achilles
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those of you who havent yet taken the NBME might not want to attempt this question to get a more valid idea of their preparation.
a 28 yr old woman is hospitalised after taking a massive dose of acetaminophen in a suicide attempt. she has type 1 DM, major depressive disorder refractory to TCA's. despite appropriate therapy she develops progressive hepatic failure and develops hepatic encephalopathy. the patient is now comatose on the 6th day of hospitalisation. CT scan of the brain shows mild diffuse swelling of the brain. an appropriately cross matched, size appropriate liver is available. which of the following is the most appropriate course of action regarding transplantation.
1-do not proceed with transplantation because DM is a contraindication
2-do not proceed with transplantation because hepatic function is likely to return over the next week
3-do not proceed with transplantation because major depressive disorder places the pt at risk for another suicide attempt
4-do not proceed with transplantation because the onset of encephalopathy and CT findings suggest bacterial meningitis
5-proceed with the transplantation
Edited by achilles on 06/01/06 - 08:26 AM
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| AAAAA
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ACP guidelines for contraindications to lvier transplantation includes
HIV disease, extrtahepatic malignancies in which recurrence is possible, unresolved sepsis, other severe medical illnesses such as cardiopulmonary compromise, and active use of alcohol or illicit drug use.
(But general contraindication include age over 70 and more...............)
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| AAAAA
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The MELD Model
In the following model, survival probability of a patient with end stage liver disease is estimated based on the following variables. Please enter data in the corresponding boxes.
The MELF score provides a eliable estimate of short term survival for liver diseases. And this pt may be suitable for liver transplantatiom
What is the INR?
What is the bilirubin? (mg/dl)
What is the creatinine? (mg/dl)
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| AAAAA
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What is MELD? How will it be used?
The Model for End-Stage Liver Disease (MELD) is a numerical scale, ranging from 6 (less ill) to 40 (gravely ill), that is used for adult liver transplant candidates. It gives each individual a ‘score’ (number) based on how urgently he or she needs a liver transplant within the next three months. The number is calculated by a formula using three routine lab test results:
• bilirubin, which measures how effectively the liver excretes bile;
• INR (prothrombin time), which measures the liver’s ability to make blood clotting factors; and
• creatinine, which measures kidney function. (Impaired kidney function is often associated with severe liver disease.)
The MELD score replaced the previous Status 2A, 2B and 3 categories. The status 1 category (patients who have acute liver failure and a life expectancy of less than 7 days without a transplant) remains in place as the highest priority for receiving an organ and is not affected by the MELD system.
A patient’s score may go up or down over time depending on the status of his or her liver disease. Many patients will have their MELD score assessed a number of times while they are on the waiting list. This will help ensure that donated livers go to the patients in greatest need at that moment.
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| AAAAA
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5 proceed with liver transplant
I do not know the real answer what I had been to transplant service and I did not remember major depression or DM Type I are contraindication.
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| AAAAA
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Liver Transplant candidate/potential recipient with major depression
Psychosocial assessments differ in content and application to candidate selection depending on the transplant program. Psychosocial status before transplant does not consistently affect medical outcome after transplant. Psychosocial status generally improves with transplant, although difficulties are prevalent in psychological adjustment and in compliance with medical regimens. Psychiatric history can predict psychological outcomes after transplant but does not consistently predict compliance. Social supports and coping strategies strengthen psychosocial outcomes. Post transplant psychosocial outcomes may predict physical morbidity and mortality. Attention to adult patients' psychosocial status and well- being throughout the organ transplant experience is important for 2 very distinct reasons. First, information about psychosocial history and current status is relevent to and frequently used for clinical decision making before transplantation. Second, information about patients' psychosocial status after transplant often provide important outcome information.
As part of any psychosocial assessment, a psychiatric evaluation should be performed tht covers both current and past mental health. Other areas that must be evaluated are patients' compliance with past and current treatment regimens and patients' histories of substance use and abuse. At the least, a brief assessment or screen for current health mental (cognitive) status should routinely be included in the psychosocial evaluation, because cognitive status will affect patients' ability to understand the transplant experience and provide informed consent, as well as comprehend what is required of them as transplant candidates and ultimately as recipients. The remaining elements of the psychosocial assessment focus on the patients' interpersonal and intrapersonal resources and liabilities. Family members' own mental health history and social functioning are also relevent in understanding the psychosocial environment of the patient. Serious mental health and/or social dysfunction in 1 or more family members can serve significant sources of stress for the patients, and may result in an absence of the support needed by the patient. The emphasis the transplant team places on evaluation findings will all vary depending upon the team's philosophy and beliefs about the role of their evaluation. Identical views about the psychosocial assessment's role in the transplant process are not shared among transplant programs.
The greatest controversary and disagreement - moral and ethical issues arise when medical care -including transplantation -is offered or denied to individuals on the basis of their psychosocial history or current status. America and Europe differ in whether they apply additional psychosocial criteria to select transplant candidates from patients who may be medically equivalent in terms of their needs for transplant.
