Societal mores also impose limitations. The scarcity of cadaveric organs creates a mismatch between the number of patients who need transplantation and the number who can undergo transplantation. Currently, there are over 93,000 persons on the waiting list for a solid organ transplantation, but only 17,000 transplants were done between January and July of 2006.¹ Some European countries follow the doctrine of “presumed consent” for postmortem donation, but the United States does not. In recent years, transplant centers have attempted to expand the donor pool by harvesting organs from persons who have been declared dead secondary to cardiac arrest (i.e., non–heart-beating donors) in addition to harvesting organs from persons who have been declared dead by neurological criteria (i.e., brain death). In response to this problem, the Institute of Medicine (IOM) created a committee to study ways in which the supply of transplantable organs can be increased. The committee’s report, released in May 2006, recommended the following: vigorous public education about organ donation; provision of more opportunities for registration as an organ donor; easier access to state donor registries; and renewed attention to improvement of organ procurement systems.²

Organ donation by living donors is an increasingly important potential source of transplantable kidneys, livers, and lungs. This is especially true in Japan where there are no defined criteria for determination of brain death and therefore few cadaveric organs are available for harvest.³ In the United States, living donors may be related to the recipient; unrelated but emotionally connected; or anonymous, altruistic strangers. In 2006, 4,252 transplanted kidneys came from deceased donors and 3,751 kidney transplants came from live donors. Parent-to-child liver transplantation (of the left lateral lobe) is an option, as is adult-to-adult transplantation of the right hepatic lobe. Living-lung donation is also an option for carefully selected candidates, but it requires a lower lobe from two different donors for each single potential recipient. The source of the donated organ, that is, from a deceased donor or living donor, does not affect recipient outcome.

Living organ donation raises several ethical questions: for example, “What is true informed consent regarding both short- and long-term risks for the donor?” and “Is the donor’s offer (be it from an emotionally connected or unrelated person) truly voluntary?” It is difficult to determine what level of risk is acceptable for a healthy, altruistic donor.⁴

Several retrospective studies of the long-term medical and psychological sequelae in living organ donors have been conducted. Short-term risks for live kidney donors include the morbidity secondary to surgery and anesthesia (e.g., bleeding and infection) and salary loss during the weeks of recovery. For kidney donors, long-term health risks include the development of microalbuminuria and the potential for renal failure in the remaining kidney. Approximately 0.1% of live kidney donors in the United States have been placed on the waiting list for a kidney transplant.⁵ To date, no deaths have resulted from living lobar lung donation, but donors do lose 15% to 20% of their total lung volume and often experience a decrease in exercise capacity.⁶ Adult-to-adult liver donation carries a significant degree of morbidity, and mortality rate estimates approach 1%. As of March 2003, there have been seven deaths among live partial-liver donors. In addition, two adult donors have required liver transplantation. This procedure is currently under investigation by the National Institute of Health (NIH) and the American College of Transplant Surgeons. Recent literature suggests that right lobectomy in a donor is less risky if the remnant liver volume is greater than 35% of the total liver volume.⁷ The long-term effects of giving up over half of one’s total liver volume are still unknown.

In the United States, the United Network for Organ Sharing (UNOS), a nonprofit organization, endowed by Congress but reporting to the Department of Health and Human Services, regulates the allocation and distribution of donor organs. UNOS has two branches: the Organ Procurement and Transplant Network (OPTN) and the Scientific Registry. The OPTN divides the country into 11 distinct geographical regions, and each region has its own waiting list. The length of time spent on the waiting list can differ among regions. Determination of priority is organ specific. For kidneys, the length of time on the waiting list is the primary determining factor, although full human leukocyte antigen (HLA) compatibility confers priority. Pediatric recipients (those patients age 12 and under) for kidneys and livers take priority over adults. The Lung Allocation Score (LAS) is a calculated score for patients over 12 years of age that represents severity of illness and the likelihood of a successful transplant outcome. That score, in addition to blood type and distance from the hospital where the donor organs are located, determines waiting-list placement for potential lung transplantation recipients. The Model for End-Stage Liver Disease (MELD) is also a calculated score that predicts how urgently a patient over 12 years of age will need a transplant within the next 3 months. The only exception to the MELD system is a special category known as “Status 1.” Status 1 patients have suffered acute hepatic failure and might die within hours or days without a transplant. Tables 58-1 and 58-2 list the LAS and MELD criteria.

