, Kamo T, Saito N, (Co-chair) Kurihara Y, (Discussant) Levy N In 2001, the number of patients on dialysis reached 220,000 in Japan, showing 4% increase over the previous year. The number also reflects the aging society; the average age of patients receiving hemodialysis (HD) treatment was 61.6, and the mean age of the patients who started dialysis was 64.3. At this symposium, 4 Japanese physicians will present various psychosocial aspects on the ‘‘life cycle of the Japanese dialysis patients’’ including the following issues: (1) factors influencing the preference of dialysis treatment time and frequency for the elderly patients; (2) problems relating to long-term chronic ambulatory peritoneal dialysis (CAPD) when sclerosing encapsulating peritonitis (SEP) forces the patients face the transition from CAPD to HD; (3) the cognitive function and emotional state as the prognostication factors for the elderly dialysis patients; and (4)