Psychiatric risk factors predicting post-liver transplant physical and psychiatric complications: a literature review.

627400 research-article2016

APY0010.1177/1039856215627400Australasian PsychiatryEftekar and Pun

Australasian

Psychiatry

Regular Article

Psychiatric risk factors predicting post-liver transplant physical and psychiatric complications: a literature review

Australasian Psychiatry –8 1 © The Royal Australian and New Zealand College of Psychiatrists 2016 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1039856215627400 apy.sagepub.com

Mahdod Eftekar Consultation Liaison Psychiatrist, Consultation Liaison Psychiatry Department, Princess Alexandra hospital, Woolloongabba, QLD, Australia

Paul Pun Consultation Liaison Psychiatrist, Consultation Liaison Psychiatry Department, Princess Alexandra hospital, Woolloongabba, QLD, Australia

Abstract Objectives: The psychiatric assessment of potential liver transplant recipients is becoming increasingly common in clinical practice. In such assessments, the psychiatrist is invited by the transplant team to assess the patient prior to the patient receiving a transplant liver to identify factors that could predict an unsuccessful post-transplant course, whether this is from a psychiatric or physical perspective. This review examined published research from 2000 to 2014 on psychological risk factors predicting post-transplant physical and psychiatric complications. Conclusions: Based on the strength of the evidence available, our review identified four risk factors: mood disorders; social supports; substance misuse; and alcohol dependence. These factors could potentially provide a framework to guide the evaluation and prediction of psychological and physical complications post-liver transplantation. Keywords: psychiatric assessment, transplant psychiatry, liaison psychiatry

T

he number of liver transplants has been increasing steadily in Australia and across the world over the last 20 to 30 years.1 The total number of deceased liver transplants increased from 190 in 2007 to 284 in 2013, a 49% increase over six years.1

the relevant articles were checked, and relevant papers were added to our database. The year 2000 was selected as the starting point of the search, as this review considers factors that are relevant to modern LT, and this area has changed dramatically in the last 15 years.

The limited supply of donor organs and the high cost of liver transplantation (LT) means that potential liver transplant recipients are carefully screened and selected. Psychopathology has been commonly observed in LT candidates, and up to 40% have been found to have comorbid psychiatric disorders.2 A history of alcohol and illicit substance abuse as etiologic factors of liver failure, higher rates of mood, anxiety, and cognitive disorders in patients with liver failure, and social stressors attached to chronic illnesses may all contribute to a higher risk of psychiatric disorders. In this review we wanted to address the evidence that documents which risk factors present in the potential liver transplant recipient can predict poor post-transplant outcomes.

The inclusion criteria were:

Method

Corresponding author: Mahdod Eftekar, Consultation Liaison Psychiatrist, CL Department, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, QLD 4102, Australia. Email: [email protected]

Four electronic bibliographic databases from 2000 to 2014 were searched, including Medline, PsycINFO, PubMed, and Scopes. In addition, the reference lists of

•• Adult sample; •• English language; •• The papers comprised a combination of qualitative and quantitative research, literature reviews, surveys, mixed methods, and time series. Exclusion criteria included child samples and studies that did not specify any pre-transplantation psychiatric risk factors or post-transplantation complications.

1 Downloaded from apy.sagepub.com at Gazi University on March 3, 2016

Australasian Psychiatry

Results

•• History of substance abuse;10,12,35

In total, 538 articles were considered for this review, of which 500 were excluded as they either did not meet the inclusion criteria or met the exclusion criteria, leaving 38 papers for qualitative synthesis (Figure 1). These papers included 28 study papers and 10 review papers (Tables 1 and 2).

•• Previous failed rehabilitation;15,36

Alcohol One of the important issues in LT assessment is the likelihood of relapse into alcohol use post-transplantation. Many studies have been performed around this question, but under-reporting has made it difficult to rely on the results of the studies in this area. Some of the risk factors identified with alcohol relapse post-transplant have a good evidence base, such as: •• Social supports, marital status;11,35 •• Family history of alcoholism;19,34,35,38 •• Less than six months of abstinence from alcohol prior to transplantation;11,12 •• Alcohol dependence diagnosis;19,38

•• Pre-LT depressive disorders.12,37 There are controversies in the literature regarding the history of alcohol abuse. In a 1999 British study, researchers compared post-transplant psychiatric and quality of life outcomes in alcoholic and non-alcoholic groups in London. They found no differences between the two groups with regard to the median scores on the measures used.39 However, the authors acknowledged that their sample may not have been large enough to detect real differences between the groups.39