Table 58-1 Criteria for Lung Allocation Score (LAS)^* (Age 12 and Older)

Diagnosis
Age
Body mass index (BMI)
Presence of diabetes
New York Heart Classification of functional status
Distance walked in 6 minutes
Forced vital capacity (FVC)
Pulmonary artery pressure (PAP)
Pulmonary capillary wedge pressure (PCWP)
Creatinine
Continuous oxygen requirement
Requirement for ventilatory support

* Adapted from United Network for Organ Sharing (UNOS): www.unos.org.

Table 58-2 Model for End-Stage Liver Disease (MELD)^* (Age 12 and Older)

Bilirubin (BR)
Prothrombin time (international normalized ratio [INR])
Creatinine

Score ranges from 6-40
Represents urgency for need of transplant within 3 months of calculation

* Adapted from United Network for Organ Sharing (UNOS): www.unos.org.

PSYCHIATRIC EVALUATION OF THE TRANSPLANT PATIENT

The psychiatrist or other mental health professional plays an important role in the evaluation of the patient who is approaching a transplant. Initially, the psychiatrist conducts a thorough psychiatric evaluation of the potential recipient to determine suitability for transplant. The psychiatrist must be familiar with medical and surgical problems facing the patient (both before and after transplantation), in order to educate both the patient and the family members about the risks and benefits of transplantation.

The psychiatrist may also act as a liaison between the patient (and family members) and the transplant team. The patient will need support, direction, and clarification of the transplant team’s expectations and concerns. The transplant team may require help interpreting a patient’s behavior. The psychiatrist can direct the team’s attention on ethical dilemmas that may arise, particularly in the area of directed living donation by a related or unrelated donor.

After transplantation, the psychiatrist will be instrumental in guiding the family through the patient’s often difficult and unpredictable postoperative course, as well as in managing the neuropsychiatric sequelae secondary to graft rejection, infection, and immunosuppression.

Pretransplant Psychiatric Evaluation

There are no universally accepted guidelines for the psychiatric evaluation of potential candidates for organ transplanta tion and little reliable or predictive data regarding “suitability for transplantation.” Some centers routinely offer a face-to-face clinical interview with a mental health provider, whereas other centers administer formal psychological testing or offer a structured or semistructured interview. Transplant centers differ in their determination of who is an “acceptable” candidate and what degree of risk they are willing to assume. Common psychosocial and behavioral exclusion criteria include active substance abuse, active psychotic symptoms, suicidal ideation (with intent or plan), dementia, or a felony conviction. Relative contraindications include poor social supports with inability to arrange for pretransplant or posttransplant care, personality disorders that interfere with a working relationship with a transplant team, nonadherence to a medication regimen, and neurocognitive limitations ⁸ (Table 58-3).

Table 58-3 Psychosocial Exclusion Criteria for Lung Transplantation

Absolute
Active substance abuse
Active psychotic symptoms that interfere with function
Suicidal ideation with intent or plan
Dementia

Relative
Poor social supports
Personality disorders that cause interpersonal difficulties with members of the transplant team
Nonadherence to medication regimen or to recommendations for procedures

