Psychiatrist role in organ transplant unit is central, as the whole structure and functionality of the team is held together by consultation liaison psychiatry team.

1. OLANIYI AYOOLUWA . C
REGISTRAR, DEPT OF MENTAL HEALTH OAUTHC
8 MAY 2023

2.  Definition and brief history
 Types of donor and organ availability
 Transplant surgery flow chart
 Transplant surgery team
 Consultation liaison psychiatrist duties
 Pre-transplantation assessment
 Peri-transplantation assessment
 Post-transplantation assessment
 Conclusion

3. Organ Transplantation :
A surgical procedure where a diseased or failed
organ is replaced by a new, healthy one.

4. As old as human existence.
Greek mythology – Pegasus (A winged horse)
Hindu mythology – Lord ganesha (A king with baby
elephant head)
Modern day Transplantation – 1963
Thomas E. Starzl
First successful liver transplant - 1967

5. Demand – very high, yet with very low supply or
available organ.
REASON :
Poor motivation for potential organ donor
Fear of loosing body part or integrity of their body /
soul.
Managing team may ignore asking relatives if they
would consent to donating.

6. Geneticall-related donors
Emotionally-related donors
Good Samaritan donors
Organ vendor
Organ exchanger

8. Patients on routine haemodialysis
Patient on waiting for kidney transplantation
Those with psychiatry disorder 2* to CKD / dialysis
Those with diagnosed psychiatry disorder prior to
onset of kidney failure

10. Nephrologist / Internist
Renal surgeon / Urologist
Psychiatrist (Consultation-liaison)
Psychologist
Social worker
nutritionist

11. Pre-transplant evaluation of the recipient
Pre-transplant evaluation of the donor
Managing psychological issues and psychiatric condition
before the transplantation
Managing apprehension of the patient before transplant
surgery
Managing post-transplant delirium

12. Addressing psychological issues and psychiatric disorders if
they emerge after the transplant
Managing issues of adherence to medications, dietary
restrictions and other recommended behavioral changes
Providing guidance on ethical issues
Interpersonal issues between the patient/family and the
member(s) of the treating team

14. DONOR ASSESSMENT
Note the identity of who provided the donor’s information
Note the donor’s identity and relationship to the recipient
Assess competency of the donor
Assess donor’s understanding of the transplant procedure and
the associated risks to his/her life.
Assess history : current / past , of :
psychiatry illness, psychoactive substance use
Assess motivation for consenting to the procedure

15. Thorough mental state examination
If clinical assessment [i.e history and mse yielded no
significant findings]
Structured clinical assessment with structured questionnaire
and scale, for objectivity.
To rule out any psychiatric disorder.

16. Psychiatry disorders of great importance :
Neurocognitive disorders (MMSE, MoCA)
Psychotic disorders (PANSS, BPRS)
Alcohol and psychoactive substance use disorders (ASSIST)
Mood disorders (HAMD, BDI, HADS)
Anxiety disorders (GADS-7)

17. Suspicion of cognitive impairment should indicate thorough
assessment of competency.
Presence of mental disorder is not a contraindication to been
a donor.
So far the potential donor has manifested satisfactory level of
competence.
And he/she is not coerced or induced.
And if he/she was, the level of coercion did not affect
he/she’s autonomy. Or say; he’s autonomy is not coerced.

18. Confirm the identity of the recipient
Assess the competence of the recipient
Assess the understanding of the patient of the pretransplant
and the transplant procedure and the risks involved
Assess for the presence of any current psychiatric illness

19. Assess for the presence of any substance use disorder
including the last intake, past history of efforts to abstain,
lapses and relapses
Assess for the presence of any psychiatric illness in the past:
Severity of symptoms, course of the symptoms, response to
treatment, side effects of medications, adherence to
medications, time to relapse in case the psychotropics are
stopped

20. Assess for personality and coping mechanisms
Assess for family history of any psychiatric disorder
Past history of undergoing surgical procedures: Reaction of
the patient to the hospitalization, adherence to the suggested
recommendations, reaction to prolonged hospital stay,
including the intensive care unit stay

21. Past history of transplant: In case the patient has undergone
transplant in the pastreason for organ failure, time to failure,
psychological reaction of the patient and the family to the
failure
Medication history: Any psychiatric issues while receiving
various medications (for example, past history of steroid
associated psychiatric manifestations)

22. Social support.
Patient’s understanding about the impact of organ transplant:
Restrictions in the movements, dietary restrictions, regular
medication intake, abstinence from the substance (s),
following measures to prevent infection, etc.
Note the findings on the mental status examination including
the level of cognitive functioning.
Apply structured assessments/scales if required

23. This is objectively done using structured scales that
assesses some psychosocial variables.
This is as required by the UNITED NETWORK FOR ORGAN
SHARING.
The scales :
1. Psychosocial Assessment of candidate for transplantation
2. The Transplant Evaluation Rating scale.
3. Stanford Integrated Psychosocial Assessment for
Transplantation.

