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IM BOARD REVIEW - Liver Disease.ppt

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					     Liver Disease
Thomas C Sodeman MD FACP
Associate Professor of Medicine
 Chief, Division of Hepatology
     University of Toledo
             Liver Disease
• Approach to abnormal labs
  – AST
  – ALT
  – Alkaline phosphatase
  – Bilirubin




                              2
                Liver Disease
• Laboratory patterns
  – Hepatitis
     • AST/ALT//Alkaline phosphatase
  – Cholestatic
     • Bilirubin/alkaline phosphatase//AST/ALT




                                                 3
                Liver Disease
• Laboratory patterns
  – Hepatitis
     • AST/ALT < 1000 viral
  – Hepatitis
     • AST/ALT > 5000 fulminant hepatitis




                                            4
You are seeing a 24 year old male to establish care. He
    states he has had no medical issues, but has noticed
    his eyes will turn yellow when he has a cold. He is
    concerned that he may develop cirrhosis like his
    father, who drank heavily. He is on no medications,
    and his examination is normal. His total bilirubin is 2.3
    mg/dL, direct bilirubin 0.2 mg/dL. Your next
    evaluations should be:
a. Reassurance
b. CT scan of the liver
c. Hepatitis serologies
d. Liver biopsy
e. HFE gene study

                                                            5
              Liver Disease
• Hyperbilirubinemia
  – Unconjugated – increased production
    • Hemolysis
  – Conjugated - dysfunction
  – Gilbert’s syndrome
  – Elevated total bilirubin – unconjugated
  – Fasting / illness


                                              6
You are asked to see a 67 year old male found at home
    and hospitalized. He has a past history of hypertension
    and dementia. His diet recently had consisted of only
    prune juice and celery. He is disheveled looking,
    emaciated, and has multiple bruises on his upper and
    lower extremities. His labs show an albumen of 1.3,
    normal transaminases, a microcytic anemia, and an
    INR of 2.5. He takes no medications at home. Your
    next step to evaluate his elevated INR would be:
a. Hepatitis serologies
b. Ceruloplasmin
c. Ultrasound of the liver
d. Vitamin K supplementation
e. Liver biopsy
                                                          7
                Liver Disease
• Measures of synthetic function
  – Short term
     • PT/INR
  – Longer term
     • Albumen




                                   8
             Liver Disease
• Measures of synthetic function
  – INR elevation due to malabsorption vs.
    dysfunction
  – Malabsorption responds to vitamin K




                                             9
             Liver Disease
• Other evaluations
  – Radiologic
  – Pathologic
  – Functional
    • HIDA




                             10
               Liver Disease
• Radiologic
  – Ultrasound – masses, flow, fat
  – CT – masses, fat
  – MR – masses, fat
  – PET – malignancy
  – ERCP – ‘plumbing’




                                     11
               Liver Disease
• Pathologic
  – Diagnosis – used when labs / imaging unclear
  – Staging – degree of fibrosis – important for
    treatment decisions and prognosis




                                               12
Your patient, a 25 year old female, just returned from a
    vacation in Mexico a month ago. Recently she has
    been feeling fatigued, and has had modest right upper
    quadrant discomfort. Yesterday she noticed that her
    eyes were yellow. Past medical history is significant for
    asthma, current medication is an inhaler. Physical
    exam reveals scleral icterus, and a slightly enlarged
    liver. Laboratories show an INR of 1.0, AST 450 U/L,
    ALT 435 U/L, and bilirubin of 3.2 mg/dL. Your next
    evaluation would be:
a. Intravenous immunoglobulin
b. Referral for liver transplantation
c. Referral for alcohol treatment
d. Lamivudine 100mg po QD
e. HAV IgM

                                                           13
                Liver Disease
• Hepatitis A
  – Incubation 2-6 weeks
  – Fecal oral
  – IgM anti HAV
  – No treatment
  – No chronic condition
  – Ig for contacts
  – Vaccine for travelers

