| Abstract|| |
We report a case of a 41-year-old man suffering from paranoid schizophrenia. The patient has been consulting in our psychiatric hospital since he was 29 years old. Eight years later, he developed kidney failure and required peritoneal dialysis. After more than two years, the nephrology team indicated a renal transplantation and his brother suggested giving his kidney. There were no obstacles for transplantation in the immune and histological compatibilities; the psychiatric staff decided to check the patient's compliance with medication. The patient was compliant to all his medications and to the salt-free diet after the transplant operation. Few weeks later, he developed steroid-induced diabetes. Through the last two years, he had psychotic exacerbations with major anxiety and fear of losing the transplant. These relapses were managed by increasing doses of antipsychotics without need for hospitalization. At the present time, three years after transplantation, the nephrologists are decreasing the immunosuppressive agents and the steroids. The renal function is optimum and the diabetes is stabilized. This case exemplifies the potential for schizophrenic patients to undergo renal transplantation and to comply with follow-up medical care through a close cooperation between the patient's family, the psychiatric staff and the nephrology team.
|How to cite this article:|
Bouhlel S. Can patients with schizophrenia undergo renal transplantation with success?. Saudi J Kidney Dis Transpl 2014;25:605-9
| Introduction|| |
Schizophrenia is a severe psychiatric disorder that affects about 1% of the general population. If we consider that the incidence of this illness is not affected by demographic factors, we can presume that there are more than 60 million schizophrenia patients worldwide.  This mental disease usually starts between the ages of 15 and 35 years and causes many problems by affecting almost all brain functions, including perceptions, cognitive functions and emotions.  Suicidal behavior is prevalent in patients suffering from this disorder as between 20% and 42% of patients attempt suicide and 10-15% are successful, which is approximately 20-times higher than in the general population.  Antipsychotics are a cornerstone in treating affected people. Their effectiveness is obvious in acute and maintenance treatment. However, drug compliance ratios are generally low because of the drugs severe side-effects and low awareness of illness.  For all these reasons, patients with schizophrenia are usually considered incompatible with successful organ transplants. They are very frequently excluded from the programs in many heart, liver and renal transplantation centers.  Some of them consider schizophrenia, even stabilized, as an absolute contraindication to organ transplantation. , The main advanced reasons were the lack of careful adherence to immunosuppressive agents and to the required diet, which can result in implant rejection and to psychosis exacerbation. However, these reasons cannot be ethically easily accepted as such situations can be considered as social stigma.
Nowadays, these attitudes are changing. Some authors, in developed countries, published cases of successful renal, liver and heart transplantations in patients suffering from schizophrenia with a good compliance to medicines. ,,,,
The aim of this report was to discuss the main required factors to allow renal transplantation in patients with schizophrenia.
| Case Report|| |
The patient was a 41-year-old unmarried man. He was the junior of four children and lived with his parents and brother. His two sisters were married and were living in their own homes. He had a high school education level with a professional training in welding. He worked steadily during 12 years as a worker in a welding company.
His mother had diabetes mellitus and hypertension, and he had an uncle and a cousin with chronic psychotic disorders.
He had a history of alcoholic, cannabis and clonazepam consumption since the age of 18 years. He stopped this consumption 11 years later, when his psychiatric disorders emerged. He also used to smoke 20-40 cigarettes per day. He had no prior record of arrests or incarcerations.
The beginning of his psychiatric symptoms started at the age of 29 years with depersonalization experiences, ideas of body transformations and foul olfactory hallucinations, leading him to wash himself several times a day to get rid of the smells. Two months later, he expressed delusions of persecution against his family members. His first psychiatric hospitalization followed a suicide attempt. This attempt was a response to hallucinatory voices commanding him to end his life as the persecutor would not leave him alone. The patient was treated with conventional antipsychotics, which made his delusions and hallucinations resolve completely.
After this first episode, the patient made four psychotic relapses following discontinuation of antipsychotics. The diagnosis was paranoid schizophrenia with episodic evolution and residual negative symptoms between episodes. At the age of 36 years, the patient was treated for bilateral renal calculi. The left renal calculi were treated by extracorporeal lithotripsy, while the right stones were treated surgically. Four years later, he developed asthenia and headaches. The clinical examination revealed high blood pressure (200/130 mm Hg). Renal ultrasound showed small, not well-differentiated kidneys. Blood analysis showed anemia, decreased platelet count and schistocytes. Urinalysis revealed proteinuria and dysmorphic red blood cells. It appeared that the patient had microangiopathic hemolytic anemia. He required ten sessions of plasmapheresis. A serologic work-up, including antinuclear antibodies, was negative. The fundus oculi examination showed stage three retinopathy. The echocardiography showed left ventricular hypertrophy with left ventricular ejection of 65%. The diagnosis was malignant hypertension complicated by a thrombotic microangiopathy.
In 2006, he developed terminal renal failure. He required hemodialysis followed 12 days later by continuous cycler-assisted peritoneal dialysis performed by his family members who were fully cooperative and compliant with hygienic requirements.
