The Stanford Integrated Psychosocial Assessment for Transplant Is Associated With Outcomes Before and After Liver Transplantation

Abstract

The Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) is a standardized psychosocial evaluation tool used in liver transplantation (LT) evaluation. We assessed the impact of the SIPAT score and subdomains on transplant waitlisting decisions and post-LT outcomes including immunosuppression (IS) nonadherence, biopsy-proven rejection, andmortality/graft failure. We conducted a single-center observational cohort study of 1430 patients evaluated for LT. Patients were divided in 2 groups based on a SIPAT cutoff score of <21 or ≥21 (higher SIPAT scores indicate higher psychosocial risk). Regression models assessed relationships between total SIPAT score and domain scores and waitlisting decisions, IS nonadherence, allograft rejection, and death/graft failure. Elevated total SIPAT and SIPAT domain scores were associated not being added to the waitlist (total SIPAT core ≥21 adjusted odds ratio [aOR], 1.78 [95% confidence interval, CI, 1.36-2.33]; readiness score ≥5 aOR, 2.01 [95% CI, 1.36-2.76]; social support score ≥4aOR, 1.50 [95% CI, 1.15-1.94]; psychopathology score ≥7 aOR, 1.45 [95% CI, 1.07-1.94]; lifestyle/substance abuse score ≥12 aOR, 1.72 [95%CI, 1.23-2.39]) and were more likely to experience IS nonadherence as measured by the tacrolimus coefficient of variation (CoV) (total SIPAT score ≥21 aOR, 2.92 [95% CI, 1.69-5.03]; readiness score ≥5 aOR, 3.26 [95% CI, 1.63-6.52]; psychopathology score ≥7 aOR, 1.88 [95% CI, 1.00-3.50]; lifestyle substance abuse score ≥12 aOR, 3.03 [95% CI, 1.56-5.86]). SIPAT readinessscore ≥5 was associated with biopsy-proven allograft rejection (aOR, 2.66; 95% CI, 1.20-5.91). The SIPAT score was independently associated with LT listing decisions and IS nonadherence, and the readiness domain was associated with the risk of allograft rejection. These findings offer insights into higher risk recipients who require additional support before and aftertransplantation.

FIG. 1.

Study flow diagram.

FIG. 2.

Adjusted impact of SIPAT total score and SIPAT domain scores on patients not being added to the waiting list for transplant. Higher scores indicate higher psychosocial risk. See Supporting Table 1 for individual items in each domain. Models adjusted for age, sex, race, MELD-Na at evaluation, liver disease diagnosis, education, and CHS. P values are derived from individual logistic regressions.

FIG. 3.

Adjusted impact of total SIPAT, SIPAT domains, and individual readiness questions on tacrolimus CoV ≥0.45. (A) Total SIPAT and SIPAT domain scores. (B) Individual readiness domain questions. Higher scores indicate higher psychosocial risk. See Supporting Table 1 for individual items in each domain. Models adjusted for age, sex, race, transplant MELD-Na, liver disease diagnosis, education, and CHS. P values are derived from individual logistic regressions.

FIG. 4.

Adjusted impact of SIPAT readiness domain score ≥5 on time to allograft rejection. Higher scores indicate higher psychosocial risk. Readiness score encompasses patient’s understanding of medical illness and the process of transplantation, willingness/desire for treatment, treatment adherence/compliance, and lifestyle habits. Model adjusted for age, sex, race, liver disease diagnosis, education, and CHS.

FIG. 5.

Summary of significant relationships: (A) not being added to the waiting list for transplant, (B) tacrolimus CoV ≥0.45, (C) posttransplant biopsy-proven allograft rejection.