General medical conditions impact on eligibility for transplantation: psychosocial problems that are unable to be resolved and have a high likelihood of impacting negatively on the patient's outcome, such as poorly controlled major psychoaffective disorder or inability to comply with complex medical regimen, are a relative contraindication. A documented history of noncompliance with medical care... even in the absence of documented psychiatric problems is a relative contraindication.
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| AAAAA
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General medical conditions impact on eligibility for transplantation: psychosocial problems that are unable to be resolved and have a high likelihood of impacting negatively on the patient's outcome, such as poorly controlled major psychoaffective disorder or inability to comply with complex medical regimen, are a relative contraindication. A documented history of noncompliance with medical care... even in the absence of documented psychiatric problems is a relative contraindication.
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| AAAAA
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Major psychoaffective disorder i.e. mania, schizophrenia are relative contraindication.
So major depression is not even a relative contraindication.
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| AAAAA
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AAAAA wrote:
Major psychoaffective disorder i.e. mania, schizophrenia are relative contraindication.
So major depression is not even a relative contraindication.
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| AAAAA
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This is the best answer I believe will help to answer this question
Assessment for Liver Transplantation
election of recipients for liver transplantation is based on 1) the severity and prognosis of the patient's liver disease; 2) related medical, surgical, and psychological factors; and 3) the desires of the patient. Severity of liver failure in patients with chronic liver disease is assessed by the Child-Pugh classification and the MELD (model for end-stage disease based) score. The Child-Pugh classification is based on empiric evaluation of 1) ascites, 2) encephalopathy, 3) prothrombin time, 4) serum bilirubin, and 5) serum albumin. The MELD score is based on 1) INR, 2) serum bilirubin, and 3) serum creatinine. The timing of placement of patients on the waiting list is based on assessment of stable versus decompensated cirrhosis. In the United States, patients are centrally listed and organs are first allocated to the sickest patient. Priority is given to patients with fulminant hepatic failure or primary allograft nonfunction. Suitability for transplant includes cardiac, pulmonary, renal, endocrine, oncological, infectious, nutritional, and psychological assessments.
Key Words: liver transplantation • Child-Turcotte-Pugh classification • porto-pulmonary hypertension • fulminant hepatic failure
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| AAAAA
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So based on the explanation I would choose
5 Go ahead with the transplantation.
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| frontal
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2 ? -do not proceed with transplantation because hepatic function is likely to return over the next week
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| achilles
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sorry folks i dont have the answer but i went for 5 myself.
hoping for lot more inputs so that we can come to the right answer.
thanks Dr AAAAA. that was really extensive but helpful.
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| AAAAA
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Dr. Frontal,
According to the guideline, it is hepatic failure that we do transplant for suitable candidate and it is THE ONLY CURE. Surgery----organ transplantation is the only cure for this very young pt despite major depression and intentional overdose for suicidal attempt (please read accidental overdose is the major cause of death ).
Let me tell you in COMMON SENSE :
Most DM Type 1 patients will present with major depression or adjustment disorder with depressed mood and suicidal attempt , but it is not the reason she is denied an organ transplant according to the ACP guideline if such liver is available !
Her major depression is probably due to DM Type 1 and I think she deserves a chance to have a new liver to correct her encepathology, and her underlying problems !
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| AAAAA
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This is a trap !
She is not an alcoholic, drug use or any major medical problems except DM I, so she is actually a very good candidate to have a liver transplant !
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| AAAAA
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Dr. Frontal,
I do take into account of your explanation seriously but there is no Cr given to prove this is a hepatorenal disease. SInce the majority of all overdose recover, this patient did suffer irreversible hepatic failure and encephalopathy, the ONLY course of treatment is liver transplantation.
OTHERWISE, SHE WILL DIE ! There is no medical treatment for this patient on Day 6 !
Peak hepatotoxicity occurs on 72-96 hours (3-4 days) after overdose of acetaminophen and most pt recovered. But she is on the downhill on Day 6, the likelihood she would recover is nil.
So I choose 5 (liver transplantation) to save her life !!!!!!!!
THERE ARE NO OTHER CHOICES TO SAVE HER LIFE IF YOU DENY HER CHANCE TO GET A NEW LIVER !
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| Jinx
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OTHERWISE, SHE WILL DIE ! There is no medical treatment for this patient on Day 6 !
Peak hepatotoxicity occurs on 72-96 hours (3-4 days) after overdose of acetaminophen and most pt recovered. But she is on the downhill on Day 6, the likelihood she would recover is nil.
So I choose 5 (liver transplantation) to save her life !!!!!!!!
THERE ARE NO OTHER CHOICES TO SAVE HER LIFE IF YOU DENY HER CHANCE TO GET A NEW LIVER !
Exactly!!!!!!--AAAAA uve explained it perfectly
answer is 5 im sure
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| frontal
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I'm convinced that I made a wrong guess. 5 does seem most appropriate. Thank you for the enlightenment!
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| achilles
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thanks so much guys. i had chosen 5 too but i was not sure of the answer and was'nt backing it up with such sound knowledge. all i could make out was that the other options were not the right answer. but now i know ! thanks again.
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| study_ing
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vow..i had chosen 2!!..guys this is defintiely a good ddiscussion
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