Substance abuse Substance abuse is a major concern in LT. There is a strong evidence base composed of meta-analyses, systematic reviews, and cohort studies, indicating that a preoperative presence of illicit substance misuse is associated with non-adherence to substance-use restrictions post-transplant, as well as a poor prognosis of the liver transplant.1,13,15,16,26,32

Figure 1. Summary of the study selection and exclusion. 2 Downloaded from apy.sagepub.com at Gazi University on March 3, 2016

Eftekar and Pun

Table 1. Characteristics of the studies included in this review Author

Study design

Participants

Instruments

Maldonado et al.3

Literature review, cohort study

102

SIPAT

Schneekloth et al.4

Retrospective cohort study

143

Rothenhäusler et al.5

Cross-sectional study

75

Calia et al.6

Prospective cohort 44 study

Martins et al.7


46

Harper et al.8

Exploratory study

112

Nickels et al.9


27

Day et al.10


80

Weinrieb et al.11

Randomized controlled design

69

DiMartini et al.12


Results

Previous suicide attempts, poor adherence to medical recommendations, past history of substance abuse, and depression were associated with shortened post-transplant survival. PAS, BDI-FS, BSI, The non-cholangiocarcinoma group might SAAST demonstrate more depression, emotional distress, and somatization given the prolonged course of health decline and transplant wait-list time. SKT, HAMD, PTSS-10, OLT recipients fulfilling the DSM-III-R SSS, HRQOL criteria for PTSD, either comorbid with MDD or not, manifested the most impaired mental and physical health status. CBA-2.0 Fear of repulsive animals and neuroticism were associated with acute and chronic graft rejection, respectively. BDI A high incidence of depression was found in liver transplantation candidates. The ability to discriminate between the positive and negative aspects of the transplant, real expectations, coherent future plans, and the ability to react to stress and to cope with frustration seem to be related to good post-transplant outcome. BDI, PAIS, MBMD, A history of illicit substance abuse is HSQ, MMSE associated with a greater non-compliance risk. Greater perceived psychosocial support is associated with higher abstinence rate from alcohol. Variables checklist In patients with histories of substance abuse, there were no differences regarding survival between patients in the group that relapsed and patients in the group that did not relapse. Variables checklist 39% of patients met the DSM-IV criteria for a lifetime diagnosis of either alcohol abuse (14%) or dependence (25%). MMSE, hepatic Patients are more likely to admit to drinking encephalopathy rating if they do not risk permanent removal from scale the waiting list. ATLFB Substance use was a strong predictor of post-transplant alcohol use. Each additional month of pre-transplant sobriety reduced the risk of drinking post-transplant by 33%. Being married provided protection against binge alcohol use. A pre-transplant depressive disorder was associated with greater risk to drink post-transplant.

(Continued)



Table 1. (Continued) Author

Study design

DiMartini et al.13

Participants

Instruments

Results


MELD

DiMartini et al.14

Prospective Cohort 36 Study

SCID

Day et al.15

Prospective cohort 155

A mixture of semistructured research interviews and self-completion questionnaires

Weinrieb et al.16


Variables checklist

DiMartini et al.17


BDI

Norris et al.18


HAM-D

Bourgeois et al.19


SCID-CV

Noma et al.20


QOL, STAI, BDI, PACT

Corruble et al.21


BDI

Corruble et al.22


TOQ

Pre-transplant characteristics of the alcohol history (alcohol dependence, short length of sobriety, family history of alcoholism, and the use of other substances) identified drinkers compared to abstainers. Additionally, the length of sobriety is the most powerful predictor of return to alcohol. Post-transplant alcohol use was associated with prior non-alcohol substance use, family history of alcoholism, and prior alcohol rehabilitation experience, but not with a prior psychiatric history or less than six months of pre-transplant sobriety. A diagnosis of alcohol-related problems was not a predictor of overall severity of psychological symptoms. Liver disease severity (Child-Pugh score) and previous psychiatric diagnoses were independent significant predictors of depressive disorders. Patients receiving MMT had worse posttransplant medical complications and a diminished rate of survival. Younger, unmarried patients with HCV and pre-transplant histories of substance use and depression were more likely to experience post-transplant depression. Patients with more severe HAM-D depression scores were more likely to be female, young, and have alcoholic or cholestatic components of liver disease. Hepatitis C patients who suffer mental and physical impairment can tolerate and complete rigorous interferon/ribavirin treatment protocols. The length of wait for LDLT, the recipients’ risk for mental illness, and the recipients’ depressive state just before LDLT were extracted as predictors of recipients’ posttransplant psychological states. Report of depressive symptoms on the waiting list predicted a decreased risk of graft failure and mortality posttransplantation. Depressive symptoms are associated with psychological rejection.

