Exploring the State of the Science of Solid Organ Transplantation and Disability Proceedings of a Workshop (2021) / Chapter Skim
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3 Organ Transplantation and Disability in Adults
3 Organ Transplantation and Disability in Adults
Pages 25-42
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From page 25... ...
Following those clinical overviews are summaries of Session 5A presentations and discussion in which speakers focused on physical, cognitive, and psychosocial functioning in adults after organ transplantation. CLINICAL CONDITIONS AND CONSEQUENCES FOR HEALTH AND FUNCTION In the first session, speakers discussed the most common types of solid organ transplants in adults -- kidney, liver, lung, and heart -- highlighting the causes of the end-stage organ disease, methods for estimating posttransplant survival, and statistics on survival and recovery outcomes across various patient groups.
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From page 26... ...
EPTS scores are designed to predict survival rates based on a variety of factors, including age, number of years on dialysis, presence of diabetes, and whether a candidate has had a prior solid organ transplant. Data published by the OPTN from deceased donor adult kidney transplants in 2008–2018 show that patients with an EPTS score of 0–20 percent had a 90 percent survival rate at 10 years after transplantation, whereas those with a score of 81–100 percent had only a 40 percent survival rate (OPTN, 2020a)
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From page 27... ...
Factors such as patient EPTS scores, donor KDPI scores, frailty, and medical contraindications all contribute to whether a kidney transplant will be successful. Liver Transplantation Shari Rogal, transplant hepatologist at the Pittsburgh Veterans Affairs Center for Health Equity Research and Promotion and assistant professor of medicine and transplant surgery at the University of Pittsburgh, began by sharing s tatistics about the prevalence of liver disease among U.S.
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From page 28... ...
While these are still a small percentage of total liver donations, Rogal explained that because donated livers are allocated based on disease severity and the sickest patients typically receive deceased donors' livers, the increase in living donors may indicate that more patients are receiving livers before extensive disease progression. While survival rates for liver transplants are high, functional status remains relatively low 1 year after transplantation.
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From page 29... ...
She pointed out that as the prevalence of liver disease continues to rise in the United States, the number of patients presenting with more severe disease at the time of transplant, coupled with high survival rates, is leading to more people experiencing disability and decreased functional status after transplantation. Lung Transplantation Lung transplants in the United States are also rapidly increasing.
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From page 30... ...
Finally, the small portion of younger transplant recipients often suffers from CF, a lifelong genetic disease that leads to accumulating lung clogging and damage. Lease explained that these patients have the best survival rates, at almost 10 years, likely due to younger age at the time of transplant and lack of comorbidities.
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From page 31... ...
As with all solid organ diseases, survival rates are largely dependent on etiology. Risk factors for mortality at both 1 year and 5 years after transplantation are similar, said Valantine, and include recipient age, body mass index, and kidney function as measured by creatinine levels.
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From page 32... ...
Valantine was optimistic about the median survival rate for heart transplant recipients being 11.6 years, and that as many as three in four are able to maintain good QOL and functional status. However, she added, a small percentage still battle disabling rejection and infection.
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Lease noted that many lung transplant recipients have experienced chronic allograft dysfunction after being exposed to respiratory viruses at work. Kimmel posed a question about gaps in the available data, as transplant registries often lack functional data.
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From page 34... ...
Patel indicated that the "Fried Criteria"2 is the most extensively validated current tool and presented several studies that demonstrated that frail kidney transplant patients are at increased risk of poor outcomes. He noted that frailty is associated with more than 50 percent odds of a 2-week or longer length of hospital stay, almost twice the risk of delayed graft function, and more than twice the risk of mortality (Garonzik-Wang et al., 2012; McAdamsDeMarco et al., 2015, 2017)
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From page 35... ...
NOTE: DGF = delayed graft function; EHR = early hospital readmission; ELD = endstage liver disease; ESRD = end-stage renal disease. SOURCES: Jignesh Patel presentation, March 23, 2021; Exterkate et al., 2016.
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From page 36... ...
. Gupta explained that kidney transplant recipients have a high prevalence of cognitive impairment, regardless of age.
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From page 37... ...
Overall, she concluded that cognitive impairment is highly prevalent among transplant recipients but the field still needs better ways to assess cognition. She pointed out that mechanisms for underlying deficits in cognitive impairment vary among different solid organs, so findings from one organ to another should not be extrapolated.
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(2001) that examined heart transplant recipients and found their first year was particularly stressful, which is expected, she said.
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Depression is a primary example -- it is associated with unhealthy physiologic changes, such as inflammation, lethargy, fatigue, poor sleep, and poor appetite. A meta-analysis showed that among transplant recipients across all organ types, those who had a pre- or posttransplant history of depression had significantly poorer survival rates and increased graft loss (Dew et al., 2015)
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From page 40... ...
But Patel commented that the general changes resulting in frailty are common to all organ transplants, so presumably the improvements found from posttransplant cardiac rehabilitation would be applicable across other solid organs. Lease asked Gupta whether patients can recognize cognitive impairment in themselves or if they must rely on a medical provider to identify and address it.
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From page 41... ...
For example, in kidney disease, reasons could be related to the disease directly, even before transplantation, or cognitive decline could be because of calcineurin inhibitors or other immunosuppressive agents that constrict blood flow, but she said it is unknown whether they affect cerebral flood flow. Additionally, cognitive decline could be related to the surgical process, she said; kidney transplant surgeries are typically shorter and easier on the body, compared to heart or lung transplants, which are longer and cause more hypotension and postoperative delirium.
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From page 42... ...
Gupta replied, noting the differences between "active COVID" and "long COVID," where patients suffer from fatigue and sometimes cognitive impairment for months afterward. Many questions remain about how these symptoms would intersect with post transplant symptoms in a transplant recipient.
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