Book Review

The Transplant Patient: Biological, psychiatric and ethical issues in organ transplantation

N Engl J Med 2000; 343:447August 10, 2000

Article

The Transplant Patient: Biological, psychiatric and ethical issues in organ transplantation
Edited by Paula T. Trzepacz and Andrea F. DiMartini. 311 pp., illustrated. New York, Cambridge University Press, 2000. $64.95. ISBN: 0-521-55354-7

Transplantation is one of the most complex and challenging enterprises of modern medicine. Despite recent progress in surgical techniques and immunosuppressive strategies, the wide-ranging societal, ethical, and psychological implications of transferring donor organs to recipients with life-threatening diseases are still poorly understood. This book takes up these problems where the pioneering treatise of Roberta G. Simmons and colleagues left off 20 years ago (Gift of Life: The Social and Psychological Impact of Organ Transplantation. New York, Wiley, 1977). In addition to affirming and extending Simmons and colleagues' descriptions of the psychological aspects of renal transplantation, the new book deals with other types of grafts (particularly liver replacements), quality-of-life analyses, cognitive-assessment techniques, psychopharmacology, and psychoneuroimmunology.

Despite the multiple authors, the 12 chapters are remarkably similar in format and length. Almost every chapter contains extensive, extremely useful summary tables. Most of the contributions recapitulate rather than analytically compare and assess the data. In contrast, the contribution by the editors on alcoholism is a masterly and balanced, yet critical, overview of the consequences of substance abuse on the outcome of organ transplantation, particularly transplantation of the liver.

Although the contribution on psychopharmacology is an excellent review of drug biotransformations and interactions, the author would have benefited from collaboration with a specialist in the transplantation field. The presentation reflects approaches that were popular almost a decade ago, when high doses of immunosuppressive drugs were believed to be essential to prevent rejection. In addition, there are multiple errors in this chapter: for example, urine is a minor, not an important, route of cyclosporine excretion, and cyclosporine, tacrolimus, and sirolimus concentrations are measured neither in plasma nor in serum but rather in whole blood.

The fascinating contribution of Kradin and Surman on psychoneuroimmunology seeks to bring knowledge of the influence of the mind on the immune system to the field of transplantation. Their overview is free of jargon, but the information on immunology is outdated. For instance, the theory of antagonism between prolactin and cyclosporine is only of historical interest. Not cited is recent work showing the effects of corticosteroids on the CD28 costimulatory pathway and the effect of psychological stress on type 2 T helper cells, on the production of interleukin-6, and on susceptibility to viral infection.

Insufficient attention is paid to psychological considerations that I believe to be important in my renal-transplantation practice. For instance, only in the chapter on children, by Canning and Stuber, is the emotional stress of transplantation paraprofessionals discussed. In his chapter on organ donation, Gillett sidesteps the primeval, mystical, superstitious, and cultural beliefs that in my experience prevent the families of potential donors from providing consent.

Overall, this book is a convenient, comprehensive, accessible presentation of many societal and psychological issues affecting the practice of organ transplantation. As a broad introduction to a wide range of topics, it will interest all transplantation-team members, but it is clearly directed toward psychologists, social workers, mental health workers, and possibly psychiatrists. As a transplantation specialist with a keen interest in psychodynamics, I am sure that this book will hold an important place on my reference shelf.

Barry D. Kahan, M.D., Ph.D.
University of Texas–Houston Medical School, Houston, TX 77030