                                14
Your patient comes in with jaundice. He is a 30 year old
    male with a history of intravenous drug abuse. He has
    not recently traveled, and drinks 2 to 3 beers a day. On
    examination he has scleral icterus and jaundice, no
    asterixis, no ascites or edema, and no stigmata of
    chronic liver disease. Past screening has been
    negative for viral hepatitis, and past medical history is
    unremarkable. Labs show as AST of 1000 U/L, ALT
    1200 U/L, alkaline phosphatase of 150 U/L, total
    bilirubin of 3.0 mg/DL, and an INR of 1.2. Your next
    step should be:
a. Referral for liver transplantation
b. CT scan of the liver
c. Hepatitis serologies
d. Liver biopsy
e. Lamivudine 100 mg PO QD
                                                           15
                Liver Disease
• Hepatitis B
  – Incubation 4 – 24 weeks
  – Parenteral
  – HBsAg, HBsAb
  – HB core Ab
  – HB e Ag, Ab
  – HBV DNA


                                16
                     Liver Disease
HBsAg   Anti HBs   IgM anti   IgG anti   HBeAg   Anti HBe    DNA
                     HBc        HBc

                                                                        Acute
 +         -          +          -        +         -         +

                                                                       Immune
  -        +          -          +         -       -/+         -

                                                                      Vaccinated
  -        +          -          -         -        -          -

                                                            <105/mL    Carrier
 +         -          -          +         -        +

                                                            >105/mL    Chronic
 +         -          -          +        +         -                 replicating




                                                                                17
Your patient comes for evaluation of her chronic hepatitis.
    She is a 53 year old nurse who contracted hepatitis B
    via a needle stick. She does not drink alcohol, and has
    well controlled hypertension. Examination is normal,
    labs show AST and ALT twice normal, and HBV DNA
    PCR shows 1,300,000 copies / mL. Liver biopsy
    showed minimal fibrosis and moderate portal and
    parenchymal inflammation. Your next step would be:
a. Reassurance
b. CT scan of the liver
c. Referral for liver transplantation
d. Tenofovir
e. Repeat liver biopsy in one year

                                                         18
                 Liver Disease
• Hepatitis B
  – Fulminant
     • Initial or reactivation
  – Chronic
     • Cirrhosis
     • Hepatocellular carcinoma




                                  19
                Liver Disease
• Hepatitis B
  – Treatment
     • Evidence of inflammation (biopsy, enzymes)
     • Elevated DNA (<10000 copies / mL)




                                                    20
                  Liver Disease
• Hepatitis B
  – Treatment
     •   Interferon – not in cirrhosis
     •   Lamivudine - resistance
     •   Adefovir
     •   Entecavir




                                         21
Your patient presents for further evaluation of hepatitis C
    found at blood donation. He is a 54 year old male in
    otherwise good health, and his route of acquisition is a
    transfusion at age 10. His examination is normal, labs
    show AST and ALT 1.5 times normal, genotype of 1a,
    and a viral load of 2,300,000 IU/mL. Testing at
    donation showed a viral level of 1,400,000 IU/mL 4
    months ago. Your next step is:
a. Pegylated interferon and ribavirin
b. CT scan of the liver
c. reassurance
d. Liver biopsy
e. HFE gene study

                                                          22
                Liver Disease
• Hepatitis C
  – Incubation 2-10 weeks
  – Parenteral
  – Pre late 1980’s – transfusion / IVDU
  – Now - IVDU




                                           23
                 Liver Disease
• Hepatitis C
  – Diagnosis
     •   Initial – anti HCV
     •   Confirmation – RNA PCR – not RIBA
     •   Additional – genotype, viral load
     •   Biopsy – long duration, duration unknown,
                confounding factors (alcohol)




