Transplantation Psychiatry in General and Malaysian Setting

Index
• Ethics in Transplant
• Organ Donation
• Life Organ Donation
• Autonomy
• Beneficence
• Non-Maleficence
• Justice
• FAQ on Transplant

Malaysian
History
• First renal transplant in
Malaysia 1975 ( living related)
• No detail documentation of
psychiatric assessment
• Expanding scope of renal
transplant in developed countries
• Importance of psychological
evaluation to explore many
concerns
• Regular collaboration with
psychiatry since early 1990s
(HKL)
• Psychiatric evaluation shall be
done on-site (respective

Introduction
• Last 50 year many advancement :
• Solid organ transplantation
• End-stage heart, liver, and
kidney failure, has emerged as
an effective form of treatment,
challenging conventional
ethical principles due to its
radical and controversial
nature.
• Success rates improve :
• Solid organ transplantation
• Controlling the transplant
patient's immune response
• Reducing acute graft loss
• Side effects of
immunosuppressive regimens.
References
1. Organ Transplant Policy Malaysia 2007
2.Guideline of Malaysian Medical Council for Organ Transplant 2006

• Life threatening -- Non-
Life Threatening
• Hand
• Laryngeal
• Knee
• Nerve, and flexor tendon
apparatus transplants.
• Ethical issues increasing :
• Despite improved survival
rates
• Unethical practices such as
organ trafficking, posing
social, moral, and ethical
dilemmas
References

advantage
s of
living
donor
transplan
t ?
References

Will I be paid
for donating
my organ ?
• The Ministry of Health will not pay you
for your organ.
• Similarly, someone who receives your
organ should not pay you in return.
• Any other form of money worth rewards,
or nonfinancial inducements are also
not allowed.
• Reimbursement
• MOH’s hospitals, all charges = FOC
• Unrecorded leave < 42 days during
the recovery period.
References

What are the
risks of
living organ
donation ?
• Most donors recover fully after the surgery
and can-do normal activities within a few
weeks after the surgery.
• Recovery period for liver donation is slightly
longer than kidney donation.
• Organ donation will not change your
lifestyle in a big way.
• There’s no evidence that it will change your
life expectancy
References

Ethics in
Transplant
• Ethical issues in
organ
transplantation can
be broadly
categorized :
• Relating to organ
donation
• Those that relate
to organ
allocation.
References

Ethics : Organ Donation
• Organ donors can be classified as live or
cadaveric.
• LRD : Live donors can come from family members
when they are known as “live related” donors
• ERD : from close friends, relatives or spouses,
when they are known as “emotionally related”
donors (ERD). As mentioned above there are also
• CD: donors who sell body parts, and they are
called “commercial” donors.
References

What are the types of Organ Donation ?
References

Ethical issues in live organ
donation
4 Basic Principles :
Autonomy
Non-maleficence
Beneficence
Justice
Parental organ donation,
Noble Act VS Principle of “Do no Harm”
Live donor transplantation for kidneys is
generally accepted Minimal risk vs
Substantial Benefit .

Respect for
Autonomy
• Altruism
• The principle of autonomy is
crucial for live organ
donation
• Voluntary decisions without any form
of coercion.
• Information
• Mentally incompetent can’t
donate
• Picky Donors choosing
recipients
References

Non-Maleficence
• Organ retrieval surgery for
transplantation:
• Involves physically harming an otherwise
healthy donor
• Posing risks of mortality and both
physical and psychological morbidity.
• Live donor : Improved self-esteem
and satisfaction from helping
loved ones.
• Perform surgery ONLY if Minimal
risk
• A well-trained surgical team with
necessary technical support is
crucial for the success and
References

Who can be a living donor ?
References

• In the context of live
organ donation
• the goal of beneficence
may override that of non
maleficence if the
probability of benefit
greatly outweighs the
risks.
References

Justice
• Allocation of organs
• Failing health VS usefulness to
society, social standing and so
on.
References

