Liver Transplant Evaluation (Case 51)

Chapter 70 Liver Transplant Evaluation (Case 51)



Hilary A. Sanfey, MB, BCh


Case: A 45-year-old man with abnormal liver function tests and a history of heavy alcohol use is referred for liver transplant evaluation.




Speaking Intelligently


When asked to evaluate a patient for liver transplantation, I look at the underlying reason for liver failure, the patient’s age and medical comorbidities, and the status of his support system in order to determine if the patient is a transplantation candidate. If there are no obvious contraindications to proceeding with the transplantation workup, I obtain the laboratory and radiological tests outlined below. Patients with a hx of substance abuse will also require a full psychiatric assessment to determine suitability and risk for future noncompliance.



PATIENT CARE



Clinical Thinking


In evaluating a patient for liver transplantation it is important to:


• Make a dx of irreversible liver disease. Liver transplantation should be considered in all patients with end-stage liver disease (ESLD) who have failed to respond to medical treatment.

• Assess the severity (sick enough to transplant but not too sick to survive).

• Identify contraindications to transplantation. Absolute contraindications include significant nonhepatic malignancy, active infection, or substance abuse.


History



• Inquire about symptoms of ESLD, including encephalopathy, ascites, GI bleeding, pruritus, altered sleep pattern, tremor.

• A detailed substance abuse hx is important to assess the use of alcohol and recreational drugs.

• Ask about past medical and surgical hx, specifically a hx of malignancy or active infection.


Physical Examination



• Full physical examination.

• Focused GI examination. Note the presence of jaundice, excoriation from pruritus, tremor, ascites, caput medusae, palmar erythema, spider nevi, and hepatosplenomegaly.


Tests for Consideration


Editor’s note: In general, preoperative testing for a patient undergoing liver, kidney, or cardiac transplantation has four objectives:


1. Compatibility testing

2. Assessing the patient’s current physiology

3. Testing the status of the patient’s immune system and testing for the possible harboring of occult infection

4. Screening for the possibility of underlying, undiagnosed malignancy (as the transplant patient will require immunosuppression)





















































1. Compatibility testing
  
• ABO blood group $30

2. Optimizing current physiology
  
• CBC, metabolic panel, LFTs $84
• Prothrombin time to assess synthetic function $25
• EKG (and cardiac evaluation if needed) $50 ($500)

3. Testing immune status and testing for occult infection
  
• Anergy panel, PPD, HIV test $115
• CXR $136
• Culture urine/sputum/blood to r/o infection $45
• Hepatitis panel (hepatitis B/C) $65

4. Screening for underlying malignancy
  
• Prostate-specific antigen (men > 50 years) to r/o prostate cancer $65
• MRA of the abdomen to look at anatomy of liver and to r/o tumors $2,500
• α-Fetoprotein to screen for hepatocellular tumor $62
• PAP smear/mammography (women > 40 years) to r/o malignancy $125

The patient’s past medical hx or symptoms may indicate other tests.






Interpretation of Liver Function Tests

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Mar 20, 2017 | Posted by in GENERAL SURGERY | Comments Off on Liver Transplant Evaluation (Case 51)

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