After two years, the patient and his family were exhausted; therefore, his brother and the two sisters offered themselves as donors for a renal transplantation. The brother's immunological and histological compatibility was the most suitable. Despite these encouraging results, the nephrology team delayed the transplantation, waiting for the psychiatrist's agreement. It was the first experience for both the nephrology team and the psychiatric staff to deal with such a situation. The decision of the psychiatrist was to check whether the patient was really compliant and whether the brother was free from mental disorders. The psychological assessment of the brother did not show any mental disorder. He affirmed at different times that he was really convinced of donation. The patient attended appointments at the psychiatric hospital every two weeks. During the follow-up, he was compliant to his medications and was well stabilized. The agreement for transplantation was made three months later.
The transplant operation was completed with success in June 2008. The patient received, immediately after transplantation, high doses of steroids (prednisolone 70 mg per day) and mycophenyl mofetil (MMF) (Cellcept) 2 g/day.
The post-operative phase was uneventful. But, a few weeks later, the patient developed induced diabetes, which was treated with insulin. The patient was examined by the nephrology team every two weeks during the first six months, then every month during the later one year.
After transplantation, the patient gave up smoking, took his treatments correctly and respected the diabetic and the salt-free diet. From a psychiatric stand point, three and nine months after renal transplantation, the patient presented psychotic relapses with delusions of reference and persecution and anxious symptoms (a fear of losing the renal allograft, anorexia and insomnia). The symptoms resolved quickly by increasing the dose of the antipsychotics without need for hospitalization.
At each relapse, the family was very attentive to prodromal symptoms and asked for support in time. Indeed, when the patient was not well, his mother, even though she was old, or his brother, even though he had to interrupt work, consulted with him at any time in order to alert us.
Currently, he has a normal renal function and his hypertension and diabetes are stabilized under treatment. As antirejection treatment, he is taking only a tablet of Cortancyl and four tablets of MMF per day.
| Discussion|| |
Our case emphasizes the potential for psychotic patients to undergo with success renal transplantation if two conditions are met: First, a good family support and second, a vigorous medical and psychiatric follow-up. A history of substance abuse and an irregular compliance to antipsychotics did not prevent the success. The literature about organ transplantation in recipients with chronic mental illnesses, and above all schizophrenia, is limited to the publication of a few case reports. ,,,,,
Dimartini and Twillman  published in 1994 a study of two cases of patients suffering from paranoid schizophrenia who had received organ transplants. The first case was a 44-year-old man who had a bone marrow transplant. He died on the 246 th post-operative day due to septic shock, while his psychiatric condition was stabilized. The second case was a 27-year-old man who had liver transplant. He was hospitalized pre-operatively in a psychiatric unit to ensure the best stabilization. Transplantation and post-operative period were uneventful. Both patients had residual symptoms with auditory hallucinations and delusions of persecution, which did not compromise the success of transplantation. In our case, the patient had a favorable outcome without requiring any psychiatric hospitalization before or after transplantation.
In 1998, Krahn  reported a case of a 42-year-old patient suffering from paranoid schizophrenia during five years with a history of dependence on alcohol. He lived on his own and had no family or social support. At the age of 40 years, he developed end-stage renal failure, indicating dialysis at the rate of three sessions per week. He was considered as a high-risk candidate for transplant because of his poor family support. Four months post-transplant, he developed depressive symptoms and stopped his antirejection and antipsychotic treatments. He explained that he regretted the hemodialysis sessions that were an opportunity for him to meet people. The nephrology team restarted antirejection treatment and he was then admitted in a psychiatry unit where he received antidepressant and antipsychotic agents. After discharge, he integrated a day hospital three days a week. This measure allowed a better control of the compliance with medications and a monitoring of psychiatric symptoms. It was also an opportunity for the patient to meet other people.
Another published case report  described a patient with schizophrenia who received a deceased renal transplant. The transplantation failed when the patient refused to take his antirejection medications or allow laboratory tests. This required the removal of the transplanted kidney. The nephrology team was not surprised by this outcome as the patient was known to have ongoing alcohol dependence.
Other authors , reported cases of successful urgent heart and liver transplants where surgery teams discovered the patient's history of schizophrenia and of poor compliance to anti-psychotics only after surgery. Despite these factors, the good family support and the intensive medical care allowed a favorable outcome.
These observations confirm the potential of successful organ transplants in patients with schizophrenia and their ability to be compliant with the requested anti-rejection measures if some conditions are satisfied. The first condition is based on an intensive medical and psychiatric post-transplant program in order to control both psychiatric symptoms and adherence with medications. The second condition is the good family support to ensure an adherence to treatment and an early detection of potential relapses. Otherwise, the integration of a day hospital or specialized institution should be a good alternative. The regularity of psychiatric follow-up is also very important as psychotic symptoms may be induced or exacerbated by steroids. , Psychiatric symptoms usually resolve after discontinuation of the treatment, but this measure may compromise the graft's survival.
Schizophrenia cannot be considered as an absolute contraindication for renal transplantation. The family support and the vigorous medical monitoring are the best guarantees for a successful transplantation. A close cooperation between the patient's family, the psychiatric staff and the nephrology team is essential.
Conflict of interest: None
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Dr. Saoussen Bouhlel
Aziza Othmana Hôpital Psychiatrique, Razi La Mannouba 2010