                                                     24
                Liver Disease
• Hepatitis C
  – Treatment
     • Stage ≥2
     • Not viral load
  – Interferon / ribavirin
     • Length depends upon genotype
        – 1 – 48 weeks
        – 2,3 – 24 weeks




                                      25
                  Liver Disease
• Hepatitis C
  – Treatment
     • Side effects
        –   Depression – (suicide)
        –   Fatigue
        –   Aches
        –   Cytopenias (RBC / WBC / plt)
        –   Thyroid
        –   Hair loss
        –   Weight loss


                                           26
                  Liver Disease
• Hepatitis C
  – Treatment
     • Reasons to stop treatment
        –   Suicidal ideation
        –   No response at 3 months (2 log drop viral load)
        –   Intolerance of side effects
        –   Not cytopenias unless severe
              » First try growth agents
              » PLT < 10,000
              » ANC <750
              » Severe anemia

                                                              27
                Liver Disease
• Hepatitis D
  – Incubation 4-24 weeks
  – Parenteral - IVDU
  – Coinfection
  – Superinfection
  – Treat HBV




                                28
                Liver Disease
• Hepatitis E
  – Incubation 2 – 9 weeks
  – Parenteral
  – Rare in US
  – Similar to HAV
  – 20% mortality in pregnancy




                                 29
             Liver Disease
•   CMV
•   EBV
•   HZV - pregnancy
•   Adenovirus




                             30
Your patient presents for evaluation of fatigue, She is a 65
    year old retired teacher with a past medical history of
    hypothyroidism and hypertension, under control.
    Examination reveals slight hepatomegaly and 1+
    pitting edema at the ankles. Laboratories show AST
    and ALT 1.5 times normal, normal bilirubin and
    alkaline phosphatase, and a normal CBC. Your next
    step is:
a. Reassurance
b. CT scan of the liver
c. Hepatitis serologies
d. ANA and serum protein electrophoresis
e. Alcohol counseling

                                                          31
             Liver Disease
• Autoimmune hepatitis
  – Distribution 3:1 F:M
  – Peaks 10-20 years, 50 years
  – Presentation
    • Chronic
    • Fulminant
  – 1/3 with another autoimmune disorder



                                           32
               Liver Disease
• Autoimmune hepatitis
  – Fatigue
  – Jaundice
  – Anorexia
  – Myalgia




                               33
            Liver Disease
• Autoimmune hepatitis
  – Ast Alt ≈ 500 (>1000)
  – ANA >1:80
  – ASMA > 1:80
  – LKM1 >1:80
  – Gamma globulin > 1.5x normal




                                   34
              Liver Disease
• Autoimmune hepatitis
  – Biopsy
  – Interface hepatitis
  – Plasma cells




                              35
                 Liver Disease
• Autoimmune hepatitis
  – Treatment
    • Prednisone / imuran
       –   80% remission
       –   2 years
       –   Relapse in 50%
       –   Retreat relapsers
    • 90% mortality untreated




                                 36
Your patient, a 58 year old woman, presents with one
    month of pruritus. She has no significant past medical
    or exposure history, no recent travel or new pets.
    Examination shows xanthomas and excoriations, and
    otherwise is normal. Labs show AST and ALT twice
    normal, and alkaline phosphatase of 450 U/L, total
    bilirubin of 1.2 mg/dL. The your next step should be:
a. Reassurance
b. CT scan of the liver
c. Hepatitis serologies
d. Liver biopsy
e. Anti mitochondrial antibody



                                                        37
             Liver Disease
• Primary biliary cirrhosis
  – Small bile duct
  – 9:1 M:F
  – Age 40-60
  – Elevated alkaline phosphatase
  – Pruritus / fatigue
  – AMA > 1:40
  – Ursodeoxycholic acid 12 -15 mg/kg
  – Osteoporosis
                                        38
Your patient, a 24 year old male with a 10 year history of
    ulcerative colitis, presents for a routine evaluation. His
    colitis has been under control with Asacol, and he has
    no other significant medical issues. Examination is
    unremarkable. Laboratories show AST and ALT twice
    normal, Alkaline phosphatase 450, total bilirubin of 1.4
    mg/dL, and a normal CBC. Your next step is:
a. Reassurance
b. CT scan of the liver
c. Hepatitis serologies
d. ERCP
e. Liver biopsy



