Published online Aug 27, 2019. doi: 10.4254/wjh.v11.i8.638
Peer-review started: March 20, 2019
First decision: April 23, 2019
Revised: May 23, 2019
Accepted: July 16, 2019
Article in press: July 17, 2019
Published online: August 27, 2019
Liver transplantation is the accepted standard of care for end-stage liver disease due to a variety of etiologies including decompensated cirrhosis, fulminant hepatic failure, and primary hepatic malignancy. There are currently over 13000 candidates on the liver transplant waiting list emphasizing the importance of rigorous patient selection. There are few studies regarding the impact of additional psychosocial barriers to liver transplant including financial hardship, lack of caregiver support, polysubstance abuse, and issues with medical non-compliance. We hypothesized that patients with certain psychosocial comorbidities experienced worse outcomes after liver transplantation.
There are certain accepted criteria to list patients for liver transplantation such as model for end-state liver disease score, age, and body-mass-index. Many patients with liver disease have significant psychosocial comorbidities that may impact outcomes after liver transplantation. There are no evidence-based guidelines regarding psychosocial aspects of the liver transplant evaluation.
The main objective of this study was to assess the impact of certain pre-transplant psychosocial comorbidities on outcomes after liver transplantation. We found that certain psychosocial comorbidities led to worse outcomes after transplantation.
For the primary outcome, there were no differences in survival. Patients with a history of psychiatric disease had a higher incidence of psychiatric decompensation after liver transplantation (19% vs 10%, P = 0.013). Treatment of psychiatric disorders resulted in a reduction of the incidence of psychiatric decompensation (21% vs 11%, P = 0.022). Patients with a history of polysubstance abuse in the transplant evaluation had a higher incidence of substance abuse after transplantation (5.8% vs 1.2%, P = 0.05). In this cohort 15 patients (3.8%) were found to have medical compliance issues in the transplant evaluation. Of these specific patients, 13.3% were found to have substance abuse after transplantation as opposed to 1.3% in patients without documented compliance issues (P = 0.03).
Patients with a history of psychiatric disease had a higher incidence of psychiatric decompensation. Treatment of psychiatric disorders led to a reduction of the incidence of psychiatric decompensation after liver transplantation. Patients with a history of polysubstance abuse and medical non-compliance had a higher incidence of substance use after liver transplantation. This study adds to the literature that this represents a high-risk population. Further multi-center and prospective studies are warranted to formulate evidence-based guidelines to assist in evaluating patients undergoing evaluation for liver transplantation.
This study highlights the importance of the psychosocial evaluation in the liver transplantation process.