The pretransplantation psychiatric evaluation should be primarily diagnostic, but it can also be both educational and therapeutic. General objectives of the psychiatric evaluation include screening of potential recipients for the presence of significant Axis I and II diagnoses that might complicate management or interfere with the patient’s ability to comply with the treatment team’s recommendations after transplantation. The diagnosis of a major Axis I disorder (such as major depressive disorder, schizophrenia, or bipolar disorder) should not be a contraindication to transplant if the patient has been stable for an extended period on appropriate medications and has adequate outpatient care and support. Transplantation is possible even in premorbidly cognitively impaired (e.g., mentally retarded) individuals with end-organ failure. Such patients may have family members who will assume legal responsibility for medical decision-making and oversee adherence to posttransplant protocols. The relationship between cognitive dysfunction secondary to end-organ failure and posttransplant function has not been well studied. Personality disorders (listed on Axis II) are more difficult to diagnose in a cross-sectional interview, but, when present, can complicate the patient’s interactions with members of the treatment team. Patients with borderline personality disorder and antisocial personality disorder are particularly problematic given their affective dysregulation, unstable personal relationships, and potential for lack of impulse control. Transplant psychiatrists must carefully assess the individual patient’s history of interpersonal relationships, substance abuse, potential for self-injurious behavior, adherence to treatment recommendations, and interactions with caregivers before making a decision as to whether such a patient can work successfully with the team.

Psychiatrists are often asked to predict a patient’s motivation for transplantation and risk for noncompliance with medication regimens. Life following transplant requires consistent attention to, and compliance with, medical protocols. Posttransplant patients must take as many as 20 medications daily, attend regular clinic appointments, self-monitor blood pressure and blood sugar, maintain good nutrition, and frequently endure uncomfortable procedures and tests. Evaluators may also wish to assess the patient’s resilience and ability to persevere despite setbacks, as well as the availability of social supports that will allow for continued care in the community and easy transportation to and from the hospital.

Frequently the question arises as to whether or not there is a conflict of interest if, as is often the case, the psychiatrist who conducts the initial screening for transplant candidacy is the same psychiatrist who works with the multidisciplinary transplant team to decide who is listed. Again, there are no national guidelines and individual transplant teams must address and resolve this ethical issue. The psychiatrist may choose to handle this situation by informing the patient and the family at the beginning of the evaluation that the information presented will be shared with other members of the team.

The issue of substance abuse in the pretransplant population is particularly important. Most transplant programs require 6 months to 1 year of sustained sobriety before initiation of the transplant evaluation, but selection criteria differ widely. In general, adult liver transplantation programs deem ongoing alcohol or drug use an absolute contraindication to transplantation.⁹ Some programs require patients to participate in a substance abuse counseling program in addition to Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) as a prerequisite for listing if they appear to be at high risk for relapse. Cigarette smoking or any form of tobacco use is an absolute contraindication to lung transplantation. Patients must demonstrate 6 months to 1 year of abstinence from cigarettes and undergo random measurements of urinary cotinine and/or serum carboxyhemoglobin as part of the evaluation process. Liver transplantation programs have less stringent rules about tobacco use in potential recipients.¹⁰ In the end, individual transplant centers must determine what degree of risk they are willing to tolerate.

Pretransplant Psychiatric Disorders

Many psychiatric disorders (such as depression, anxiety, adjustment disorders, and substance abuse) are common in the pretransplant candidate population, regardless of the type of end-stage organ failure. Other disorders are unique to patients who suffer from a particular type of end-organ failure.

Usually, there is a significant wait between the time of listing for transplant and the actual transplant itself. Many patients with heart failure must wait in a hospital’s intensive care unit (ICU) attached to a cardiac monitor or an intraaortic balloon pump (IABP). Years can go by while the patient with lung disease waits at home, sometimes far from a transplant center, becoming gradually sicker and more sedentary. The wait is stressful. A call from a member of the transplant team saying that an organ is available can come at any time or not at all. Sometimes a patient arrives at the hospital only to learn that the quality of the harvested organs is not good enough—the so-called “false start.” Loss of physical strength and productivity (with accompanying role change within the family or community) can lead to adjustment disorders and to depression.

The prevalence of major depression in patients with end-stage renal disease (ESRD) is unknown, but estimates range from 5% to 22%.¹¹ Dialysis, disorders in endocrine function (such as hyperparathyroidism), and chronic anemia can also contribute to depression. The dialysis-disequilibrium syndrome with resultant cerebral edema, as well as uremia itself, can precipitate a change in mental status or even a frank encephalopathy. Patients with renal failure are prone to delirium from the accumulation of toxins (e.g., aluminum) or prescribed medications that are normally cleared through the kidney.