39

53

(Continued)


Eftekar and Pun

Table 1. (Continued) Author

Study design

Participants

Instruments

Results

Huffman et al.23

Case study

–

–

Blanch et al.24

Cross-sectional

126

PAIS

Baranyi et al.25


123

TERS

Pantiga et al.26

Case-control study 150

TMT

Sorrell et al.27

Cross-sectional

RBANS

Telles-Correia et al.28


MAQ

Holzner et al.29


55

SIP

Mamah et al.30

Case study

–

–

Those with a severe personality disorder scored higher on measures of emotional impairment, but they were not associated with a higher rate of return to alcohol during the follow-up period. Older age at transplant was found to be associated with poorer post-transplant outcome. Candidates with low levels of adjustment in psychosocial functioning before transplantation are at higher risk of developing overall mental distress symptomatology after transplantation. Subclinical hepatic encephalopathy is very frequent in patients with hepatic cirrhosis. Subcortical cognitive impairments can be relatively subtle and can easily escape clinical attention because language and memory are relatively preserved. The group with liver disease due to alcohol had the highest rates of impairments on neuropsychological testing. Adherence among liver transplant candidates positively correlated with personality traits (agreeableness, which is related to a cooperative rather than a suspicious, antagonistic attitude toward others), coping strategies (planning), and social support. Patients whose preoperative optimistic expectations remained unfulfilled claimed to have a markedly lower quality of life. Mania may occur by chance association during drug treatment, particularly in patients with pre-existing bipolar disorder.

300

ATLFB: Alcohol-Timeline Follow-back questionnaire; BDI-FS: Beck depression inventory-fast screen; CBA: Cognitive behavioral assessment; DSM: Diagnostic and Statistical Manual of Mental Disorders; HAMD: Hamilton depression rating scale; HSQ: Humor style questionnaire; HCV: Hepatitis C virus; HRQOL: Health related quality of life; LDLT: Live donor liver transplant; MDD: Major depressive disorder; MBMD: The Millon behavioral medicine diagnostic; MELD: Model for End-stage Liver Disease; MMT: Methadone maintenance treatment; MMSE: Mini-mental state examination; MAQ: Measure of attachment qualities; PAS: Panic and agoraphobia scale; PTSS 10: Post traumatic stress scale 10; PTSD: Post traumatic stress disorder; PAIS: The psychosocial adjustment to illness scale; PACT: Rating scales for the psychosocial evaluation of organ transplant candidates; QOL: Quality of life; RBANS: The Repeatable Battery for the Assessment of Neuropsychological Status; SIPAT: The Stanford Integrated Psychosocial Assessment for Transplantation; SAAST: Self-Administered Alcoholism Screening Test; SKT: Short cognitive performance test; SSS: Sensation seeking scale; SCID: The Structured Clinical Interview for DSM-IV Axis I Disorders; SCID-CV: The Structured Clinical Interview for DSM-IV Axis I Disorders- clinical version; STAI: State-Trait Anxiety Inventory; SIP: Sickness impact profile; TOQ: The transplant organ questionnaire; TERS: Transplant evaluation rating scale; TMT: Train Making Test.



Table 2. Review papers reviewed for this study Author

Study design

Size

Results

Jowsey et al.2

Review article

–

Crone et al.31

Review article

Potts32

Review article

–

Addolorato33

–

Dew et al.34

Commentary on previous paper Meta-analysis

Patients with a history of pre-transplant psychiatric problems, poor social support, or patients who used coping strategies involving avoidance have been found to be at risk for psychiatric disorders posttransplantation. Social support and no substance abuse are positive predictors of sobriety. Minimal hepatic encephalopathy has been found in cirrhotic patients with normal clinical and neurological exams but impairment on neuropsychological testing. Intravenous drug misusers have intrinsically poor prognoses. The outcomes are best when the transplant candidates understand all of the requirements, have the personal resilience (and social support) necessary to cope with them, and have the ability and willingness to comply. There is a low risk of relapse in alcoholic patients.

