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Transplant Hep Boards > Ascites, SBP, HRS > Flashcards

Ascites, SBP, HRS Flashcards

1
Q

When should fluid restriction be employed?

A

When there is hyponatremia (Na<125), should restrict fluid to 1L a day
Having ascites without hyponatremia does not require fluid restriction

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2
Q

What weight loss per day is recommended in someone with peripheral edema and someone without?

A

Peritoneal membrane can resorb 500 cc per day. So in a patient without peripheral edema, can lose 0.5kg/day. In someone with peripheral edema, can lose 1kg/day

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3
Q

How can you use 24 hour urinary sodium to guide therpay in ascites?

A

if Na excretion is lower than the intake –> insufficient diuresis dose

Persistent ascites despite adequate urinary sodium excretion –> dietary indiscretion

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4
Q

How can you use the urinary Na/K ratio to help guide therapy?

A

Urine Na/K >1, patient should be losing fluid weight, and if not, dietary non compliance should be suspected

Urina Na/K <1, in suffisaient natriuresis, so need to increase diuresis

Think “diuresis should be wasting more Na than K”

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5
Q

What is max dose of spironolactone and lasix in ascites?

A

Spironolactone max dose is 400/day
Lasix ís 160

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6
Q

What can be used for muscle cramping in cirrhosis?

A

baclofen 10mg/day up to 30 mg/day
Albumin 29-40/week

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7
Q

What is first line treatment of moderate ascites (grade 2)

A

moderate Na restriction (2g/day) + diuretics (spironolactone with or without lasix).

Of note- a study showed in first episode of ascites, spironolactone alone was effective. Those with longstanding ascites respond better to combination of lasix and aldactone

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8
Q

What is half life of aldactone? What are alternatives to aldacone due to gynecomastia

A

three days, so shouldn’t be titrated up before 72 hours.

alternatives = amiloride or epleronone
100 mg of spironolactone = 50 mg of eplerenone or 10 mg of amiloride

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9
Q

What is treatment of grade 3 ascites

A

grade 1 ascite = only detected by U/S
Grade 2 ascites- moderate ascites
grade 3 = marked dissension of abdomen

Grade 3 treatment = LVP. After paracentesis, Na restriction and diuretics should be started

Referral for LT should be at grade 2 or grade 3 ascites

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10
Q

What drugs should be avoided in cirrhosis and ascites?

A

Any drug that can further reduce the effective arterial volume and renal perfusion and nephrotoxins

Ace inhibitors
NSAIDS
Aminoglycosdes
IV contrast is ok

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11
Q

When do you give albumin after a paracentesis and how much?

A

You should give 6-8g albumin for every liter removed (but don’t need to given unless more than 5L removed)

So if remove 5L, give 40 g
if remove 8L, give 64 g

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12
Q

When is the risk of post paracentesis circulatory dysfunction the highest?

A

When >8L is removed. So shouldn’t really remove more than 8L at a time

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13
Q

How do you use NSSB in ascites?

A

Mixed data, but not necessarily contraindicated in patients with ascites. But cation should be taken in patients with hypotension, HYPONATREMIA and AKI.

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14
Q

Correction of which electrolyte helps with hyponatremia?

A

hypokalemia

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15
Q

How do you manage hypoNa of 126-135?

A

if no symptoms and cirrhosis, can monitor and start fluid restriction to 1500cc/day

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16
Q

how do you manage hypoNa of 120-125 in cirrhosis?

A

water restriction to 1L/day and cessation of diuresis

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17
Q

How do you manage hypoNa of 120?

A

more severe water restriction with albumin infusion

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18
Q

Can you use vaptans in cirrhosis and hypoNa?

A

yes, but should be used with caution and short term (<30 days)

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19
Q

How fast can you correct chronic hypoNa in cirrhosis

A

increase Na by 4-6 mEq/24 hour, not to exceed 8 mEq in 24 hours to decrease rate of ODS

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20
Q

What are MELD exceptions points for HH?

A
  1. At least 1 thora >1 L weekly in last four weeks
  2. Pleural fluid is trasudative by pleural albumin-serum albumin gradient of at least 1.1
  3. No evidence of heart failure
  4. culture negative on 2 separate occasions
  5. pleural cytology is benign on 2 separate occasions
  6. There is a contraindication to TIPS
  7. Diuretic refractory
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21
Q

What do you do for someone with positive culture but PMN<250?