Commercialization of
Transplantation
• In the 1980s
• Immunosupressive drugs
• Increase QOL of Transplant pt VS Dialysis
• Increased demand VS Low Supply
• Third-world and developing countries like
India, Pakistan, and the Philippines.
• Poverty-driven desperation, lowered standards
in donor selection, and criminal activities
like organ trafficking and forced donations
from prisoners.
• Regulatory attempts
• Financial Compensation for Cadaveric Organ
Donation
• Rewarding Owner
• Not Universally Accepted

ETHICAL ISSUES IN
CADAVERIC ORGAN
DONATION
• In Western countries,
Cadavers are Primary
source
• Consent for cadaveric
organ donation
• “Opting in“ VS “Opting
Out” / “Presumed
Consent”
• Respect for the Dead Vs
Multi-Organ Retrieval.
• Brain death = FINAL
criterion
References

What are
the type
of
investiga
tions ?
References

CONFIDENTIALITY
References
2.Guideline of Malaysian Medical Council for Organ
Transplant 2006

PROTOCOL FOR
ORGAN
TRANSPLANTATION
• Unrelated living donors NOT
ACCEPTED
• except under special
circumstances
• ONLY after strict evaluation by
the Unrelated Transplant
Approval Committee (UTAC)
References

CONCLUSION
• Ethical concerns have been integral to organ
transplantation from its inception, and they will
remain a significant consideration in the field's
development.
• Doctors in the field must stay informed about
ethical issues to avoid transgressing ethical
principles,
• Anticipated developments in transplantation, such as
the availability of organs or tissues through
genetic engineering or cloning for xeno-
transplantation, will introduce new ethical issues
in medical practice.

Transplantation
Psychiatry - 2
Dr.Sabbitan Balakrishanan
UPM-HPJB

Index
• Rationale of psychiatric assessment
• Roles of psychiatrist/mental health personnel
• Domains of psychiatric evaluation
• Contraindications
• Post op assessment
• Psycho-Pharmacology In Transplantation

Case
Vignette
Mrs.ID (55)(Elder Sister)  Ms.C (40)(Younger Sister)
Illness: ESRF unknown cause x 5 years
•Incidental finding – abnormal kidney function 2014.
•No specific complaints – profile worsened and required dialysis
Illness presentation:
Treatment : Hemodialysis x 1 year
•Regular dialysis 3 times a week
•cannot arrange long holidays
•feels tired in between dialysis
•occasional block during dialysis and failed grafts
Issues with dialysis:

Psychosocial issues:
•stay together
•unemployment
•financial limitation
Motivation and understanding about surgical
procedure:
Donor
•Under private psychiatry – Bipolar Disorder
•underestimate medications – economic reasons
•sensitive skin reactions
•on-going wound infections
•very anxious about possible allergic response
•DASS scores – very severe ( stress/ anxiety)
Recipient
•Not happy to continue with haemodialysis – keen for transplant
surgery
•Not sure about operative procedure – complication
•Inadequate knowledge about post-op care

Significance of
Proper
Assessment
• Surgical success requires
significant behavioral change to
implement healthy lifestyle
• Psychiatrists are typically asked
:
• to predict the likelihood of patient
compliance after transplantation
• assess preoperative and postoperative
psychiatric syndromes
• R/ship dynamics between affected
parties
References
1. Medved, V., Medved, S., & Skočić Hanžek, M. (2019). Transplantation Psychiatry: an Overview. Psychiatria
Danubina, 31(1), 18–25. https://doi.org/10.24869/psyd.2019.182.Guideline of Malaysian Medical Council

Pre-Transplant Assessment
Best environment
for making a
voluntary
informed choice
Donor to feel at
ease to make
decision by non
treating team
Identification
of pre-existing
or potential
psychological
problem is
essential
Liaise with
other team
members
References

Content of assessment
Individual
Assessment
Joint Assessment
- Assess motivation and
expectations
- Determine
understanding of
process
- Explore difficulty
- Freedom of expression
- Establish
opportunity to discuss
about issues
- Background and
response of other
family members
- R/ship before and
since offer
References

