(PO-132) (PO-132) Successful Resumption of Clozapine with Immunosuppressants in Liver Transplantation: Case Report and Review of Literature

Background/Significance:
Prevalence of hepatitis C is 17% for those with severe psychiatric illness as compared to 1% in the general population (1). Individuals with hepatitis C virus (HCV) can suffer from disease progression that ultimately necessitates liver transplantation due to decompensated cirrhosis or hepatocellular carcinoma (HCC) without cirrhosis. There is a paucity of literature to inform liver transplantation for those with psychotic illness, specifically those receiving clozapine treatment. Clozapine is indicated for treatment refractory schizophrenia. Agranulocytosis, a known side effect of clozapine, is an additive risk for patients on myelosuppressive immunosuppressants post-transplantation. Here we report a case of a patient who successfully resumed clozapine treatment post liver-transplantation.

Case:
Ms. A is a 67 year-old woman with schizoaffective disorder stable for over 10 years. Psychotropics include clozapine 50mg nightly, bupropion 100mg daily, and trazodone 25mg nightly. Notable past medical history includes HCV that led to cirrhosis, HCC, MELD score of 16, and recurrent encephalopathy, which led to need for liver transplantation. Pre-transplantation psychosocial assessments revealed a strong support system and lengthy period of psychiatric stability. Consultation-liaison psychiatry service was involved immediately post-operatively. Anti-rejection immunosuppressants included mycophenolate-mofetil 540mg twice daily and tacrolimus 4mg twice daily.Clozapine treatment resumed at 50mg, with total serum level of 274ng/mL. Her absolute neutrophil count revealed a nadir of 2100/microL 4-days after initiating immunosuppressants. She remained stable from a psychiatric perspective.

Discussion:
Limited literature is available on solid-organ-transplants for patients with psychotic disorders and those treated with clozapine; this is possibly related to stigma purportedly inherent in some listing criteria relating to transplant candidates with psychiatric, specifically psychotic, diagnoses (2). A case series reviewed 35 kidney and liver transplants in patients with pre-existing psychotic disorder diagnosis, although none of the patients were treated with clozapine (3). One case report for renal transplantation described successful continuation of clozapine treatment without agranulocytosis (4).

Conclusion/Implications:
Psychiatrists are well poised to advocate, when appropriate, for patients with psychotic disorders, including those requiring clozapine treatment, to receive solid-organ-transplantation. Clozapine and anti-rejection-immunosuppressants can be safely used together. Further investigation of factors that predict successful outcomes in patients with severe mental illness and solid-organ-transplantation can reduce stigma and ensure equitable access to this life-saving intervention.

References:
1. Hughes E, et al: Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness: a systematic review and meta-analysis. Lancet Psychiatry 2016;3(1):40-48.
2. Cahn-Fuller K and Parent B: Transplant eligibility for patients with affective and psychotic disorders: a review of practices and a call for justice. BMC Medical Ethics 2017;18:72.
3. Zimbrean P and Emre S: Patients with psychotic disorders in solid-organ transplant. Progress in Transplantation 2015;25(4):289-296.

4. Harrington C and Kreiss J: Successful Use of Clozapine with Immunosuppressive Therapy in a Renal Transplant Patient. Psychosomatics 2018;49(6):546-548.