Patients with cardiac failure are also at risk for depression and delirium. These patients can spend long periods in the ICU awaiting transplantation with little contact with the world outside. Delirium can be caused by decreased cerebral blood flow, by multiple small ischemic events, or by IABP treatment.¹² The development of the left ventricular assist device (LVAD) as a bridge to heart transplantation offers a chance for improved quality of life and functional status in this population.

Hepatic failure (e.g., from cirrhosis) is also associated with a high degree of depression and subclinical or frank encephalopathy. Treatment of the mood disorder can result in a more positive outlook and in better self-care. Suicide attempt by toxic ingestion (e.g., of acetaminophen) can result in sudden, drastic hepatic failure and in an immediate need for transplantation. These patients are more difficult to assess because they are often on ventilators. The psychiatric consultant must therefore rely on collateral sources of information about the patient’s premorbid function.

Patients with end-stage lung disease are likely to suffer from anxiety disorders, particularly panic disorder, in addition to adjustment disorders, depression, and delirium. Most patients who are not anxious premorbidly, become anxious in the setting of increasing shortness of breath. They often describe anticipatory anxiety (in the setting of planned exertion), panic attacks, and agoraphobia, despite adequate oxygen supplementation. A decreasing radius of activity leads to both adjustment disorder and, sometimes, major depression, as patients struggle to cope with their relentless and progressive inability to perform even simple activities of daily living (ADLs). Extremely compromised patients with pulmonary failure may become delirious from hypoxia or hypercapnia or from medications (such as intravenous benzodiazepines and narcotics) used to treat their anxiety and pain.

TREATMENT OF THE PRETRANSPLANT PATIENT

Psychiatric care of the pretransplant patient is based on the bio-psycho-social approach. Psychotropic medications are often a mainstay of treatment. Psychotherapeutic intervention can be helpful as well. Enhancement of a network of social support from family members, neighbors, and friends is crucial. Substance abuse counseling may be required for at-risk patients. Transplant centers may offer support groups run by mental health professionals or clinical nurse special-ists that welcome both pretransplant and posttransplant patients.

Psychopharmacological management of the pretransplant patient follows the adage, “start low and go slow.” Choice of medication and dosage depends on the patient’s diagnosis, as well as on the type and degree of organ failure.

The selective serotonin reuptake inhibitors (SSRIs) are usually the first-line treatment of depressive disorders, given their benign side-effect profile and anxiolytic effects. For patients who also struggle to refrain from cigarette smoking, bupropion may be a good choice. Antidepressants are metabolized in the liver, and it is wise to use lower doses for patients with hepatic disease. In addition, there is some evidence to suggest that SSRIs can put patients at increased risk for upper gastrointestinal bleeding and therefore should be used with caution in patients with portal vein hypertension and with cirrhosis.¹³ SSRIs must also be used with caution in patients with resistant bacterial infections who require the antibiotic linezolid (a weak monoamine oxidase inhibitor [MAOI]) because of the risk of serotonin syndrome.¹⁴ With the exception of paroxetine, the SSRIs are well tolerated in patients with ESRD. Likewise, clearance of venlafaxine is reduced in renal failure and the metabolites of bupropion hydrochloride (which are excreted by the kidney) may accumulate and cause seizures in these vulnerable patients.¹¹

Benzodiazepines are the mainstay of anxiety management; nonetheless, some transplant teams are unwilling to use them because of their addictive potential. Shorter-acting agents (such as lorazepam) are preferable because longer-acting agents (such as chlordiazepoxide) have active metabolites that can accumulate (particularly in patients with hepatic failure) and cause toxicity. Low-dose atypical antipsychotics (such as risperidone or olanzapine) can also be helpful in the treatment of anxiety in those patients who cannot tolerate benzodiazepines because of the risk of respiratory depression or abuse. Risperidone and olanzapine can worsen diabetes mellitus, which often occurs in patients with ESRD, and these agents should be used with caution.

