Transplant Psychiatry. Stephen Potts & Roger Smyth Department of Psychological Medicine Royal Infirmary of Edinburgh

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1 Transplant Psychiatry Stephen Potts & Roger Smyth Department of Psychological Medicine Royal Infirmary of Edinburgh

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7 Liver / Recipient

8 Functions of the liver largest solid organ with ~500 functions detoxification; digestion; excretion; protein metabolism; glucose/glycogen storage & metabolism; iron storage; immunological; blood clotting no artificial alternative Liver diseases ALD, other toxic hepatitis, viral hepatitis (A-E), NAFLD (NASH), AIH, CC PBC, PSC, ischaemic cholangiopathy HCC, cholangiocarcinoma Haemochromatosis, Wilson s disease, Crigler Najjar syndrome Treatments for liver disease specific - e.g. alcohol abstinence; antivirals; weight loss; steroids; venesection symptomatic - e.g. stenting; TIPSS; paracentesis; banding; nutritional supplementation; ß-blockade

9 Chronic liver failure months to years jaundice; ascites; cachexia; fatigue; itch variceal bleed; SBP; encephalopathy Acute liver injury days to weeks encephalopathy; coagulopathy; pain; organ failure Progression CLF -> ESLD -> transplant ALI -> FHF -> transplant

10 Liver transplantation first procedure in humans , first in UK , first in Scotland 1992 Orthotopic Liver Transplantation (OLT) allograft from deceased or living donor donation after brain death (DBD) or donation after cardiac death (DCD) Outcomes 10% operative and perioperative mortality ~87% one year and 67% five year survival requires lifelong immunosuppression and follow-up Transplantation in the UK regulated by NHS Blood and Transplant seven centres

11 Routine assessment One week, complex, MDT assessment Listing decisions by transplant team in line with national protocols The waiting list listed by blood group (O, A, B, AB) within blood group, listed by UKELD score - INR, creatinine, bilirubin, Na+ i.e. priority by clinical need, not time on list super-urgent have national priority Mortality on the list ~15%

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13 15% 5% 5% 10% 65% Alcohol Alcohol & drugs Drugs Mental disorder Overdose

14 6% 6% 12% 76% Alcohol Alcohol & drugs Drugs Mental disorder

15 Should we consider patients with alcoholic liver disease for liver transplantation?

16 GMC guidance 57. The investigations or treatment you provide or arrange must be based on the assessment you and your patient make of their needs and priorities, and on your clinical judgement about the likely effectiveness of the treatment options. You must not refuse or delay treatment because you believe that a patient s actions or lifestyle have contributed to their condition. Good Medical Practice (2013) General Medical Council

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18 ALD patients must undergo assessment of their drinking before being considered for liver transplantation

19 Notes review Interview with patient Interview with relatives Discussion with GP Discussion with addictions team Interview with patient

20 1 Alcohol diagnosis 2 Length of abstinence 3 Action after evidence of harm 4 Motivation to abstinence 5 Attitude to drinking 6 Involvement with treatment services 7 Environment change

21 Fulminant Hepatic Failure secondary to Paracetamol OD

22 FHF secondary to POD ~90+% of FHF cases (in Scotland) toxic effects likely with >10g daily due to conversion to N-acetyl-p-benzoquinoneimine (NAPQI) when normal metabolic pathway saturated toxicity more likely: - delayed treatment - staggered OD - low body weight / anorexia treatment with N-acetylcysteine effective Transfer to specialist unit for specialist hepatology / anaesthetic management availability of urgent OLT The listing decision taken by duty team using King's College Criteria urgent psychiatric opinion in OD cases, or where psychiatric factors relevant

23 INR Hours

24 Absolute contraindications Previous deliberate self harm Five or more lifetime episodes, unless previous events occurred many years ago Substance misuse Current substance dependence; alternatively active substance misuse in a severe chaotic fashion (may include IVDU) Severe mental disorders Chronic, severe, poor prognosis mental illnesses especially if refractory to appropriate treatment; mental disorders in which the patient will have no capacity to express wishes or understand circumstances Declining transplant Refusal to accept transplantation when capacity is present; consistently expressed wish to die in the absence of explanatory mental illness

25 Dilemma: Alcoholic Hepatitis

26 Kidney / Donor

27 Living donor Directed donation - Genetically / emotionally related - Paired - Pooled - Chain Non-directed (aka "altruistic" donation) Directed altruistic ("Facebook donation )

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30 Risks to donors 1 in 3,000 mortality Minor complication rate Long term risks (CHD, HT, ESRF, preeclampsia) 1in 200 mortality 25% complication rate?long term risks

31 Activity (HTA approvals 17-18) Kidney (1166) Directed: 856 Paired/pooled: 201 Non-directed (altruistic): 98 (8%) Directed altruistic: 11 (1%) Liver (48) Directed: 36 Non-directed (altruistic): 12 (25%)

32 Altruistic donation 2006: slow start : rapid increase 2013: steady state (10%) 2018: all start chains

33 Surgical view at RIE 2006: Reluctance/distaste They must be nuts 2018: Enthusiastic embrace The best possible outcome"

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41 But where is the psychiatry? 2006: HTA mandated psychiatric assessment of all altruistic donors before invasive investigation Did not specify form, process or range of outcomes Early years: >25% ruled out on psychiatric grounds (severe personality disorder, recurrent depressive illness, substance misuse, factitious disorder) 2012: HTA withdrew mandatory requirement (as not based on underlying law) Clinical bodies (NHS-BT/UKT/BRS/BTS/RA) still recommend

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45 Key recommendations Assess all potential altruistic donors Psychiatrist/psychologist - with knowledge of process and risks Early - before invasive tests With full access to records (GP, mental health) May be enhanced (3rd party, repeat, scales)

46 Purpose of assessment

47 Contra-indications (absolute/relative)

48 Potential altruistic kidney donor 31 year old male, partner, no children, graphic designer partner ambivalent, employer supportive Mild - moderate depressive episodes in 20s no psychiatric contact, mood stable on SSRI Motivation: just want to be helpful no prior contact with renal disease / dialysis not engaged in other altruistic activity appears to understand the risks

49 What if the variables changed? Age: 71 years - assessment reveals mild cognitive loss 21 years (see below) Gender: female - at increased risk of pre-eclampsia Psychiatric history more severe, more recent, on meds Support: partner opposed, employer obstructive

50 What if the variables changed? Motivation: consonant with altruism / giving something back rescue fantasy - contact with grateful recipient public acclaim atonement for previous offending specifically religious restitution e.g. after bereavement (how soon is too soon?)

51 Dilemma: the young donor

52 Further Information Websites NHS Blood and Transplant - UK Organ Donation and Transplantation - British Transplantation Society Papers - Potts, S., et al. Mental health assessment of altruistic non-directed kidney donors: An EAPM consensus statement. J Psychosom Res. 107, (2018). Karvellas, CJ., et al. Medical and psychiatric outcomes for patients transplanted for acetaminophen-induced acute liver failure: a case-control study. Liver International. 30(6), (2010). Mathurin, P., et al. Early Liver Transplantation for Severe Alcoholic Hepatitis. N Engl J Med. 365, (2011).

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