Donor Assessment
Donor
• Purpose
• Likely outcome
• Operation
• Complication
• Medication
• Lifestyle modification
• Social support
• Financial implication
• Past psychiatric illness
• Current mental health
issues
• Coercion
• Unresolved conflicts
• Reward/gain
• Substance use
References

Domain of Assessment
Recipient
• Purpose
• Likely outcome
• Operation
• Complication
• Medication ( s/effects)
• Compliance
• Lifestyle modification
• Social support
• Financial implication
• Past psychiatric illness
• Current mental health
issues
• Unresolved conflicts
• Substance use
• Personality challenges
References

Special
Considera
tion
Magnitude and complexity of
process
Deleterious effect of
depression and grief
• Anxiety
• Immunosuppressive drugs on mental
state
• Alcohol and drugs on outcome
• Lifestyle
Effects of :
Prognosis in non-compliance
Need for follow-up
References

Post-Transplant
Doner Recipient
• Wellbeing
• Fear
• Lifestyle
modification
• Self esteem
• Expectation to
recipient
• Wellbeing
• Side effects of
treatment
• Treatment
adherence
• Goal achievement
Effects on Relationships

Liver
Transplant
• 90 % of liver transplantation 2 Liver Cirrhosis.
Abstinence establishment is crucial. 1
• Main Scope of Assessment : Therapeutic cooperation and
risk of recurrence.2
• Recurrence is up to 50%, good psychosocial support
needs to be established. 2
• Patients who Do Not Have Problems in family
interactions and socioeconomic consequences more likely
to Maintain Abstinence. 1
References
1.Hartmann A, Heilmann C, Kaps J, Bejesdorf F, Zah W, Albert W et al.: Body image after heart transplantation compared to mechanical
aortic valve insertion. Int J Psychiatry Clin Pract 2017; 21:277-282 .
2. Iruzubieta P, Crespo J & Fábrega E: Long-term survival after liver transplantation for alcoholic liver disease. World J Gastroenterol
2013; 19:9198–9208

Renal
• The most frequent psychological problems : MDD, Anxiety ,
Poor Adherence 1
• Since renal donation from living donors is very common,
psychiatrist must estimate the donor’s knowledge about
whether the donation is voluntary.
• Impulse decision : triggered by emotions, material
compensation or by family pressure.
• Family dynamics; decision making. 1
• Renal recipients with failing graft :
• Guilt towards the donor, because of organ waste.
• Fear of not having the support for another transplant within
the family. 1
• Psychiatrist Role : Psychological support and counselling ,
reduce emotional tension and other possible psychological
reactions. 1
References
1. Naqui R 2015 : Evaluation of psychiatric issues in renal transplanting setting. Indian J Nephrol 2015;

Lung
• Recognize their STATE:
• Prolonged state of functional
decline, -> leads to
restriction in physical
activity, complex medical
regimens, and the necessity for
nursing care.
• > 47 % = Anxiety & Adjustment d/0
(awaiting lung transplantation ).
3
• 28 % = PD or GAD
References
1. Barbour et al 2006: Psychosocial issues in the assessment and management of patients undergoing lung transplantation. Chest 2006; 129:1367-1374
2. Smith PJ, Blumenthal JA, Trulock EP, Freedland KE, Carney RM, Davis RD et al.: Psychosocial predictors of mortality following lung transplantation. Am Journal of Transplantation 2016; 16:271-277
3. Parikh ND, Ladner D, Abecassis M & Butt Z: Quality of life for donors after living donor liver transplantation: A review of the literature. Liver Transpl 2010; 16:1352-1358