Patients who require mood stabilizers (such as lithium, valproic acid, or carbamazepine) can continue to take them before transplantation. Because these medications have a high level of plasma protein-binding, much lower doses are required in patients with ESRD. Lithium is completely eliminated by dialysis; therefore, serum levels should be obtained just before dialysis and a dose should be given just after dialysis.

Psychotherapy can also be an extremely important therapeutic intervention for patients approaching transplant. Even the relatively brief psychiatric pretransplant evaluation can serve as a good opportunity for patients to share their hopes and dreams for the future, as well as their fears of ongoing illness and of death either before or after transplant. Some psychiatrists will refer pretransplant patients to other mental health providers for therapy because they feel that they cannot maintain the patients’ confidentiality and continue to report to other members of the transplant team (personal communication, TransplantPsychiatry@googlegroups.com, 2006). Common issues raised in psychotherapy include grief over loss of productivity, guilt over dependent status, adaptation to changing role within the family and community, sexual dysfunction, cognitive slowing secondary to medication, and conflict between the reluctance to wish anyone ill and the desire for a deceased donor’s organ.

CARE OF THE POSTTRANSPLANT PATIENT

The postoperative period is unpredictable. Some patients recover rapidly and are able to leave the hospital within several weeks. Others can be less fortunate and spend many weeks or even months in the ICU, endure lengthy stays on the transplant unit, and face discharge to a rehabilitation facility. Common sequelae in the immediate postoperative period include delirium, anxiety, and depression. In the long term, patients can manifest continued anxiety and depression, develop problems with body image, fail to adhere to posttransplant medication regimens, and even revert to active substance abuse.

Short-term Care

The hallmark of the early postoperative period for almost all transplant patients is delirium. The etiology can be multifactorial but usually represents a combination of medication effects or withdrawal states, metabolic changes, or infectious processes. Heart transplantation patients are at risk for intraoperative cerebral ischemia that may predispose them to delirium in the very early postoperative period. Lung transplantation patients may become hypoxic. All of the immunosuppressive medications can cause psychotic symptoms (such as paranoid delusions and auditory and visual hallucinations [with or without accompanying delirium]). Cyclosporine and tacrolimus can also cause a periventricular leukoencephalopathy that can manifest as an acute mental status change. High-dose steroids can also precipitate psychotic symptoms (Table 58-4).

Table 58-4 Potential Psychiatric Side Effects of Immunosuppressant Agents

Management of delirium demands a search for the etiology and treatment of the underlying disorder. Cautious use of neuroleptics (such as haloperidol) can offer relief from disabling and frightening symptoms. Haloperidol is usually a first choice because it can easily be given intravenously and it is primarily metabolized by the process of glucuronidation rather than by the cytochrome P-450 isoenzymes. Gabapentin can be helpful in the management of steroid-induced psychosis (if the patient can take oral medication), with dosage adjustment made for renal insufficiency.

Early symptoms of depression (e.g., mood changes, sleep disturbance, irritability, and poor concentration) may be secondary to medications (such as beta-blockers or steroids) or may represent a recurrence of a premorbid mood disorder. Sometimes, new symptoms of depression herald the development of infectious processes (such as cytomegalovirus [CMV] or Mycobacterium avium complex [MAC]). Treatment with the SSRIs can be helpful both for their antidepressant and anxiolytic effects.

Anxiety symptoms in the early postoperative period can result from rapid medication adjustments in benzodiazepines or narcotics, from early immunosuppressive toxicity, or from sepsis. In lung transplant patients, anxiety can accompany acute rejection, pneumonia, or pleural effusion. Treatment strategies include gradual tapering of high-dose intravenous or oral benzodiazepines and/or narcotics followed by maintenance with a low-dose, short-acting benzodiazepine (such as lorazepam). Patients who have a premorbid generalized anxiety or panic disorder that recurs may be managed with a combination of an SSRI and a benzodiazepine.

