indidoc1
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42.
A 38-year-old woman receives a liver transplant for severe hepatic insufficiency caused by hepatitis C. She is the mother of three children, fathered by two different husbands. Tissue crossmatch done before the transplant predicted no histocompatibility problems, and perfusion of the transplanted organ started within 7 hours of harvesting the cadaveric organ. Three days after surgery, she develops hyperbilirubinemia, elevated transaminases, and elevated alkaline phosphatase. Which of the following is the most likely diagnosis?
A. Acute rejection episode
B. Damage to the liver from prolonged ischemia
C. Hyperacute rejection caused by preformed antibodies.
D. Recurrence of hepatitis C
E. Technical problems with the vascular or biliary anastomosis
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| neuroblastoma
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A
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| cool doctor
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E
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| me007
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B?
hyperacute rejection - during min,
acute - weeks (-A and -C)
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| Vietnamese
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A
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| doyoudig
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D. Recurrence of hepatitis C - pt who recieve liver transplants usually given ribavirin n iv immunoglobin to prevent hep c recurrence
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| deja_vu
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E?? is ALP suggesting cholestasis?
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| tamerbashir
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B
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| indidoc1
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The correct answer is E. Transplanted livers do well from an immunologic standpoint, but are bedeviled by technical problems. The first diagnostic assumption when problems occur soon after the operation revolves around the many anastomoses that were done.
Acute rejection episode (choice A) is the next best answer, and the next choice after technical problems have been ruled out.
Ischemia time indeed can be a problem (choice B) but is not likely to be the culprit in this case. Transplanted hearts and lungs have to be reperfused within 6 hours if at all possible, but the usual timetable in livers is 8-16 hours. At 7 hours, this one was done fast.
Hyperacute rejection (choice C) is a tempting diagnosis for someone who has been pregnant several times, but interestingly enough the concern does not apply to livers. Livers seem to be virtually immune to such problems, even when they have been detected by testing before transplantation. In this case, we even have the extra luxury of a reassuring tissue crossmatch (seldom possible within the limited time available, but we were told it was done).
Virtually all patients who get a new liver because the old one was destroyed by hepatitis C eventually do get recurrent disease (choice D), but they do not get it within days, and in most cases the transplanted organ survives the onslaught from the virus.
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