Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA.
Department of Medicine, Duke University Medical Center, Durham, NC, USA.
Int J Psychiatry Med. 2020 Nov;55(6):421-436. doi: 10.1177/0091217420906637. Epub 2020 Feb 13.
Posttransplant depression has been linked to increased risk for adverse outcomes in lung transplant patients. Maintaining target serum immunosuppressant levels is also essential for optimal lung transplant clinical outcome and may be a crucial predictor of outcomes. Because depression could affect medication nonadherence, resulting in out-of-range immunosuppressant levels, we examined the relationship between posttransplant depression, immunosuppressant medication trough level variability, indexed by out-of-range values on clinical outcomes and coefficient of variability, and clinical outcomes.
A consecutive series of 236 lung transplant recipients completed the Center for Epidemiological Studies-Depression two-month posttransplant. Immunosuppressant trough levels (i.e., tacrolimus or cyclosporine) within the range of individualized immunosuppressant targets were obtained at three-, six-, nine-month follow-up clinic visits. Clinical outcomes including hospitalizations and mortality were obtained from medical records.
Fourteen percent of patients were classified as depressed (Center for Epidemiological Studies-Depression ≥16), 144 (61%) of patients had at least 25% out-of-range immunosuppressant values, and the average coefficient of variability was 36%. Over a median of 2.6 years (interquartile range = 1.2), 32 participants died (14%) and 144 (61%) had at least one unplanned, transplant-related hospitalization. Both depression (hazard ratio = 1.45 (1.19, 1.76), p < . 01) and immunosuppressant variation (immunosuppressant out-of-range: hazard ratio = 1.41 (1.10, 1.81), p < .01) independently predicted more frequent hospitalizations and higher mortality.
Early posttransplant depression was associated with significantly worse clinical outcomes. While immunosuppressant level variability is also related to adverse outcomes, such variability does not account for increased risk observed with depression.
移植后抑郁与肺移植患者不良结局的风险增加有关。维持目标血清免疫抑制剂水平对于优化肺移植临床结局也是至关重要的，并且可能是结局的重要预测指标。由于抑郁可能会影响药物的依从性，导致免疫抑制剂水平超出范围，因此我们研究了移植后抑郁、免疫抑制剂药物谷值水平变异性（通过超出临床结局和变异系数范围的数值来表示）与临床结局之间的关系。
连续 236 例肺移植受者在移植后两个月完成了流行病学研究中心抑郁量表评估。在随访的 3 个月、6 个月和 9 个月的门诊就诊时，获取个体化免疫抑制剂靶目标范围内的免疫抑制剂谷值水平（即他克莫司或环孢素）。从病历中获取临床结局（包括住院和死亡）。
14%的患者被诊断为抑郁（流行病学研究中心抑郁量表评分≥16），144 例（61%）患者至少有 25%的免疫抑制剂值超出范围，平均变异系数为 36%。在中位数为 2.6 年（四分位距为 1.2 年）的随访期间，32 名患者死亡（14%），144 名患者（61%）至少有一次计划外与移植相关的住院。抑郁（危险比=1.45（1.19，1.76），p<0.01）和免疫抑制剂变异性（免疫抑制剂超出范围：危险比=1.41（1.10，1.81），p<0.01）独立预测了更频繁的住院和更高的死亡率。
移植后早期抑郁与更差的临床结局显著相关。虽然免疫抑制剂水平的变异性也与不良结局有关，但这种变异性并不能解释抑郁所观察到的风险增加。