Heart
• 15-25% has Body Image Problem 2
• 47% Anxiety symptoms
• 2% Depression (Due to lifelong
immunosuppressive therapy and
fear of rejection 4 Higher
incidence in pts w
Comorbidities.
• Simultaneous heart and lung
transplantation :
• Moment for rejoicing and
appreciating a new lease on
life, leading to shifts in
priorities, including altruism
and spirituality
References
1. Inspector et al 2004 : Another person's heart: magical and rational thinking in the psychological adaptation to heart transplantation. Isr J Psychiatry Relat Sci 2004; 41:161-73 .
2. Hartmann et al 2017.: Body image after heart transplantation compared to mechanical aortic valve insertion. Int J Psychiatry Clin Pract 2017; 21:277-282
3. Vamos M et al 2010: Organ transplantation and magical thinking. Aust N Z J Psychiatry 2010; 44:883-7
4. Chenyu Yet al., 2013 : Anxiety, depression and associated factors among inpatients waiting for heart transplantation. Shanghai Arch Psychiatry 2013; 25:165-173

Childhood
• The most important factor affecting
a child's ability to cope with
treatment is the response of her
parents to the disease and
treatment. 1
• Parents = HIGH ANXIETY 1
• In an unstable family constellation
: Grand parents
• Disorganized families
• Risk for noncompliance,
(nonregulated medication of a
child organ recipient). Graft
Loss 50 % 1
• Psychiatric interventions are
targeted at parental dysfunction,
communication difficulties, and
provision of support during the
treatment.
References
1. Falkenstein et al., 2004 : Non-compliance in children post-liver transplant. Who are the culprits? Pediatr Transplant 2004; 8:233-6

Childhood
• Parents are under constant
psychological strain.
• Chronic Illness VS Waiting
time ( >10 years)
• 1/3 parents have syx of2 :
• PTSD
• Avoiding behavior,
impulsive thoughts, or
irritability
• Children react to chronic
illness through the defense
mechanism of regression 1:
• Manifests as a fear and
isolation or aggression and
References
1. Muscara et al., 2015: Parent distress reactions following a serious illness or injury in their child: a protocol paper for the take a breath cohort study. BMC Psychiatry 2015; 15:153.
2. Felnhofer A, Kothgassner OD & Klier C: How to prevent depression? Current directions and future challenges in children with chronic medical conditions. Psychiatr Danub 2016;
28:441-451

Psychiatry SE of
Immunosuppressive therapy
Drug Psychological S/E Neurological S/E
Cyclosporine Anxiety, Delirium,
Hallucinations,
Epileptic Attacks,
Tremor, Paresthesia,
Cerebellar Blindness
Somatic side effects
recognized in intensive
care units; Magnetic
resonance scan may show
typical changes
Tacrolimus
Anxiety, Restlessness,
Insomnia, Delirium
-
Mycophenolate Mofetil
Anxiety, Depression,
Somnolence
-
Corticosteroids
Delirium, Euphoria,
Depression, Insomnia,
Irritability
References
1. Taylor et al., 2010 : Use of psychotropics in special patient groups. In: The Maudsley prescribing guidelines, 10th ed. UK: MGB Books, 2010;
335-463

Psycho-Pharm in Pre/Post Transplant
Class Group Consideration & SE References
Antidepress
ant
SSRI First choice, cautious of CYP3A4
inhibition; Fluvoxamine most
potent inhibitor; Fluoxetine,
Paroxetine, Sertraline have
inhibitory properties; Citalopram
has no interaction with CYP3A4
enzyme
Taylor et al., 2010
SNRI Cardiovascular side effects
(hypertension, tachycardia) in
patients with cardiovascular side
effects of immunosuppressive
therapy
Khan et al., 1991
Bupropion May lower epileptogenic threshold;
Use with caution due to
neurotoxicity of immunosuppressive
drugs
Taylor et al., 2010
Mirtazapine (NaSSA) May aggravate dyslipidemia and
increased body weight; Justified
in cachectic patients
Montgomery, 1995
TCA Contraindicated for heart
transplant patients due to
significant anticholinergic and
cardiovascular side effects
MAOI Contraindicated with SSRIs; Can
References
1. Taylor et al., 2010 : Use of psychotropics in special patient groups. In: The Mandsley prescribing guidelines, 10th ed. UK: MGB Books, 2010;
335-463

