Psychosocial factors in selection for liver transplantation
BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7230.263 (Published 29 January 2000) Cite this as: BMJ 2000;320:263All rapid responses
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EDITOR - In examining the selection process for organ
transplantation, Masterson (1) is correct is stating that physicians share
the public’s prejudice against people with mental illness. In a survey of
US transplant centres, active (sic) schizophrenia was an “absolute
contraindication” to transplantation in 92% of cardiac, 67% of liver and
73% of renal units (2). Controlled schizophrenia was relatively
contraindicated in 51%, 65% and 62% respectively. During the first eleven
years of a heart transplantation programme in Montreal, 226 transplants
were completed, but 28 people were denied the procedure on the basis of a
psychiatric diagnosis (3). 7 had continued alcohol or drug abuse, 6
noncompliance and 2 each with multiple suicide attempts, borderline
personality, “unrealistic expectations” or mental retardation .
Interestingly, when the American Psychiatric Association issued a
statement on discrimination against its patients, it focused on
employment, ignoring health service discrimination (4). Orentlicher (5)
had previously pointed out that denial of transplantation based on
schizophrenia or noncompliance violated the Americans with Disabilities
Act.
Masterson (1) also comments on the increased mortality rates (all
causes) from all mental disorders1, but fails to challenge the medical
profession about the contribution we make to these deaths in using
assumptions and value judgements to deny access to treatments such as
transplantation. If an investigation or treatment is medically justified,
then it should be available to everyone, regardless of any psychiatric
label.
Peter Byrne
consultant psychiatrist
Community Mental Health Team, 2-4 Radnor Park Avenue, Kent CT19 5HN.
byrnepr@nascr.net
1.Masterson, G. Psychosocial factors in selection for liver
transplantation. BMJ 2000; 320: 263-4.
2.Levenson, JL, Oldbrisch, ME. Psychosocial evaluation of organ transplant
candidates. Psychosomatics 1993; 34: 314-23.
3.Phipps, L. Psychiatric evaluation and outcomes in candidates for heart
transplantation. Clin Invest Med 1997; 29: 388-95.
4.APA. Position statement on discrimination against persons with previous
psychiatric treatment. Am J Psychiatry 1997; 154:7.
5.Orentlicher, D. Psychosocial assessment of organ transplant candidates
and the Americans with Disabilities Act. Gen Hosp Psychiatry 1996; 18 (6
Suppl): 5-12.
Competing interests: No competing interests
Patients with hepatitis B should not be given low priority in transplantation
EDITOR - The editorial by Masterton1 on psychosocial selection of
patients for liver transplantation was timely and informative. Liver
transplantation is dependent upon public support (for continued organ
donation, and state support in running a transplantation programme). It is
vital that debate takes place concerning patient selection.
It is right
that, in assessing a patient's suitability for a transplant, clinicians
place great emphasis on the prognosis following transplantation. We are
therefore concerned that the author suggested that patients with chronic
hepatitis B virus (HBV) infection have a poor outcome following
transplantation, and should therefore, by implication, be given low
priority for transplantation. In the past HBV recurrence has been
problematic following liver transplantation, and in the setting of
immunosuppression has been associated with fibrosing cholestatic
hepatitis, accelerated cirrhosis, and a 3 year survival of only 44% in
those with re-infection of the graft2. However, the introduction of
hepatitis B immunoglobulin (HBIG)3, and then lamivudine prophylaxis4 has
been shown to markedly reduce HBV replication post transplantation, and
the rate of HBV-related graft loss.
Lamivudine therapy, either alone, or
in combination with HBIG, has been shown to be associated with >97%
patient survival after a median follow-up of more than 2 years5. Longer
term follow up will confirm whether these significantly improved responses
are maintained. The development of lamivudine resistant variants of HBV
remains a challenge, which, it is hoped, may be minimised with the
development of other combinations of antiviral agents.
Nevertheless, the
introduction of new therapies over the last five years has led to a
greater improvement in medium term survival for patients transplanted for
hepatitis B than for any other single indication. Therefore, we do not
believe that patients requiring liver transplantation should be given
low priority on the basis of HBV infection being the cause of their liver
disease.
Reference List
1. Masterton, G. Psychosocial factors in selection for liver
transplantation. BMJ 2000;320:263-264.
2. Samuel D, Muller R, Alexander G, Fassati L, Ducot B, Benhamou JP
et al. Liver transplantation in European patients with the hepatitis B
surface antigen. N.Engl.J.Med. 1993;329:1842-7.
3. McGory RW, Ishitani MB, Oliveira WM, Stevenson WC, McCullough CS,
Dickson RC et al. Improved outcome of orthotopic liver transplantation for
chronic hepatitis B cirrhosis with aggressive passive immunization.
Transplantation 1996;61:1358-64.
4. Grellier L, Mutimer D, Ahmed M, Brown D, Burroughs AK, Rolles K
et al. Lamivudine prophylaxis against reinfection in liver transplantation
for hepatitis B cirrhosis. Lancet 1996;348:1212-5.
5. Nery JR, Weppler D, Rodriguez M, Ruiz P, Schiff ER, Tzakis AG.
Efficacy of lamivudine in controlling hepatitis B virus recurrence after
liver transplantation. Transplantation 1998;65:1615-21.
Dr George Webster BSc MRCP
Clinical Research Fellow
Dr Eleanor Barnes BSc MRCP
Clinical Research Fellow
Dr Andrew Burroughs FRCP
Consultant Physician and Hepatologist
Prof Geoffrey Dusheiko FCP(SA) FRCP FRCP(Ed)
Professor of Medicine
Centre for Hepatology,
Royal Free and University College Medical School,
Royal Free Campus,
Rowland Hill Street,
London
NW3 2PF
Competing interests: No competing interests