DiMartini et al.35

Review article

–

Krahn and DiMartini36

Review article

–

Dew et al.37

Meta-analysis

147

McCallum and Masterton38

Systematic review

–

54 studies

Poorer social support, a family history of alcohol abuse/dependence, and a pre-transplantation duration of abstinence of six months or less each mildly increased the risk for post-transplantation relapse. The patient demographic characteristics, pre-transplantation psychiatric and illicit drug history, and pre-transplantation participation in rehabilitation bore little to no association with relapse. Chronicity of alcohol addiction, family history of alcohol dependence, rehabilitation experiences, personality disorders, affective disorders, and stable social supports may be fruitful areas to explore. Good social support is predictive of a lower risk for non-adherence. Methadone treatment is not a risk factor for non-adherence. The candidate’s ability to work with the transplant team, patterns of non-adherence, and quality of social support should all be considered in personality disorders. Pre-transplant substance-use history strongly predicted non-adherence to the substance-use restrictions post-transplant. Social stability, no alcohol problems among first-degree relatives, older age, no repeated alcohol treatment failures, good compliance with medical care, no current polydrug misuse, and no co-existing severe mental disorder are associated with alcohol abstinence. Duration of preoperative abstinence was a poor predictor of abstinence.

Depression There is a strong association in the literature between depression and post-liver transplant complications. Younger, unmarried patients, patients with poor social support, and patients with hepatitis C and pre-LT histories of alcohol/substance use and depression were more likely to experience post-transplant problematic trajectories of depressive symptoms.18–21 Post-transplant complications of pre-transplant depression include:

•• Increased morbidity/mortality post LT:22,28,29 Depression is significantly associated with shortened post-transplant survival and greater risk for post-transplant infection.29 •• Psychological rejection:30 Psychological rejection refers to the refusal of the new organ,6 with the patient feeling that the transplant is foreign and does not belong to them.30 •• Recipient’s post-transplant psychological distress.23


Eftekar and Pun

Personality disorders There is a lack of research literature on the complications of LT in patients with personality disorders. Our knowledge in this area is sketchy and is mainly based on anecdotal evidence, case studies, and studies that did not specifically target LT. Maladaptive personality traits or disorders and somatization may contribute to poor treatment or medication adherence and engagement with the treatment team.4 Approximately one transplanted patient out of two undergoes considerable emotional stress during the transplant process.22 Therefore, it is quite rational that patients with poor coping strategies would not do very well. Psychosocial adjustment depends on personality traits, such as coping strategies or a personal locus of control.24 Those with low levels of adjustment in psychosocial functioning before transplantation are at a higher risk of developing overall mental distress symptomatology after transplantation.25

Cognitive disorders It is not very difficult to diagnose severe cases of liver encephalopathy; however, mild cases can be quite challenging. Some studies use the term “minimal hepatic encephalopathy” (mHE) to refer to subclinical cases. Depending on the diagnostic criteria and approach utilized, the prevalence of mHE has been reported to range

from 30% to 84%.27 The effects of encephalopathy, especially mHE, on quality of life and outcomes in patients prior to and following transplant are significant as evidence is accumulating that suggests the persistence of mHE following LT.33

Discussion Table 3 shows the psychiatric risk factors that the authors identified through this literature review. These risk factors have different levels of evidence, as outlined in the table. We believe that any pre-transplant psychiatric assessment should include the above items, especially the few risk factors that have a good level of evidence, including: (i) history of depression; (ii) history of substance abuse; (iii) risk of alcohol dependence and family history of alcohol dependence; and (iv) level of social support. Several literature reviews have demonstrated that there is a relative absence of evidence-based guidelines for pretransplant psychosocial and behavioral screening,27 while better screening of some symptoms may help us to better predict some psychiatric and medical complications after the liver transplant. We believe that patients with the aforementioned risk factors would benefit from a psychiatric assessment to address the possible impact of those risk factors on the transplant process. However, it is very important to recognize that Table 3 only outlines the risk factors that have been substantiated in

Table 3. Areas that should receive greater focus in the psychiatric assessment of liver transplant patients Variable

