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

6. Survival • National Survival Liver: 1995:77.5% 2001: 80.3% 1996:76.0% 2002: 82.3% 1997:78.3% 2003: 81.8% 1998:79.6% 2004: 83.0% 1999:79.3% 2000:80.5%

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 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

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

12. Gender

13. Age & Years of Education

14. DSM-IV Axis I Diagnoses(Clinical Condition)

15. DSM-IV Axis III Diagnoses(Health/Medical Issues)

16. DSM-IV Axis V Global Assessment of Functioning Scale

17. 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

18. 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)

19. Findings continued • 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

21. MELD & Ammonia

23. Sleep Inventory Findings

24. Psychosocial Assessment of Candidates for Transplant (PACT) Findings

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

26. Other Outcomes

27. 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