                                                            39
              Liver Disease
• Primary sclerosing cholangitis
  – Medium and large duct disease
  – 80% associated with ulcerative colitis
  – Increased alkaline phosphatase
  – Dominant strictures
  – Cholangiocarcinoma / colon ca
  – Osteoporosis
  – No effective treatment

                                             40
Your patient presents for routine follow up. He is a 53 year
    old lawyer with a past medical history of hypertension,
    elevated cholesterol and type 2 diabetes. He is on
    therapy for all three diseases. Examination is normal
    except for obesity. Labs show a normal AST, ALT of
    60 U/L, normal alkaline phosphatase and bilirubin.
    Previous labs have been normal. Your next step
    should be:
a. Reassurance
b. CT scan of the liver
c. Hepatitis serologies
d. Liver biopsy
e. Repeat labs in 3 months

                                                          41
             Liver Disease
• NASH
 – Fatty liver – cirrhosis
 – Obesity
 – DM
 – Hyperlipidemia
 – TPN
 – ALT>AST <200
 – Diagnosis of exclusion

                             42
                Liver Disease
• NASH
 – Treatment
   •   Weight loss
   •   Control of diabetes / lipids
   •   Gastric bypass
   •   PPAR-g agents




                                      43
              Liver Disease
• Alcoholic liver disease
  – Alcoholic liver disease
     • 80 g / d men
     • 40 g / d women
     • AST 2x ALT <300




                              44
                  Liver Disease
• Alcoholic liver disease
  – Alcoholic hepatitis
     •   Elevated AST>ALT bilirubin INR WBC
     •   Discriminant function >35
     •   4.6[Pt-Ptcontrol] + bil (mg/dL)
     •   Neutrophils on biopsy
     •   Treatment
          – Prednisone / pentoxyphylline / TNF a agents




                                                          45
You are seeing a new patient, a 35 year old male. He
   complains of some fatigue, but otherwise is in good
   health. Examination is normal. His family history
   includes cirrhosis in an uncle and CAD. Labs show
   normal liver enzymes, a ferritin of 750 mg/L, and iron
   saturation of 88%. Your next step is:
a. Reassurance
b. CT scan of the liver
c. HFE gene study
d. Hepatitis serologies
e. Liver biopsy with quantitative iron level




                                                       46
              Liver Disease
• Hereditary Hemochromatosis
  – Most common inherited disorder in Europeans
  – C282Y         H63D
  – Autosomal recessive
  – Ferritin elevation
     • 400
  – Iron saturation
     • 50%


                                             47
              Liver Disease
• Hereditary Hemochromatosis
  – Diabetes
  – Cardiomyopathy
  – Arthritis PIP/DIP




                               48
             Liver Disease
• Hereditary Hemochromatosis
  – Ferritin > 1000 / elevated AST – biopsy
  – No role for iron index




                                              49
Your patient , a 35 year old male with hereditary
    hemochromatosis (C282Y/C282Y) presents asking
    about therapeutic options. His labs showed AST and
    ALT twice normal, ferritin of 1300 mg/L, iron saturation
    of 92%. Liver biopsy showed minimally increased
    fibrosis. Your next step is:
a. Reassurance
b. Chelation with desferroximine
c. Weekly therapeutic phlebotomy
d. Low iron diet and observation
e. Penicillamine therapy




                                                          50
               Liver Disease
• Hereditary Hemochromatosis
  – Phlebotomy
    • Initially weekly
  – Ferritin<50
    • Q three months




