Transcript Slide 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
The Magnificent Liver
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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.
End-Stage Liver Disease
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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).
Adult Cadaveric Liver Transplantation
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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.
Liver Transplants/Survival
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4500 liver transplants per annum
Mostly cadaveric, except for children
One year survival- 81.4%
Five year survival- 66.1%
Hawaii Post-transplant Outcomes (01/01/200406/30/2006) One year Adult graft survival
(based on 33 transplants) (%)81.82
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%
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California Pacific Medical Center
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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%.
Coping With Liver Disease
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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
Psychological Evaluation in Liver
Disease
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Role of psychological evaluation: Assessment of
risk factors for noncompliance, motivation,
capacity, psychopathology, substance abuse; pretransplant clinical management planning;
collateral interviews to assess support system
Psychological Evaluation in Liver
Disease
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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
Transplant Assessment Protocol
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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
Gender
50
45
40
35
30
25
20
15
10
5
0
Male
Female
Frequency
Percent
Males
46
71.9
Females
18
28.1
Age & Years of Education
N
Age
64
N
Years of
Education
64
Minimum Maximum
39
68
Minimum Maximum
10
25
Mean
52.391
Std.
Deviation
6.326
Mean
Std.
Deviation
13.547
2.423
DSM-IV Axis I Diagnoses
(Clinical Condition)
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
Axis I Diagnoses
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
DSM-IV Axis V
Global Assessment of Functioning Scale
Mean
54.0169
Median
45.0000
Std. Deviation
14.279
Minimum
20
Maximum
90
Psychosocial Severity Markers
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When comparing individuals with and without
Delirium, a higher proportion of Delirium
patients reported sleep disturbance (64% vs.
38%, chi square, .09, ns)
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The Global Assessment of Functioning Scale
appears to be the single most effective predictor
of psychosocial severity
Psychosocial Severity Markers
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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)
Findings continued
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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
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Thought Problems
Attention Problems
Syndrome
Significance
ANOVA
Thought
ABCL
Attention
ABCL
Thought
ASR
.026
Attention
ASR
.005
.000
.010
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
Rand -36
Category
MELD & Ammonia
Statistics
N
Mean
Median
Std. Deviation
Minimum
Maximum
Percentiles
Valid
Missing
25
50
75
MELD at
Assessment
64
0
14.4375
14.0000
5.56028
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40.00
11.0000
14.0000
17.0000
Ammonia at
Assessment
64
0
63.0156
53.0000
52.84523
.00
267.00
25.2500
53.0000
92.2500
Rand -36
Category
25th
Quartile
Mean
MIN MAX
Emotional WellBeing
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
20.00
83.00
Sleep Inventory
Findings
Sleep Category
Valid
Missing
Total
no sleep problems
Minimal (1-5)
Mild (6-10)
Moderate (11-15)
Severe (16-20)
Total
System
Frequency
1
9
17
14
10
51
13
64
Percent
1.6
14.1
26.6
21.9
15.6
79.7
20.3
100.0
Valid Percent
2.0
17.6
33.3
27.5
19.6
100.0
Cumulative
Percent
2.0
19.6
52.9
80.4
100.0
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
Outcomes
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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
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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
Other Outcomes
Clinical Management : Psychosocial
Issues & QOL
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Delirium/Encephalopathy Management
Ammonia control (lactulose, antibiotics)
 Nutritional Issues (no red meat; 80 grams/day of
protein)
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Sleep Disturbance
Antidepressant medications
 Sedative hypnotics
 Sleep hygiene
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