Psychiatric Aspects of Kidney Transplantation

Itai Danovitch

The psychiatric approach to the transplant recipient can be divided into two major components: the psychosocial evaluation for transplant candidacy and the management of symptoms in post-transplantation patients. This chapter reviews the psychiatric evaluation, diagnosis, and treatment of renal transplant recipients as well as the psycho-social evaluation of living kidney donors. The chapter also includes a concise, symptom-based guide for management of psychiatric symptoms.

BACKGROUND

The relationship between kidney disease and mental illness is bidirectional. Co-occurring psychiatric disorders are associated with poor transplant outcomes. This has been attributed to behavioral factors, such as nonadherence, as well as physiologic factors, such as modification of immunologic and stress responses. Likewise, end-stage renal disease (ESRD) generates vulnerability toward mental illness. In addition to the psychosocial impact of severe medical illness, the internal biochemical milieu of ESRD has been likened to a chronic stress state. Elevated cytokines and inflammatory mediators play a putative role in the pathophysiology of depression. Additionally, peptide and steroid hormones that are ordinarily metabolized by the kidneys circulate at higher levels among patients with ESRD and may contribute to both mood and anxiety disorders.

Despite the growing recognition of comorbid psychiatric disorders among patients with ESRD, provision of treatment remains limited. For instance, it has been estimated that although up to 40% of transplant recipients report depressive symptoms, less than 20% of ESRD patients with depression actually receive treatment for it. Although in many cases it may be reasonable for the primary medical team to initiate treatment, the complexity of psychiatric issues in transplant recipients often requires subspecialty care. Within academic medicine, the mental health needs of transplant recipients and donors lie within the scope of transplant psychiatry—a subsection of psychosomatic medicine, which is, in turn, a subspecialty of psychiatry.

EVALUATION

Whether it is for a healthy donor or an ailing patient, psychiatric assessment begins with a comprehensive biopsychosocial evaluation. The evaluating clinician should make sure to inquire about emotions such as mood or anxiety, alterations in perceptions, morbid thoughts about self-harm or harm to others, behavioral symptoms such as adherence, risk taking, and drug use, and environmental and interpersonal stressors. These domains may be moderated by positive prognostic factors such as social supports, insight, spirituality, and the use of adaptive coping mechanisms. Given the prevalence of neurocognitive symptoms, as well as the degree to which they may masquerade as depression, the initial evaluation should include an assessment of cognitive function. A baseline Mini-Mental State Exam (Fig 17.1) is particularly useful as an anchor
point against which any subsequent deterioration or improvement of cognition can be compared.

FIGURE 17.1 The Mini-Mental State Examination, a useful tool for assessing cognitive function and documenting subsequent decline. Scores of 24 or higher are generally considered normal. (Adapted from Folstein MF. Mini-Mental State Examination [MMSE]. Psychopharm Bull 1988;24:689-692.)

Transplant Donors

The ethical dictum to “do no harm” is the guiding principle in the evaluation of the transplant donor. In parallel to comprehensive medical screening, psychological vulnerability factors should be identified and addressed accordingly. A thoughtful psychiatric interview can uncover subtle coercive factors contributing to a donor’s decision, and it is the duty of the transplant team to ensure that these issues are addressed and resolved with the donor in a manner that protects his or her well-being. Among domestic partners, for instance, it is important to inquire about past and present domestic violence. The psychiatric evaluation of prospective donors should characterize the donor’s understanding of renal illness and transplant surgery, their relationship to the patient, their expectations of outcome, whether they have anticipated potential economic, social and psychological
consequences of the procedure, and finally, how they have arrived at their decision. Additionally, given the skewed risk-benefit equation that characterizes a healthy person submitting to an elective medical procedure to remove an organ, it is critical to evaluate and re-evaluate decision-making capacity. Table 17.1 presents a guide for the psychosocial evaluation of the potential unrelated transplant donor. Table 17.2 suggest characteristics that serve as risk factors for, or protective factors against, poor psychosocial outcomes in living kidney donors, emphasizing factors of heightened importance for unrelated donors (see Chapter 6).

TABLE 17.1 Required Components of the Psychosocial Evaluation of Living Unrelated Kidney Donors

History and current status: Obtain standard background information regarding such areas as the prospective donor’s educational level, living situation, cultural background, religious beliefs and practices, significant relationships, family psychosocial history, employment, lifestyle, community activities, legal offense history, and citizenship.

Capacity: Ensure that the prospective donor’s cognitive status and capacity to comprehend information are not compromised and do not interfere with judgment; determine risk for exploitation.

Psychological status: Establish the presence or absence of current and prior psychiatric disorder, including but not limited to mood, anxiety, substance use, and personality disorders. Review current or prior therapeutic interventions (counseling, medications); physical, psychological, or sexual abuse; current stressors (e.g., relationships, home, work); recent losses; and chronic pain management. Assess repertoire of coping skills to manage previous life or health-related stressors.