Anxiolytics
Class Group Consideration &
SE
Reference
Anxiolytics
Lorazepam,
Oxazepam,
Temazepam
Short-term
elimination and
absence of active
metabolites;
Preferred for
patients with
lung
transplantation
Taylor et al.,
2010
Quetiapine
Drug of choice
for patients with
lung
transplantation
and comorbid
anxiety
disorders; Avoid
Taylor et al.,
2010
References
335-463

MS/ AP / PT
Class Group Consideration &
SE
Reference
Mood Stabilizers Lithium
Recommended
single dose of
600 mg daily
after each
dialysis session
for patients on
dialysis
Taylor et al.,
2010
Antipsychotics
Haloperidol,
Quetiapine
Haloperidol or
Quetiapine
advised due to
short half-life
of elimination;
Consider
metabolism in
liver transplant
patients
-
Individual and
Beneficial, with
individual
therapy leading
References
335-463
2. Abbey et al 1998: Group therapy and organ transplantation. Ind J Group Psychother 1998; 48:163-85

• stay together
• unemployment
• financial limitation
procedure:
Donor
• Under private psychiatry – Bipolar Disorder
• underestimate medications – economic reasons
• sensitive skin reactions
• on-going wound infections
• very anxious about possible allergic response
• DASS scores – very severe ( stress/ anxiety)
Recipient
• Not happy to continue with haemodialysis – keen for
transplant surgery
• Not sure about operative procedure – complication
• Inadequate knowledge about post-op care

Case
Vignette
Mr.H (Uncle) ( 55 ) -> Mr.I (Nephew) (25)
Illness: ESRF with hypertension unknown
cause x 7 years
Illness presentation:
• Recurrent body swelling and reduced effort tolerance x
3 months.
Treatment : Haemodialysis x 5 years
Issues with dialysis:
• regular dialysis 3 times a week
• not consistent with schedule
• Poor compliance
• difficult to comply to treatment plan
• poor control of blood pressure ( polypharmacy)

•no suitable parents ( mother has Diabetes Mellitus and
father has fatty liver)
•initial family conflicts more than 10 years –not in
contact since then
•recipient cannot control fluid intake ( active field work
– promoter)
•non supportive employer – difficult to take off
procedure:
•Keen to donate in view of family ties with family support
•Received explanation from nephrology doctors
•very determined to proceed
•no suggestive coercion about decision making
•no documented past history or current psychopathology
Donor
•Not happy to continue with haemodialysis – keen for
transplant surgery
•Not sure about operative procedure – complication
•Not sure about post op care
•Not sure of commitment towards treatment and relationship
with auntie
Recipient

Conclusion
Donation of an organ puts one’s life at risk to help
another – generous and altruistic
Psychological assessment as important integral part
Psychological input to facilitate transplant process
Assessment may enhance donor self esteem and r/ship
May need strong collaboration between treating teams,
mental health assessors and patients

References
• Organ Transplant Policy Malaysia 2007
• Guideline of Malaysian Medical Council for Organ Transplant 2006
• National Genetic Education and Development Centre, National Health Service UK.
• The National Organ Tissue and Cell Transplantation Policy, Ministry of Health Malaysia, 2007.
• WHO Guiding Principles on Human Cell, Tissue and Organ Transplantation, May 2010.
• “Perioperative Mortality and Long Term Survival Following Live Kidney Donation” in Journal of the
American Medical Association, Vol. 303, No. 10, March 10, 2010.
• “Live Donor Liver Transplantation” in Journal of Liver Transplantation, Vol. 12, 2006.
• Taylor et al., 2010 : Use of psychotropics in special patient groups. In: The Maudsley prescribing
guidelines, 10th ed. UK: MGB Books, 2010; 335-463
• Abbey et al 1998: Group therapy and organ transplantation. Ind J Group Psychother 1998; 48:163-85
• Montgomery et al., 1995 : Safety of mirtazapine: a review. Int Clin
Psychopharmacol 1995; 10 (Suppl 4):37-45

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