                               51
You are seeing a 22 year old female in the hospital for
   elevated liver enzymes. She was hospitalized for acute
   psychosis a week earlier. On examination she has
   choreaform movements of her hands, and otherwise
   examination is normal. Labs show AST and ALT twice
   normal, an alkaline phosphatase of 50 U/L, and is
   otherwise normal. Your next step is:
a. No further testing
b. Serum ceruloplasmin
c. Spot urine copper
d. Liver biopsy
e. Hepatitis serologies



                                                       52
              Liver Disease
• Wilson’s disease
    – Age 15-40
• Acute – fulminant failure
    – Hemolytic anemia
•   Chronic – cirrhosis
•   Ceruloplasmin <20 mg/dL
•   24 hour urine copper >80 mg/24h (>250)
•   Psychiatric symptoms
                                             53
                 Liver Disease
• Wilson’s disease
  – ATPB7
• Treatment
  – Penicillamine
  – Trientine        lifetime
  – Zinc
  – Transplant – FHF, cirrhosis
    • curative

                                  54
              Liver Disease
• Alpha-1 antitrypsin
  – Phenotype
  – ZZ
  – SS
  – SZ
  – MZ
  – MM
  – Null / null

                              55
             Liver Disease
• Alpha -1 antitrypsin
  – Variable presentation
  – Cirrhosis
  – Emphysema
  – Neither
  – HCC




                             56
             Liver Disease
• Storage diseases
  – Amyloid
  – Glycogen storage
  – Lipopolysaccharidoses




                             57
                Liver Disease
• Liver masses
  – Benign
    • Usually asymptomatic unless very large
    • Found incidentally
  – Malignant
    • Metastatic / primary
    • Primary more likely with cirrhosis




                                               58
You are seeing your patient in follow up for an abnormal
    CT. She is 45 and had a CT in the emergency room for
    nephrolithiasis, which has resolved. She has no
    significant past medical history, and is on no
    medications. Repeat CT with contrast shows a 2cm
    mass with peripheral enhancement in the left lobe, and
    a 3cm mass in the right, also with the same
    enhancement. Your next step is:
a. Reassurance
b. CT guided liver biopsy
c. Serum E. histolytica antibodies
d. Referral for surgery
e. Serum alpha fetoprotein

                                                        59
               Liver Disease
• Liver masses
  – Benign - CT
    • Adenoma – OCP / hormones
       – Irregular enhancement
    • Hemangioma – most common
       – Peripheral enhancement
    • Focal nodular hyperplasia
       – Central scar
    • Cysts
       – Hypodense

                                  60
Your patient presents for follow up of an abnormal CT
    scan. He is a 54 year old with a history of alcoholic
    cirrhosis, complicated by ascites and modest
    encephalopathy. CT showed a 3cm mass in the right
    lobe with arterial enhancement, and nodularity of the
    liver consistent with cirrhosis. INR is 2.2, bilirubin is 3.1
    mg/dL, and ascites was present. Your next step is:
a. Referral for hospice
b. CT guided liver biopsy of the mass
c. Referral for systemic chemotherapy
d. Referral for liver transplantation
e. Referral for surgical removal of mass



                                                               61
                Liver Disease
• Liver masses
  – Malignant
    • Metastatic
    • Hepatocellular carcinoma
       – Arterial phase enhancement
       – Underlying disease
    • Cholangiocarcinoma




                                      62
                Liver Disease
• Liver masses
  – Abscesses
    • Amoebic
       – Often not associated with colitis
       – Metronidazole
    • Pyogenic
       – Diverticulitis
       – Non-enhancing
       – Drainage



                                             63
                 Liver Disease
• Drug hepatotoxicity
  – Acute
  – Chronic
  – Idiopathic




                                 64
                 Liver Disease
• Drug hepatotoxicity
  – Acute
  – Chronic
  – Idiopathic




                                 65
                Liver Disease
• Drug hepatotoxicity
  – Acute
     •   Acetaminophen
     •   Isoniazid
     •   Dantrolene
     •   Nitrofurantoin
     •   Sulfonamides
     •   Phenytoin
     •   Disulfiram
     •   Ketoconazole