Long-term Care

Patients undergoing solid organ transplantation are effectively exchanging one set of problems, those related to end-organ failure, for another set: rejection of the allograft; side effects of immunosuppressive medications; and possible progression of an underlying systemic disease. Although transplant teams certainly inform potential recipients of the risks and benefits of the procedure, many of those recipients (and their families) have unrealistic expectations of their rate of recovery and their overall quality of life following transplantation.

Disappointment and dashed hopes can precipitate mood changes. Frequent medical setbacks, understood by the treatment team to be part of the normal course of events, discourage patients and family members. Family members can aggravate the situation by expecting too much, too soon from the transplant recipient. Alternatively, family members or friends who have served as caretakers for many years may be unable to relinquish control, even when the recipient is clearly stronger and better able to care for himself or herself.

Transplant recipients have spent many years of their lives in and around hospitals. After transplant, they gradually move back into their community. Initially, clinic visits can be biweekly. As time goes by, patients come into the hospital less and less often. Many transplant patients get anxious as they transition from the close monitoring provided by the medical and surgical teams to a more independent stance. Phone contact with a member of the team can be helpful in such circumstances. These patients also benefit from regular attendance at a transplantation support group where, under the guidance of a knowledgeable team leader, they can share their experiences with other transplant recipients.

Almost all transplant recipients take steroids, and most have some visible changes in body habitus. Patients exhibit a cushingoid distribution of body fat and can suffer, among other things, hirsutism and easy bruising. Young women patients in particular struggle with these changes in their bodies and may be more likely than other transplant recipients to refuse to take the steroids as prescribed. This level of noncompliance is extremely worrisome because it can result in potentially life-threatening acute or chronic rejection. Prompt psychiatric evaluation of the noncompliant transplant recipient for the presence of an underlying mood or adjustment disorder is essential in order to prevent rejection of the allograft. Ideally, use of supportive psychotherapy might help such patients to understand the potentially self-destructive nature of their actions and to devise strategies that could ensure better adherence.

Substance abuse can also reemerge in the posttransplant period, even though the patient may have had years of sobriety before transplantation. Members of transplant teams have difficulty managing the liver transplant recipient who begins drinking again or the lung transplant recipient who picks up a cigarette not only because of their concern regarding risk to the allograft, but also because of their tremendous disappointment in the patient’s behavior.

PEDIATRIC TRANSPLANTATION

In 2006, pediatric patients accounted for approximately 7% (1,387) of all organ transplants done in the United States (19,719).¹ Fifty percent of those transplants were for children between ages 11 and 17 years.

Pediatric transplant patients differ from adult transplant patients in a number of ways. A parent or appointed legal guardian makes the medicolegal decisions; the children (infants, toddlers, and school-age children) are not responsible for the decision to proceed with transplant or for pretransplant and posttransplant care. Most young patients require transplant because of congenital disorders (such as biliary atresia, cardiac malformations, or pulmonary atresia) and are not held responsible for their disease. A child’s ability to understand the serious nature of his or her illness and the risks and benefits of transplant depends on the child’s age and developmental stage. Many transplant patients have never had the chance to enjoy age-appropriate activities. The severity of their illness might have imposed limitations on school attendance and social interactions and bred a profound dependence on parents and other caregivers.

The primary goal of the psychiatrist who cares for pediatric transplant patients is to help the child maintain a normal developmental trajectory in the face of life-threatening illness. The psychiatrist must also attempt to balance the needs of the child with the needs of parents, siblings, and involved members of the extended family. No one wants to deny a child the chance for a longer life. However, children, like adults, may not be appropriate candidates for transplantation. Sometimes a child is disqualified for transplantation because of the inability of adult caregivers to provide adequate monitoring or to follow the instructions of the treatment team. The psychiatrist who works with young patients with end-organ failure must also be able to understand and to withstand the anger and disappointment of members of the treatment team when faced with such a situation.