Evidence

History of illicit substance abuse

1 meta-analysis, 4 cohort studies, 2 systematic reviews, 1 exploratory study, 1 review article 1 meta-analysis, 2 cohort studies, 1 systematic review, 1 review article 5 cohort studies, 1 systematic review 1 meta-analysis, 2 cohort studies, 1 systematic review, 1 exploratory study, 3 review articles 1 cohort study, 1 cross-sectional study, 1 review article 1 meta-analysis, 2 cohort studies 1 cohort study, 1 systematic review, 1 review article 2 cohort studies, 2 review articles 2 cross-sectional studies 1 cohort study, 1 review article 1 cohort study, 1 review article 1 cohort study 1 systematic review 1 systematic review 1 case study

Family history of alcohol dependency History of depressive illnesses Level of social supports Cognitive deficits Length of alcohol abstinence History of previous failed alcohol/substance rehabilitations Poor coping mechanisms in the past Realistic expectations from transplant History of alcohol abuse Antagonistic personality Length of wait for transplant History of poor adherence Previous suicide attempts History of mania



studies over the last 15 years. It does not rule out any other parts of an assessment that an experienced psychiatrist finds vital to assess in a particular patient. It is important to consider that due to the sparse literature, none of the mentioned risk factors are a contraindication of receiving a liver transplant by itself. These factors should only be used as a guide, because there will always be individual factors that cannot be covered by population-based psychiatric evidence. Further research needs to be acquired in terms of these gaps in the literature, and there needs to be more weighing of individual risk factors in a comprehensive riskmeasurement battery.

17. DiMartini A, Dew MA, Chaiffetz D, et al. Early trajectories of depressive symptoms after liver transplantation for alcoholic liver disease predicts long-term survival. Am J Transplant 2011; 11: 1292. 18. Norris ER, Smallwood GA, Connor K, et al. Prevalence of depressive symptoms in patients being evaluated for liver transplantation. Transplant Proc 2002; 34: 3286. 19. Bourgeois JA, Canning R, Suggett K, et al. Depressive symptoms and physical/mental functioning with interferon/ribavirin treatment of posttransplant recurrent hepatitis C. Psychosomatics 2006; 47(3): 255. 20. Noma S, Hayashi A, Uehara M, et al. Comparison between psychosocial long-term outcomes of recipients and donors after adult-to-adult living donor liver transplantation. Clin Transplant 2011; 25: 715. 21. Corruble E, Barry C, Varescon I, et al. Report of depressive symptoms on waiting list and mortality after liver and kidney transplantation: A prospective cohort study. BMC Psychiatry 2011; 11: 7. 22. Corruble E, Barry C, Varescon I, et al. The Transplanted Organ Questionnaire: A validation study. J Psychosom Res 2012; 73: 323.

Disclosure The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.

23. Huffman JC, Popkin MK and Stern TA. Psychiatric considerations in the patient receiving organ transplantation: A clinical case conference. Gen Hosp Psychiatry 2003; 25: 486.

References

24. Blanch J, Sureda B, Flaviá M, et al. Psychosocial adjustment to orthotopic liver transplantation in 266 recipients. Liver Transplant 2004; 10(2): 228–233.

1. ANZLT Registry. Report, Princess Alexandra Hospital, Australia, 2015. 2. Jowsey SG, Taylor ML, Schneekloth TD, et al. Psychosocial challenges in transplantation. J Psychiatr Pract 2001; 7: 405–408. 3. Maldonado JR, Dubois HC, David EE, et al. The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT): A new tool for the psychosocial evaluation of pretransplant candidates. Psychosomatics 2012; 53(2): 3. 4. Schneekloth TD, Jowsey SG, Biernacka JM, et al. Pretransplant psychiatric and substance use comorbidity in patients with cholangiocarcinoma who received a liver transplant. Psychosomatics 2012; 53: 17. 5. Rothenhäusler HB, Ehrentraut S, Kapfhammer HP, et al. Psychiatric and psychosocial outcome of orthotopic liver transplantation. Psychother Psychosom 2002; 71: 286. 6. Calia R, Lai C, Aceto P, et al. Psychological risk factors for graft rejection among liver transplant recipients. Transplant Proc 2011; 43: 1123–1127. 7. Martins PD, Sankarankutty AK, Silva Ode C, et al. Psychosocial distress in patients listed for liver transplantation. Acta Cir Bras 2006; 21(1): 40 8. Harper RG, Wager J and Chacko RC. Psychosocial factors in noncompliance during liver transplant selection. J Clin Psychol Med Settings 2010; 17: 71. 9. Nickels M, Jain A, Sharma R, et al. Polysubstance abuse in liver transplant patients and its impact on survival outcome. Exp Clin Transplant 2007; 5: 684.