Relationship with the transplant candidate: Review the nature and degree of closeness (if any) to the recipient, such as how the relationship developed and whether the transplant would impose expectations or perceived obligations on the part of either the donor or the recipient.

Motivation: Explore the rationale and reasoning for volunteering to donate, that is, the “voluntariness,” including whether donation would be consistent with past behaviors, apparent values, beliefs, moral obligations, or lifestyle, and whether it would be free of coercion, inducements, ambivalence, impulsivity, or ulterior motives (e.g., to atone or gain approval, to stabilize self-image, to remedy psychological malady).

Donor knowledge, understanding, and preparation: Explore the prospective donor’s awareness of any potential short- and long-term risks for surgical complications and health outcomes, both for the donor and the transplant candidate; recovery and recuperation time; availability of alternative treatments for the transplant candidate; and financial ramifications (including possible insurance risk). Determine that the donor understands that data on long-term donor health and psychosocial outcomes continue to be sparse. Assess the prospective donor’s understanding, acceptance, and respect for the specific donor protocol, including willingness to accept potential lack of communication from the recipient and willingness to undergo future donor follow-up.

Social support: Evaluate significant other, familial, social, and employer support networks available to the prospective donor on an ongoing basis as well as during the donor’s recovery from surgery.

Financial suitability: Determine whether the prospective donor is financially stable and free of financial hardship; has resources available to cover financial obligations for expected and unexpected donation-related expenses; is able to withstand time away from work or established role, including unplanned extended recovery time; and has disability and health insurance.

From Dew MA, Jacobs CL, Jowsey SG, et al. Guidelines for the psychosocial evaluation of living unrelated kidney donors in the United States. Am J Transplant 2007;7:1047-1054, with permission.

Transplant Recipients

From pretransplantation screenings, to capacity assessments, to symptomfocused evaluations, the psychiatric assessment of transplant recipients varies a great deal depending on the goal at hand. The evaluation should be framed according to the reason for the assessment, and the patient needs to understand the examiner’s intentions, whether it is to address psychiatric symptoms or as a general screening component of the pretransplantation assessment.

The evaluation of transplant recipients is a psychosomatic evaluation in the broadest sense of the term. The clinician must make an effort to differentiate psychiatric presentations of renal illness from somatic manifestations of psychiatric illness. For instance, somatic symptoms of uremia, such as insomnia, anorexia, lethargy, can be mistaken for depression (Table 17.3). Similarly, immunosuppressive medications such as steroids can induce wideranging neuropsychiatric presentations. Although psychiatric measures can be helpful, many have called into question the validity of scales that were designed to detect psychopathology in the general population, and efforts are ongoing to develop reliable, valid, and clinically feasible measures for targeted use in patients with advanced renal disease. Psychosocial eligibility determinations are controversial and have largely been determined through consensus guidelines. The Canadian Society of Transplantation has issued evidence-based guidelines on psychosocial eligibility for kidney transplantation (Table 17.4).

Psychological Impact

It is simply not possible to overstate the profound psychological impact of kidney transplantation. Whereas all forms of illness undermine the fantasy of invulnerability that buoys the “sense of self,” the significance of a failing organ system requiring replacement by donation from another person is an enormous challenge for the psyche and one that can only be understood when framed within the background of social, religious, spiritual, ethnic, and cultural perspectives. Add in the emotional strain of chronic dialysis, the uncertainty involved in waiting for a transplant, the disfigurement that can occur with chronic renal disease, and the repercussions of powerful immunosuppressive medications and you have the makings for an upheaval of the mind as well as the body. The fact that some people manage to navigate these challenges without becoming symptomatic is a testament to protective factors such as resilience and psychosocial support.

Any psychiatric assessment, even if it only does so indirectly, must pay heed to how the above dynamics are integrated and psychologically metabolized. Where the evaluator notes areas of resistance, discomfort, embarrassment, or demoralization, a brief supportive exploration may be indicated to characterize what thoughts or feelings are disturbing, and why. The sheer existential challenge of life suddenly redefined in terms of “survival years” may lead patients to call into question firmly held beliefs. We live in a culture that places exceeding value on body image, and the physical changes that can develop may further undermine previously stable parts of identity. Marital discord is highly prevalent among patients with ESRD, a particular concern because investigations of social support have suggested that “perception” of support may be more important than support itself as a predictor of survival. In some cases, there may be a vital role for individual therapy, group therapy, or family therapy.