                                66
                  Liver Disease
• Drug hepatotoxicity
  – Chronic
     •   Nitrofurantoin
     •   Etretinate
     •   Diclofenac
     •   Minocycline
     •   Trazadone




                                  67
                Liver Disease
• Drug hepatotoxicity
  – Chronic
  – Granulomatous – alkaline phosphatase
     •   Allopurinol
     •   Carbamazepine
     •   Hydralazine
     •   Quinidine




                                           68
              Liver Disease
• Fulminant failure
  – Acute liver failure (jaundice, INR)
  – Encephalopathy
  – No pre-existing liver disease




                                          69
               Liver Disease
• Fulminant failure
  – Acetaminophen
     • 24 hour nomogram
     • Mucomyst
  – Viral
     • HAV, HBV
  – Ischemic
  – Wilson’s

                               70
              Liver Disease
• Cirrhosis
  – Encephalopathy
  – Ascites
  – Varices
  – Hepatorenal syndrome
  – Hepatocellular carcinoma
  – Transplant


                               71
Your patient present for follow up She is a 45 year old with
    a history of cirrhosis secondary to alcohol and hepatitis
    C. her manifestations have included ascites, treated
    with furosemide and aldactone, and encephalopathy,
    treated with lactulose. She denies any forgetfulness as
    does her husband. Her labs show an ammonia of 120
    mg/dL, up from 98 mg/dL last month. Your next step is:
a. Reassurance
b. Increase lactulose
c. Add oral neomycin
d. Restrict dietary protein
e. Increase diuretics



                                                           72
                Liver Disease
• Encephalopathy
  – Elevated ammonia
  – Predisposing factors
    •   Bleeding
    •   Diet
    •   Constipation
    •   Infection




                                73
                Liver Disease
• Encephalopathy
  – Treatment
    •   Lactulose - compliance
    •   Neomycin – ototoxicity
    •   Flagyl
    •   Xifaxin
    •   Zinc




                                 74
              Liver Disease
• Varices
  – Esophageal
  – Gastric
  – Rectal
  – Screening
    • Dx of cirrhosis
    • Grade 1-2 – repeat 1-2 years
    • Grade 3-4 – banding / b blockers


                                         75
You are seeing a patient in the emergency room. He is a
    28 year old with a history of excessive alcohol intake
    for 12 years. He presented with large volume emesis
    of bright red blood. His hemoglobin is 6.2 g/dL, INR
    3.4, platelets 22,000 / mL. A central line has been
    placed, fluid resuscitation has been started, and the
    gastroenterologist has been called. Your next step is:
a. Placement of a Sengstaken-Blakemore tube
b. Endotracheal intubation
c. Platelet transfusion
d. Fresh frozen plasma
e. Emergent TIPS placement



                                                        76
               Liver Disease
• Varices
  – Active bleeding
  – Treatment
    •   Intubation
    •   Transfusion to Hb 8
    •   Banding
    •   Sclerosis
    •   Sengstaken Blakemore
    •   TIPS
    •   Surgical shunt

                               77
             Liver Disease
• Portal hypertensive gastropathy
  – Iron deficiency anemia
  – Responds to b-blockers




                                    78
You are seeing a 46 year old in follow up. She has cirrhosis
    secondary to autoimmune hepatitis, and has recently
    developed lower extremity edema and non-tense
    ascites. Examination is otherwise unremarkable, and
    labs show a creatinine of 1.0 mg/dL, and an albumen
    of 2.1 g/dL. She is currently on furosemide 20 mg/day.
    Your next step is:
a. Change to aldactone 100 mg / day
b. Salt restriction to 500 mg / day
c. Fluid restriction to 1 liter / day
d. Increase furosemide to 40 mg / day and add aldactone
    100 mg / day
e. Albumen infusion