25. Baranyi A, Krauseneck T and Rothenhäusler HB. Overall mental distress and healthrelated quality of life after solid-organ transplantation: Results from a retrospective follow-up study. Health Qual Life Outcomes 2013; 8(11): 7. 26. Pantiga C, Rodrigo LR, Cuesta M, et al. Cognitive deficits in patients with hepatic cirrhosis and in liver transplant recipients. J Neuropsychiatry Clin N eurosci 2003; 15(1): 84. 27. Sorrell JH, Zolnikov BJ, Sharma A, et al. Cognitive impairment in people diagnosed with end-stage liver disease evaluated for liver transplantation. Psychiatry Clin Neurosci 2006; 60: 180. 28. Telles-Correia D, Barbosa A, Mega I, et al. Adherence correlates in liver transplant candidates. Transplant Proc 2009; 41(5): 1731. 29. Holzner B, Kemmler G, Kopp M, et al. Preoperative expectations and postoperative quality of life in liver transplant survivors. Arch Phys Med Rehabil 2001; 82(1): 73. 30. Mamah D, Hong BA, Chapman WC. Liver transplantation in a patient with undiagnosed bipolar disorder. Transplant Proc 2004; 36(9): 2718. 31. Crone CC, Gabriel GM and DiMartini A. An overview of psychiatric issues in liver disease for the consultation-liaison psychiatrist. Psychosomatics 2006; 47: 196. 32. Potts SG. Transplant psychiatry. J R Coll Physicians Edinb 2009; 39: 332.

10. Day E, Best D, Sweeting R, et al. Detecting lifetime alcohol problems in individuals referred for liver transplantation for nonalcoholic liver failure. Liver Transplant 2008; 14: 1612.

33. Addolorato G. Alcoholic hepatitis and liver transplantation: The good news and what to do about it. Front Psychiatry 2012; 10(2): 1.

11. Weinrieb RM, Van Horn DH, Lynch KG, et al. A randomized, controlled study of treatment for alcohol dependence in patients awaiting liver transplantation. Liver Transplant 2011; 17: 540.

34. Dew MA, DiMartini AF, Steel J, et al. Meta-analysis of risk for relapse to substance use after transplantation of the liver or other solid organs. Liver Transplant 2008; 1: 168.

12. DiMartini A, Day N, Dew MA, et al. Alcohol consumption patterns and predictors of use fol lowing liver transplantation for alcoholic liver disease. Liver Transplant 2006; 12: 819. 13. DiMartini A, Dew MA, Day N, et al. Trajectories of alcohol consumption following liver transplantation. Am J Transplant 2010; 10: 2309.

35. DiMartini A, Weinrieb R and Fireman M. Liver transplantation in patients with alcohol and other substance use disorders. Psychiatr Clin 2002; 25: 200. 36. Krahn LE and DiMartini A. Psychiatric and psychosocial aspects of liver transplantation. Liver Transplant 2005; 11: 1161.

14. DiMartini A, Day N, Dew MA, et al. Alcohol use following liver transplantation: A comparison of follow-up methods. Psychosomatics 2001; 42: 59.

37. Dew MA, DiMartini AF, De Vito Dabbs A, et al. Rates and risk factors for nonadherence to the medical regimen after adult solid organ transplantation. Transplantation 2007; 83: 866.

15. Day E, Best D, Sweeting R, et al. Predictors of psychological morbidity in liver transplant assessment candidates: Is alcohol abuse or dependence a factor? Transpl Int 2009; 22: 607.

38. McCallum S and Masterton G. Liver transplantation for alcoholic liver disease: A systematic review of psychosocial selection criteria. Alcohol Alcohol 2006; 41: 362.

16. Weinrieb RM, Barnett R, Lynch KG, et al. A matched comparison study of medical and psychiatric complications and anesthesia and analgesia requirements in methadonemaintained liver transplant recipients. Liver Transpl 2004; 10(1): 103–104.

39. Gledhill J, Burroughs A, Rolles K, et al. Psychiatric and social outcome following liver transplantation for alcoholic liver disease: A controlled study. J Psychosom Res 1999; 46: 359–368.


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