© Springer International Publishing Switzerland 2017
Maggi A. Budd, Sigmund Hough, Stephen T. Wegener and William Stiers (eds.)Practical Psychology in Medical Rehabilitation10.1007/978-3-319-34034-0_2222. Transplants
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Aleda E. Lutz Saginaw Veterans Affairs Medical Center, 1500 Weiss Street, Saginaw, MI 48602, USA
Keywords
Organ transplantCopingAdjustmentAdherenceMorbidityTopic
Organ transplantation is the last line of treatment for patients with end-stage organ failure. The wait for an organ and recovery from the transplant procedure involves substantial changes to patients’ physical health, psychological well-being, occupational abilities, social relationships, and self-care. Patients are at great risk for both medical and psychiatric illness and require substantial adjustment and adaptation in their lives. It is therefore necessary for transplant teams and interdisciplinary care teams to be aware of these risks in order to intervene to improve functioning and long-term outcomes.
Importance
Approximately 28,000 transplantations are performed annually in the United States. This includes an estimated 12,000 kidney transplants, 4500 liver transplants, 2100 heart transplants, 1000 pancreas transplants, and 850 lung transplants. However, the number of candidates added to the wait list exceeds the number of those receiving transplants with an estimated 15 patients dying on waiting lists each day [1]. For major surgeries, candidates in the United States wait 2 or more years for an organ and 10–18 % of candidates die while waiting [1]. The number of living donor donations has increased over time but has not kept pace with the increasing rate of patients in need. Organ shortages create pressure for appropriate allocation of organs to assure optimal utility, with priority to provide organs to those who are able to care for them. Attention to the needs and difficulties facing patients—including adjustment, substance use, and psychological distress—are important to ensure optimal outcomes .
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The following are the most commonly transplanted organs:
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Kidney (“Nephric” = “Renal” = Region of the kidneys)
End-stage renal disease can be secondary to various disease processes, including diabetes with renal manifestation, polycystic kidney disease, hypertension, and nephrotoxic (kidney damaging) drug use.
Uremia co-occurs with renal failure, which is a metabolic disturbance when waste products in the urine are retained in the blood that can also interfere with optimal cognitive functioning.
Dialysis is common while waiting for a viable organ, an energy- and time-consuming procedure that interferes with day-to-day functioning and flexibility [2].
Kidneys can be donated from both deceased (cadaveric) donors or living donors; humans can live with one kidney.
Survival rates following cadaveric kidney grafts 1-year post surgery is 91.9 %, and 5-year survival is 72.0 % [1].
Living donor donation improves survival rate, with 95.9 % at 1 year, and 84.9 % at 5 years [1].
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Liver
Liver transplants are most commonly performed for cirrhosis secondary to chronic viral hepatitis or alcohol abuse, though there are a multitude of diseases that can bring about the need for transplantation, including abnormalities and malformations, drug toxicity, cirrhosis, and early-stage cancers [2, 3].
Patients with liver disease can be lethargic and may become encephalopathic. They may demonstrate global cognitive deficits that may or may not be reversible.
Livers can be acquired from living or cadaveric donors.
Donation survival at 1 year is 87.7 %, and at 5 years is 74.3 % [1].
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Heart
Heart transplantation is performed for patients who have been identified as having symptoms of Class IV heart failure (e.g., inability to carry on any physical activity without discomfort, with symptoms of heart failure present even at rest), and who are unresponsive to other medical therapies or procedures.
Heart failure can be due to ischemic disease, familial variables, viral, idiopathic, and postpartum cardiomyopathies [2].
One-year survival rates after a first-time heart transplantation is 87.7 %, and 5-year survival is 72.5 % [1].
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Pancreas
Pancreas donation is typically considered for patients with advanced insulin-dependent diabetes.
More than 90 % of pancreas transplants are completed simultaneously with a kidney, often for diabetic patients with both renal manifestation of the disease and other diabetes-related complications [2].
Pancreas survival is typically greater in the context of simultaneous kidney–pancreas transplant compared to pancreas-only procedures, with a 91.6 % survival rate at 1 year, and 76.3 % survival rate at 5 years for those receiving the double transplant [1].
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Lung
Lung transplant can be a treatment option for patients with chronic obstructive pulmonary disease (COPD), cystic fibrosis, pulmonary fibrosis, and pulmonary hypertension.
This procedure is often recommended with a heart transplant for patients with combined pulmonary/cardiac diseases, though this is rarely performed because of the reduced availability of both organs, and prioritization over patients who require only one organ [2].
Pulmonary rehabilitation programs can improve patients’ quality of life but typically does not halt disease processes.
One-year survival for these patients is 83.8 %, and 5-year survival is 47.5 % [1].
Combined heart and lung transplant survival is 67.5 % at 1 year and 39.7 % at 5 years [1].
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Bone Marrow and Stem Cell
Most stem cell transplants use the patient’s own cells (autologous transplantation).
Most bone marrow transplants originate from living donors (allogenic transplantation).
These procedures are most often used to treat leukemias and lymphomas, aplastic anemia, and occasionally, cancers [5].
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Practical Applications
The risks facing candidates emphasizes the importance of assessment and treatment of medical and psychiatric conditions, management of risk factors, and implementation of treatment at all stages.
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Psychiatric Disorders and Psychological Distress
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Before transplant
Adjustment disorders, anxiety disorders, and depression are prevalent among transplant candidates. The pretransplant period may involve significant anxiety, including fears about the procedure and mortality risk. Many patients and their families report that the wait period is the most stressful part of the transplantation process [6] with the waiting period often resulting in frustration and increased uncertainty .
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After transplant
Following transplantation, psychiatric distress, depression, and anxiety disorder rates are higher compared to the general population, regardless of organ systems and time posttransplant [7, 8]. Furthermore, postoperative depression, anxiety, and hostility have been associated with elevated levels of medical nonadherence and reduced posttransplant survival in some populations [9–11].
Mood symptoms
Medications (i.e., immunosuppressants) and medical conditions (i.e., electrolyte imbalances, thyroid disorders, and nutritional deficiencies) may impact mood [6].
Even patients with successful transplantation procedures carry an ongoing risk of organ rejection and illness, which increases anxiety.
Body image changes often occur due to weight gain and surgical scarring [12]. Loss of libido and sexual activity can also occur, often secondary to poor body image.
Be aware of risk factors
Psychiatric, behavioral, and psychosocial risks—are crucial to minimize posttransplant complications and improve outcomes [13]. Early identification of risks allows a treatment team to address psychological needs to optimize patient readiness for transplant [14].
Patients are at an increased risk for psychiatric disorders if they have a pretransplant psychiatric history, are female, have impaired physical functioning, lack social support, and have prolonged hospitalization [12, 15].
Assess Coping Skills
Many patients experience poor posttransplantation coping. The quality of coping skills should be examined, including ability to deal with lifestyle changes.
Be aware of mixed feelings about the transplantation process
Candidates may have conflicting feelings of hope, excitement, fear of surgical risk, and pondering the meaning of living with someone else’s organ(s). Patients may also fear being ineligible for transplantation [12].
Psychological Screening
Various screening measures for mood symptoms are currently available. Commonly used depression instruments include the Beck Depression Inventory (BDI-II) and Patient Health Questionnaire (PHQ-9). An assessment of risk factors should consider comorbid psychiatric conditions, health behaviors that may influence posttransplant morbidity and mortality (i.e., tobacco use, poor eating, or exercise habits), and the patient’s ability to modify health behaviors over the long term. Coping strategies can be examined with the brief COPE and the Ways of Coping Scale.
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