                                                          79
              Liver Disease
• Ascites
  – Decreased albumen – oncotic pressure
  – Increased portal pressure
  – Increased splanchnic blood flow
  – Increased water retention due to activation of
      renin / angiotensin / aldosterone axis




                                                     80
                  Liver Disease
• Ascites
  – Initial evaluation
     • Hepatic vs cardiac
     • Tap
        –   OK if INR up / plt down
        –   SAAG
        –   Cell Count
        –   Culture
        –   ? cytology



                                      81
              Liver Disease
• Ascites
  – Treatment
  – Aldactone 100 mg/day
  – Lasix 40 mg / day
  – Max 400 / 160
  – Sodium / water restrictions




                                  82
               Liver Disease
• Ascites
  – Tap – risk of HRS – replace albumen 8g/L

  – Indications for repeat taps
     • ? Infection
     • Diuretic resistance
  – TIPS
     • Diuretic resistance
  – Denver shunt
                                               83
               Liver Disease
• Spontaneous bacterial peritonitis
  – Often asymptomatic
  – Monobacterial
  – Ascitic fluid cell count / culture
     • > 250 PMN
  – Inpatient – cefotaxime
  – Outpatient - quinolone
  – Prophylaxis – after one episode
     • Weekly quinolone

                                         84
             Liver Disease
• Hepatorenal syndrome
  – Renal vasoconstriction
  – Cr > 1.5 mg/dL or CrCl <40 mL/min
  – Urine protein <500 mg/d
  – No shock
  – No renal parenchymal disease
  – No improvement after stopping diuretics /
     1.5 L NS challenge

                                                85
              Liver Disease
• Hepatorenal syndrome
  – Indication for transplant
  – TIPS




                                86
                 Liver Disease
• Hepatocellular carcinoma
  – Rare in no liver disease
  – Often asymptomatic
     • Pain, weight loss, fever
  – Worse risk
     • Hemochromatosis , α1AT, HBV
  – Alpha fetoprotein – Q six months
     • <100
     • Trend
     • >500
  – Scans Q six months

                                       87
Your patient presents for follow up. She is 54, and has a
    history of cirrhosis secondary to hepatitis C, which has
    not been treated yet. She has no encephalopathy or
    ascites, and other than fatigue feels well. Labs show
    an INR of 1.1, bilirubin of 1.2 mg/dL, platelets of
    98,000 / mL, creatinine of 1.1 mg/dL, and a viral load
    of 1,300,000 IU/mL. Endoscopy recently shoed no
    esophageal varices. She is concerned about getting on
    a transplant list. Your next step is:
a. Reassurance
b. Referral for transplantation
c. Referral for liver biopsy
d. Referral for hospice


                                                          88
                 Liver Disease
• Liver transplantation
  – Indication
     • Dysfunction
     • Hepatocellular carcinoma
     • Storage / metabolic problems
  – MELD score
     •5     – normal
     • 5-15 – below listing
     • >15 – listable

                                      89
                Liver Disease
• Liver transplantation
  – Contraindications
     •   Active infection
     •   Extrahepatic malignancy
     •   HIV
     •   Severe extrahepatic diseases – CAD, COPD
     •   noncompliance




                                                    90
                 Liver Disease
• Liver transplantation
  – Post transplant issues
     •   Diabetes
     •   Hypertension
     •   Renal insufficiency
     •   Recurrence of disease
          – HCV/PBC/PSC/AIH
     • Rejection
     • Plumbing - anastamoses
     • Malignancy - skin
                                 91
               Liver Disease
• Vaccination
  – HBV
    • Health care workers, jail, sewer, military
    • Children
  – HAV
    • Travel to endemic areas
  – Underlying liver disease
    • Recommended in all


                                                   92

				
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