TABLE 17.2 Characteristics Serving as Risk Factors for, or Protective Factors I Against, Poor Psychosocial Outcomes in Living Kidney. Donors Factors of Heightened Importance for Unrelated Donors In Italics

Lower Risk or Protective	Higher Risk
No diagnosable psychiatric disorder or significant psychiatric symptoms	Significant past or ongoing psychiatric symptoms or disorders
No evidence of substance abuse	Substance abuse or dependence
Financial resources that could cover unexpected costs	Limited financial capacity to manage donation (lost wages, travel, job concerns)
Health insurance	Lack of health insurance
Knowledgeable about potential risk and benefits to donor or recipient	Limited capacity to understand donor risks and recipient benefits and alternatives
	Increased medical risks (e.g., chronic pain conditions)
Little to no ambivalence about proceeding with donation, realistic expectations about the donation experience, and potential recipient outcomes	Marked ambivalence about donating, or unrealistic expectations about the donation experience and potential recipient outcomes
Altruistically motivated; a history of medical altruism	Motives reflecting desire for recognition, or a desire to use the donation to develop personal relationships (e.g., desire for publicity, desire for a relationship with an individual or with treatment providers)
History of reasonable adaptation to typical life stressors, no recent significant losses or stressors	Multiple family stressors, obligations, or concerns
	Subordinate relationship (e.g., employee or employer) or other evidence of coercion
	Evidence of, or expectation of, secondary gain (e.g., avoidance of military duty, financial support from recipient)
Support from family for donation; knowledge by family of possible donation	Poor relationship with family; poor family support for donation
From Dew MA, Jacobs CL, Jowsey SG, et al. Guidelines for the psychosocial evaluation of living unrelated kidney donors in the United States. Am J Transplant 2007;7:1047-1054, with permission.

TABLE 17.3 Symptom Parallels Between Depression and Uremia

Uremia	Depression
Encephalopathy	Depression
	Poor concentration
Anorexia	Decreased appetite
Sleep apnea	Insomnia
Anemia	Decreased energy
Volume overload
Neuropathy, arthropathy	Somatization
Restlessness, akathisia	Anxiety
	Guilt
	Suicidality

TABLE 17.4 Canadian Society of Transplantation Consensus Guidelines on Psychosocial Eligibility for Kidney Transplantation

	Given the importance of adherence to therapy in transplant outcomes, all patients should have a pretransplantation psychosocial evaluation by an experienced competent individual to assess for:
	○	Cognitive impairment (grade C)
	○	Mental illness (grade C)
	○	Nonadherence to therapy, laboratory monitoring, or follow-up (grade C)
	○	Drug or alcohol abuse (grade C)
	Cognitive impairment is not an absolute contraindication to kidney transplantation (grade B). However, particular care must be taken to ensure that informed consent can be obtained and that a support system is in place to ensure adherence to therapy and patient safety.
	A history of psychiatric illness is not an absolute contraindication for kidney transplantation. Such patients should be assessed to ensure that they are capable of giving informed consent and adhering to therapy (grade B).
	Patient nonadherence to therapy is a contraindication to kidney transplantation, given the use of immunosuppressive agents with a narrow therapeutic window, the impact of nonadherence to therapy on risk for acute rejection and premature graft loss, and the scarcity of donor organs (grade A). Patients should be informed of the importance of adherence to therapy as well as the number of medications, clinic visits, and blood work required before transplantation (grade B).
	Kidney transplantation should be delayed until patients have demonstrated adherence to therapy (attendance for dialysis and compliance with medications) for at least 6 months (grade C).
	Kidney transplantation should be delayed until the patient has demonstrated freedom from substance abuse for at least 6 months (grade C).
The strength of evidence supporting each recommendation was graded using the system developed by the Canadian Task Force on Preventive Health Care as follows:
	Grade A—There is good evidence to support.
	Grade B—There is fair evidence to support.
	Grade C—The existing evidence is conflicting, but other factors may influence decision making.
	Grade D—There is fair evidence to recommend against.
	Grade E—There is good evidence to recommend against.
From Knoll G, Cockfield S, Blydt-Hansen T, et al. Canadian Society of Transplantation: Consensus guidelines on eligibility for kidney transplantation. CMAJ 2005;173:S1, with permission.

Adherence

The way in which an individual copes often has the antecedents of the challenges that they will face. Most patients adhere to medication regimens very closely in the days after transplantation, but as the reality of living with a chronic illness sets in, adherence may wane. Nonadherence is defined as failure to follow treatment recommendations (nutritional, pharmacologic, or lifestyle) despite cognitive understanding of their significance. Misunderstandings resulting from language barriers, education, inadequate informed consent, or alterations in cognition are separate phenomena. An initial assessment must attempt to characterize how the patient has coped with difficulties in the past as well as the present. What emotional strategies have they used? Do they have, and make use
of, social supports? Also, how do they understand their current situation? What challenges do they anticipate? What kinds of defense mechanisms do they use?

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