24. 8 subscale
Each item scored from 0 – 4
0 – Poor candidate
4 – Excellent candidate
The subscales :
Family or support system stability
Family or support system availability

25. Psychopathology / stable personality factors
Risk for psychopathology
Healthy lifestyle / past illness behavior
Drug and alcohol use
Drug use judgment
Compliance with medication and medical advice
Relevant knowledge and receptiveness to education

26. SCORE OUTCOME
4 Excellent Candidate
3 Good Candidate
2 Acceptable candidate with
reservations
1 Borderline candidate.
Candidate can be accepted for
transplant, but with conditions
0 Not fit for transplant

27. DEPRESSION
• Prevalence 0-100% (20-27%); associated with non-compliance, mortality, ↓QOL,
• suicide; Consider impact of sexual dysfunction, cognitive impairment, change
• in lifestyle, somatic sx; self reports less helpful; hard to interpret somatic sx
Cognitive
Disorders
• Dementia: vascular, dialysis dementia (rare), malnutrition
• Delirium: Uremia, anemia, acid-base/electrolyte disturbances, PRES, dialysis
• disequilibrium syndrome, malnutrition/Wernicke’s, subdurals
Anxiety &
PTSD
• 33-45% in some studies; phobias & panic disorder most common; PTSD related
• to dialysis experience; negative impact on QOL

28. Insomnia
• On Dialysis: Insomnia, Restless Leg Syndrome, Obstructive sleep
Apnea, excessive daytime sleepiness, poor sleep quality
Psychological
• Somatic sx; impact of lifestyle/dietary/fluid restrictions; waiting
for transplant;
• impaired self/body image; sexual dysfunction; role changes
• uncertain future; dependence on machine;
maladaptive illness perceptions; loss
• of freedom/control;

29. Cluster A
• Suspiciousness may interfere with decision making, consent
and subsequent treatment adherence.
Cluster B
• May make too much demand on the carerer post transplant predisposing
them to burnout.
• May find it difficult to follow suggestions by transplant team
Cluster C
• Anxious-avoidant may also interfere with consent.
• Patient may show excessive or abnormal dependence on managing team
post transplant which may negatively impact recovery.

30.  Living DONORS : first degree relatives of the recipient. Must show
proof by genetic testing or legal document.
 If first degree relatives not available, then a willing donor not biologically
related can donate.
 This donor and recipient are required to get approval from the
authorized govt committee .
 Where it is ascertained the donation is altruistic and not coerced or
induced.
 The donors competency is evaluated and if competent his autonomy
prevails.

31.  Brain dead donors :
 Transplantation authorizing committee may approve if the donor had been
certify brain dead by neurologist.
 Dead donor :
 The donor had committed to donate his organ after death in a signed
document with at least 2 witnesses while still alive.
 In summary the 2 important ethical consideration is
 Autonomy of both recipient and donor
 Equity and justice as it relates to resource sharing, esp the scarce organ.
 NB: people with IDs are exempted from donation, as its difficult to
ascertain altruism, autonomy and competency.

32.  Reassess patient to affirm competency
 Evaluating for psychological disturbance that may arise just prior
to surgery
 Treating post operative delirium and other post transplant
psychological reaction.
 These include;
 Acute stress reaction , adjustment disorder and depression
 Delirium.
 In treating delirium avoid benzodiazepines.

33. Now the surgery was a success and the patient now on the
ward.
The challenges that may arise of concern to psychiatrist:
Delirium
Treatment refusal and non-adherence to immune-
suppressant medications.
Hostility to managing team.
Management of patients psychotropic medications

34.  REASONS / CAUSES
Sub-acute delirium
Major depression with florid feeling of hopelessness and wish
to die.
Psychosis – with suspiciousness and persecutory delusions
relating to the managing team and medications.
Neurocognitive impairment – leading to forgetting medication
regimen and dosage confusion.

35. Delirium is objectively assessed with delirium rating scale –
revised v-98.
If established; investigate the cause and treat. Low dose
antipsychotics – haloperidol.
Common cause – electrolyte derangement esp potassium.
Depression can be assessed with BDI.
If established antidepressant [sertraline or escitalopram] are
approved in low dose. CBT may be indicated.

36. Mostly due to adjustment and post surgery stress reactions.
May also be due to psychiatry disorders esp ; psychotic
disorders, personality disorders and neurocognitive
disorders.
Other times may be due to communication gap between the
patient and the managing team.
Here, the psychiatrist should engage the patient for his
concerns and also the managing team.
Help to improve communication between them.

37. WHICH DRUGS NEED ATTENTION IN RENAL
TRANSPLANT?
Those with :
Active metabolites
Excreted unchanged by the kidney (lithium, Topiramate,
pregabalin, and Gabapentin.
Renal side-effects / toxicity.

38.  Renal transplantation is a highly complex surgical intervention
for CKD with good success rate and also favorable prognosis.
 It is multidisciplinary, with each coordinating unit is as important
as the whole coordinating / transplant team.
 The role of consultation-liaison psychiatrist can not be over-
emphasized as he is involve in the transplantation process,
from conception of the need to give the patient a new healthy
kidney to the surgery. Post surgery success is also highly
dependent on continuous patient’s review and follow up by the
psychiatrist.

39. Kaplan textbook of psychiatry
Chapter 27.13 ; Psychosomatic medicine / Organ
transplantation and Psychiatry.

40. THANKS FOR LISTENING …