Saudi Journal of Kidney Diseases and Transplantation

: 2019  |  Volume : 30  |  Issue : 6  |  Page : 1492--1494

Kidney transplantation among patients with severe mental illness

NA Uvais1, Benil Hafeeq2, Feroz Aziz2,  
1 Department of Psychiatry, Iqraa International Hospital and Research Center, Calicut, Kerala, India
2 Department of Nephrology, Iqraa International Hospital and Research Center, Calicut, Kerala, India

Correspondence Address:
N A Uvais
Department of Psychiatry, Iqraa International Hospital and Research Center, Calicut, Kerala

How to cite this article:
Uvais N A, Hafeeq B, Aziz F. Kidney transplantation among patients with severe mental illness.Saudi J Kidney Dis Transpl 2019;30:1492-1494

How to cite this URL:
Uvais N A, Hafeeq B, Aziz F. Kidney transplantation among patients with severe mental illness. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2020 Feb 21 ];30:1492-1494
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Full Text

To the Editor,

People with severe mental illness (SMI), including schizophrenia, bipolar disorder, and other nonorganic psychotic illnesses, are known to have the shorter life expectancy, due to a variety of causes, including physical illnesses such as cardiovascular diseases.[1] Chronic kidney disease (CKD) is an independent risk factor for cardiovascular diseases and is associated with premature mortality. Hence, people with SMI with comorbid CKD have compounded risk of having cardiovascular diseases, resulting in premature mortality.

Literature suggests that people with SMI have a higher prevalence of CKD than general population due to an increased prevalence of several risk factors including smoking and diabetes and the chronic use of lithium. A recent study conducted at UK primary care found that patients with SMI had a greater prevalence of CKD compared to the general population.[2] The study also showed a 6.5-fold increase in odds of CKD in patients with a history of lithium prescription and a 1.5-fold increase in odds of CKD even among patients with no history of lithium exposure and after adjustment for differences in known risk factors for CKD.[2] In addition, the study also found that patients with SMI had an increased prevalence of renal replacement therapy. Considering the higher prevalence and advanced nature of CKD (stage 5) among patients with SMI, kidney transplantation would be a reasonable option to promote survival and to improve quality of life. However, kidney transplantation among patients with SMI is a matter of debate and the impact of a patient’s history of SMI on his/her transplant eligibility differs among transplant centers across the world.

Cahn-Fuller and Parent reviewed the practices of transplant eligibility for patients with SMI recently.[3] The American Society of Transplantation guidelines recommend mental health screening of each candidates for kidney transplantation and states mental illness as a relative contraindication to transplantation, and stress that renal transplant candidates with a history of mental illness should undergo evaluation, counseling, and if necessary, treatment by appropriate mental health professionals before transplantation.[3] However, limited information is available about the specific selection criteria used by transplant centers across the nation. A comprehensive analysis comparing the psychosocial evaluations used by various transplant programs found that active schizophrenia and current suicidal ideation listed as absolute contraindications for at least half of kidney transplant programs studied.[3] Furthermore, a family history of mental illness, controlled schizophrenia, current affective disorder, a history of affective disorder, a recent suicide attempt, history of one or more suicide attempts, poor social support, and medical noncompliance were listed as relative contraindications for transplantation across various kidney transplant programs.[3]

Psychiatric illness is thought to negatively impact transplant outcomes through a number of mechanisms such as poor adherence to medication regimes, poor social support, self-injurious behaviors, hyperprolactinemia, and drug-drug interactions between psychiatric and immunosuppressant medications.[4] However, recent research findings about posttransplant outcomes of patients with SMI indicates that these psychiatric illnesses are not consistently associated with poor outcomes. Literature regarding the impact of depression on post-transplant outcomes suggest that pretransplant depression did not negatively impact post- transplant survival among kidney transplant recipients, but they are at an increased risk of return to dialysis.[5] Another study found that SMI did not impact posttransplant recovery and patients with pretransplant mental illness experienced the same rates of graft rejection and three-year survival as recipients without mental health disorders.[6] Furthermore, mental illness also did not impact medical compliance. A recent retrospective study that examined the impact of preexisting psychotic disorders on transplant outcomes among 10 patients with a history of psychosis, of which four (40%) were kidney transplant, found good adherence with medication regimens following transplantation. Although, patients had psychiatric complications after transplantation including psychotic episodes, it never lead to any adverse medical events.[4] Thus, the current evidence does not support the practice of barring patients with SMI from transplantation on the basis of their psychiatric illness alone. Considering the benefits of kidney transplantation in terms of survival and quality of life, the exclusion of patients with SMI, except in cases where there is a high risk of completing suicide after transplantation or has a long history of medical noncompliance, is unjust. Rather, recent studies should motivate transplant services to consider the risky behaviors associated with psychiatric illness as potentially modifiable risk factors and should actively work in liaison with psychiatric services to reduce poor posttransplant outcome among patients with SMI. There are good models of such team approaches where transplant services utilized psychiatric and social resources resulting in reduction in the incidence of posttransplant morbidity and mortality. Such a model was described by Zimbrean and Emre in 2015 which consists of the following steps; initial social worker evaluation, psychiatric evaluation in patients with history or active psychiatric symptoms or disorders, decision by the psychiatrist regarding fitness for transplant surgery based on the risk assessment of symptoms with regard to risk to self or interference with medical care and history of adherence to various treatments, pretransplant psycho education, and counseling to increase insight into their illness, periodic psychiatric reassessments while the candidates are on the waiting list, psychiatric evaluation as soon as the patient can cooperate with assessment following transplant surgery, a regular schedule of psychiatric follow-up following discharge and the involvement of the local community mental health providers for taking care of recurrence as early as possible in the community.[4]

Conflict of interest: None declared.


1Doherty AM, Gaughran F. The interface of physical and mental health. Soc Psychiatry Psychiatr Epidemiol 2014;49:673-82.
2Iwagami M, Mansfield KE, Hayes JF, et al. Severe mental illness and chronic kidney disease: A cross-sectional study in the United Kingdom. Clin Epidemiol 2018;10:421-9.
3Cahn-Fuller KL, Parent B. Transplant eligibility for patients with affective and psychotic disorders: A review of practices and a call for justice. BMC Med Ethics 2017;18:72.
4Zimbrean P, Emre S. Patients with psychotic disorders in solid-organ transplant. Prog Transplant 2015;25:289-96.
5Rosenberger EM, Dew MA, Crone C, DiMartini AF. Psychiatric disorders as risk factors for adverse medical outcomes after solid organ transplantation. Curr Opin Organ Transplant 2012;17:188-92.
6Evans LD, Stock EM, Zeber JE, et al. Post-transplantation outcomes in veterans with serious mental illness. Transplantation 2015; 99:e57-65.