Transplant eligibility for patients with affective and psychotic disorders: a review of practices and a call for justice

Abstract

BackgroundThe scarcity of human organs requires the transplant community to make difficult allocation decisions. This process begins at individual medical centers, where transplant teams decide which patients to place on the transplant waiting list. Each transplant center utilizes its own listing criteria to determine if a patient is eligible for transplantation. These criteria have historically considered preexisting affective and psychotic disorders to be relative or absolute contraindications to transplantation. While attitudes within the field appear to be moving away from this practice, there is no data to confirm that eligibility criteria have changed.Main bodyThere are no nationwide guidelines detailing the manner in which affective and psychotic disorders should impact transplant eligibility. Individual transplant centers thus form their own transplant eligibility criteria, resulting in significant inter-institution variability. Data from the 1990s indicates that the majority of transplant programs considered certain psychiatric illnesses, such as active schizophrenia, to be absolute contraindications to transplantation. A review of literature reveals that no comprehensive data has been collected on the topic since that time. Furthermore, the limited data available about current practices suggests that psychiatric illness continues to be viewed as a contraindication to transplantation at some transplant centers. In light of this finding, we review psychiatric literature that examines the impact of affective and psychotic disorders on transplant outcomes and conclude that the presence of these disorders is not an accurate predictor of transplant success. We then discuss the requirements of justice as they relate to the creation of a just organ allocation system.ConclusionWe conclude that transplant eligibility criteria that exclude patients with affective and psychotic disorders on the basis of their psychiatric diagnosis alone are unjust. Just listing criteria must incorporate only those factors that have a causative effect on posttransplant morbidity and mortality. Justice also demands that we eliminate current inter-institution practice variations in favor of national transplant eligibility criteria. Given the limited data available about current practices, we call for an updated study investigating the manner in which affect and psychotic disorders impact transplant eligibility determinations.

Mental health and chemical dependency services at US transplant centers

“…Over 15% of transplant centers in the dataset do not offer any MH services and over 60% do not offer any CD services. These services are critical as transplant patients are required to have comprehensive psychosocial assessments for listing and many require ongoing psychosocial support and MH and CD treatment . Additionally, since the publication of a landmark trial that reported favorable outcomes of early liver transplant for severe alcoholic hepatitis, there has been a significant practice change.…”

“…In an effort to mitigate the negative effects of psychosocial issues on outcomes for transplant patients, the organizations that govern transplantation in the United States have developed guidelines. The US Centers for Medicare & Medicaid Services (CMS) require that patients be assessed for substance abuse or behavioral or psychiatric issues before being placed on a transplant waitlist and all transplantation‐related professional organizations recommend comprehensive psychosocial assessment of transplant candidates . The United Network for Organ Sharing (UNOS) states that transplant centers must make mental health and social support services provided by appropriately trained individuals available to transplant patients .…”

“…The US Centers for Medicare & Medicaid Services (CMS) require that patients be assessed for substance abuse or behavioral or psychiatric issues before being placed on a transplant waitlist 27 and all transplantation-related professional organizations recommend comprehensive psychosocial assessment of transplant candidates. 28 The United Network for Organ Sharing (UNOS) states that transplant centers must make mental health and social support services provided by appropriately trained individuals available to transplant patients. 29 However, whether these appropriately trained individuals are uniformly available at transplant centers is an unanswered question.…”

Evolving ethics, policy and reimbursement issues of vascularized composite allotransplantation: Symposium summary

“…Despite the challenges facing VCA, they are not unlike those affecting the solid organ transplant community where insurance coverage has been secured. 26–28 Collaboration, universal data collection using common outcomes measures as well as consensus statements will be essential to obtaining coverage.…”

Klinikinis Atvejis: Paciento, Sergančio Šizofrenija Ir Turinčio Transplantuotą Inkstą, Gydymo Ypatumai

“…Šiuo metu nėra daug mokslinių duomenų, kurie patvirtintų šį pasirinkimą kaip teisingą [8][9][10]. Amerikos transplantacijos asociacijos duomenimis, psichikos liga nėra absoliuti kontraindikacija inkstų transplantacijai, tačiau sergantieji turėtų būti konsultuojami, įvertinama jų sveikatos būklė ir, jei reikia, gydomi [11].…”