A Biopsychosocial Formulation of Psychosis after Kidney Transplantation: When Cultural Identity and Biology Collide

ABSTRACT

Background: When working with colleagues of predominantly biological perspectives, it is an important role of the consultation psychiatrist to recognize psychosocial factors that may be impacting a patient's pathology. This case exemplifies the importance of such education between psychiatric and transplant providers. Case This is a 38-year-old divorced Russian man, with history of cannabis use and childhood trauma;and history of ESRD secondary to IgA nephropathy s/p DDKT on tacrolimus/mycophenolate/prednisone. Eighteen months after transplantation, in the setting of daily cannabis use, he developed psychosis with persecutory delusions, referential experiences, and experiences of thought alienation. The content of his delusions was tied closely to his experience of emigration from Russia, having spent his childhood in Volgograd/Stalingrad after the dissolution of the USSR. He was found to have a tacrolimus level of 20, above goal-range of 8-10. He was medically hospitalized and followed by psychiatry. The medical, transplant, and psychiatry teams collaborated to downtitrate his tacrolimus and initiate treatment with antipsychotic medication. His psychosis initially improved but recurred six months after discharge. At that time, there were several changes to his presentation of diagnostically significance. His tacrolimus level was found to be within goal. He had also recently recovered from COVID-19, self-discontinued olanzapine, and ceased cannabis use. The patient's new persecutory delusions developed concurrently with the conflict between Russia and Ukraine, raising suspicion that activation of trauma was playing a larger role. Discussion(s) Biologically, the effect of cannabis on immunosuppression through CYP3A4 inhibition is relevant, as is the independent relationship between cannabis, tacrolimus and psychosis1,2 At the time of writing, any effect of the change to belatacept is yet unknown. Psychologically, trauma history likely contributed to suspiciousness toward others and persecutory delusions. There is also evidence to suggest a relationship between trauma, cannabis and psychosis.3 Culturally, his sensation of being targeted was likely related to his Russian identity, immigrant status, and the current international conflict. Conclusion/Implications This case demonstrates multiple contributing factors to psychosis in a patient post-transplant, which include psychological, trauma-related, and cultural factors in addition to those explained by pathophysiology of transplant, substance use, and immunosuppression. Transplant psychiatry has an essential role in educating our colleagues and patients about the multitude of contributors to psychiatric health post-transplant. References 1. Nogueira JM, Freire MJ, Nova VV, Jesus G. When Paranoia Comes with the Treatment Psychosis Associated with Tacrolimus Use. Case Rep Nephrol Dial. 2021;11(2)241-246. 2. Sikavi D, McMahon J, Fromson JA. Catatonia Due to Tacrolimus Toxicity 16 Years After Renal Transplantation Case Report and Literature Review. J Psychiatr Pract. 2019;25(6)481-484. 3. Tomas-Roig J, Piscitelli F, Gil V, et al. Effects of repeated long-term psychosocial stress and acute cannabinoid exposure on mouse corticostriatal circuitries Implications for neuropsychiatric disorders. CNS Neurosci Ther. 2018;24(6)528-538. Copyright © 2022