The imperative for longitudinal follow-up in renal transplant candidates with psychiatric contraindications to surgery

To the Editor

Kidney transplantation demonstrates superior mortality and morbidity outcomes compared with long-term renal dialysis (Chadban et al., 2020). Post-operative outcomes are generally poorer for renal transplant recipients with uncontrolled psychiatric illnesses, neurodevelopmental disorders, active substance use, insufficient social supports and treatment non-adherence (Chadban et al., 2020). Medical complications associated with high-risk psychosocial factors include infection, hospital re-admission, organ rejection, increased cost of care and reduced life expectancy (Chadban et al., 2020). Preoperative identification and modification of high-risk psychosocial factors is therefore important.

Clinical practice guidelines produced by Kidney Disease Improving Global Outcomes (Chadban et al., 2020), Canadian Society of Transplantation (Knoll et al., 2005) and American Society of Transplantation (Kasiske et al., 2001) recommend that each prospective renal transplant candidate undergoes psychiatric assessment. These clinical guidelines make clear that a history of mental illness is not preclusive, but specify that active psychiatric illness or substance use is a contraindication to renal transplantation.

Three renal transplant candidates with end-stage kidney disease underwent psychiatric assessment at a pre-transplant renal outpatient clinic. Each patient was diagnosed with an active psychiatric illness that contraindicated renal transplantation. The first patient, a 54-year-old male, qualified for a diagnosis of a major depressive episode in the context of marital discord. His depression remitted after 5 months following psychiatric intervention and resolution of active psychosocial stressors. The second patient, a 57-year-old female with a history of major depressive disorder, qualified for a diagnosis of an adjustment disorder with mixed anxiety and depressed mood, in the context of an acute deterioration in her renal function. She declined psychotropic medications but accepted referral to a community psychologist, which led to a restoration of her mood. The third patient, a 27-year-old female, qualified for a diagnosis of an adjustment disorder with anxiety in the context of uncontrolled hypertension, peripheral oedema and associated functional and occupational impairment. Her adjustment disorder resolved following effective pharmacological management of her hypertension along with referral to a clinical psychologist for supportive psychotherapy. With assertive treatment and psychiatric follow-up, all three patients achieved full remission of their active psychiatric conditions and subsequently became eligible for transplantation.

This narrative literature review highlights the risks posed by preoperative psychiatric illness in renal transplant candidates and hence the importance of the pre-transplant psychiatric assessment. The accompanying case series provides examples of psychiatric recovery in renal transplant candidates provided assertive treatment and follow-up. This correspondence seeks to highlight the value of re-assessment following management of active psychiatric conditions in renal transplant candidates whose life-saving surgery was initially contraindicated.