Pretransplant Evaluation

As with adults, there are no standardized tools to guide the psychiatric evaluation of children who face organ transplantation. Unlike with adults, however, the order and style of the interview depend on the child’s age and developmental stage. With a prepubertal child, it is appropriate to meet first with the parents or guardians to obtain a coherent, chronological history and to assess the parents’ understanding of the risks and benefits, as well as their history of compliance in obtaining care for their child. With an adolescent, it is helpful to interview the child alone, before speaking with the parents, in order to support his or her independence and wish for autonomy. Again, the psychiatric evaluation should address the following issues: presence of significant Axis I disorders (such as mood disorders, anxiety disorders, and learning disabilities) in the patient or in a caregiver; history of past or current substance abuse; relationship with caregivers; patient’s and family’s motivation for transplant; ability of the caregivers to comply with treatment recommendations (medication regimen and appointments); adequacy of social supports; and assessment of stressors within the family, such as marital discord or financial problems.

Although parents or guardians must be the ones to give “consent” for the surgery and postoperative care, a verbal child must be able to “assent” to the surgery and be willing to participate in treatment. Both parents and children must be fully engaged in preparation for transplant, as well as be able and willing to work together toward a common goal.

The question of the adolescent transplant candidate who abuses substances is particularly important. Adolescents are less likely than adults to have longstanding struggles with substance abuse, but they are often recreational users of alcohol or street drugs, particularly in social situations. The normal adolescent’s need for autonomy and independence often leads to substance use, despite an intellectual appreciation of the grave risks. Some teens with liver disease drink alcohol, and some teens with lung disease smoke cigarettes or marijuana. This behavior usually stops as the illness progresses and the patient becomes more medically compromised. It is difficult to know, however, whether this change reflects a true understanding of the risks, or whether it is simply a short-term response to the fear of jeopardizing their transplant candidacy.

Adolescents often struggle to comply with medication regimens and treatment recommendations before transplant. They are seeking to forge their own identity and to separate themselves from their parents. At the same time, they desperately want to be part of their peer group and look just like everyone else. Often this translates into, for example, a teenager with cystic fibrosis who refuses to take enzymes at lunch in the cafeteria, or go to the nurse for an insulin injection in the middle of the day. Because nonadherence is a major cause of graft rejection in adolescents, a history of this kind of behavior pattern in a pretransplant candidate is worrisome—even though it is consistent with the patient’s age and developmental stage.

Posttransplant Care

The postoperative care of the pediatric transplant patient is similar to that of the adult. Delirium is a common occurrence. The immunosuppressive medications can cause neuropsychiatric symptoms, and high-dose steroids can precipitate psychosis. Cautious use of intravenous haloperidol remains the mainstay of treatment.

Evidence suggests that the extent to which pediatric patients with life-threatening illnesses feel traumatized both by the procedure and by its sequelae correlates with the parents’ sense of stress.¹⁵ Parents’ perception of and reaction to the life-threatening nature of the illness, the surgical procedure, and the risks following the transplant can also affect the child’s risk for posttraumatic stress disorder (PTSD). Pediatric organ transplant recipients experience symptoms of PTSD at rates comparable to those of children with other life-threatening conditions. Interestingly, the likelihood of experiencing such symptoms (e.g., reexperiencing, having flashbacks, or manifesting avoidance) does not seem to be related to the type of organ transplant and is more common in those adolescents with relatively mild complications. This reinforces the “subjective” nature of both the parents’ and patients’ response to the traumatic event.¹⁶

In general, however, pediatric transplant patients do well. They feel better, return to school, and resume many of their activities. They do not demonstrate significant new psychopathology, although premorbid psychiatric illness may recur. Pediatric liver transplantation patients demonstrate significant neuropsychological deficits and developmental delays in intellectual and academic functioning, both before and after transplantation, thought to be related to the effect of chronic liver disease on the developing brain.¹⁷ Standard doses of immunosuppressive medication may also interfere with academic performance in vulnerable children (personal communication, September 2006), but this has not been systematically studied.