A

no need for antibiotics as it should self resolve or is a contaminant. Repeat diagnostic para is needed to see if progression to SBP occurs

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22
Q

When do you need to do a repeat para for SBP?

A

Should be done with giving antibiotics empirically (i.e PMN>250, negative culture at 48 hours)

Should do it 2 days after intiiation of abx. Decrease in PMN <25% from baseline, means not responding and should broaden abx coverage and rule out secondary bacterial peritonitis

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23
Q

What do you do with NSBB in SBP?

A

only need to be held in patients who develop hypotension (MAP <65) or AKI. otherwise can continue

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24
Q

What are requirements for primary SBP prophylactic?

A

Cirrhosis and low ascitic fluid protein (<1.5):
- renal dysfunction (Cr >1.2)
- BUN >25
or
-Na <130

or
- liver failure with T bil >3 and CP >9

of admitted and have ascitic protein <1

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25
Q

What is the goal of NE in HRS?

A

start at 0.5 mg/hr to achieve an increase in MAP of at least 10 mag Hg or an increase in UOP of >200 mL/4 hours. If one of these goals is not met, increase dose every 4 hours by 0.5 up to max of 3 mg/hr

albumin should also be given to main a CVP fo 4 to 10

Ultimately, the response to terlipressin or NE is Cr <1.5 or within 0.3 of baseline Cr in 14 days. If Cr remains at or above pretreatment level over 4 days with max doses of vasoconstrictor tolerated, then therapy may be discontinued

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26
Q

All patients with cirrhosis and AKI should have what?

A

a LT eval given the high short term mortality even in responders to vasocontrictor therapy

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27
Q

What are criteria for SLK?

A

1, AKI:
a. dialysis at least once every 7 days for six weeks
b. GFR <25 once every 7 days for six weeks

  1. CKD with GFR<60 for >90 days and one of the following:
    - ESRD
    - GFR<35 at the time of or after registration on kidney waiting list
  2. metabolic disease
    a. atypical HUS with mutation
    b. methylmalonic acid
    c. oxaluria
  3. safety net = any patient who is registered on kidney waitlist between 60 and 365 days after LT and is either on chronic hemodialysis or have eGFR <20 will qualify
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28
Q

How is AKI in cirrhosis defined?

A

Rise in SCr ≥ 50% from the baseline or rise in SCr ≥ 0.3 mg/dL in <48 hours

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29
Q

What is the major cause of renal failure in cirrhosis?

A

Infection, followed by hypovolemia, followed by HRS

those with renal failure associated with infections and HRS had the lowest 3-month survival probabilities

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30
Q

What is post paracentesis circulatory dysfunction?

A

activation of the renin-angiotensin system that occurs because of the removal of large amounts of ascites

although clinically silent, may be associated with ascites re-accumulation, hyponatremia, HRS, and decreased surviva

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31
Q

How much albumin is given with vasoconstrictors in HRS?

A

Concomitant administration of albumin and vasoconstrictor drugs (1 g/kg of body weight on day 1 followed by 20–40 g/day).

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32
Q

When to use hypertonic saline in hyponatremia?

A

Hypertonic saline is rarely used in the stable patient without evidence of severe symptoms such as seizures due to the risk of rapid correction

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33
Q

How long before and after should anti-platelets be held prior to liver biopsy?

A

Held for several to 10 days before, restarted 48-72 hours after

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34
Q

When should warfarin be held and restarted after liver biopsy?

A

held 5 days before, restarted the day following biopsy

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35
Q

Someone with Crohn’s, presents with ascites but synthetic function is preserved. What do you think

A

NRH from AZA
non cirrhotic form of portal HTN

NRH also associated with hematologic malignancy (myelodysplastic syndrome, PV, essential thrombocytosis, hypercoagu states like factorV

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36
Q

What do you see on biopsy for NRH

A

alternating regions of atrophic liver with no inflammation or firbosis

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37
Q

CK7

A

stain for bile ducts

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38
Q

What is reversal for dabigatran

A

idarucizumab

daba is a thrombin inhibitor

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39
Q

What is protamine

A

reversal for heparin

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40
Q

What are TEG parameters for transfusion

A

if max amplitude is <30 mm, can give platelets

If reaction time >40 min, given FFP

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41
Q

When does ablation lead to curative response

A

usually when tumor is < 3cm

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42
Q

Does use or sirolimus decrease recurrence of HCC

A

one study in SRTR showed less recurrence if sirolimus used, but not statistically significant

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43
Q

Which HCC treatment can cause hepatic abscesses

A

TACE, due to bacterial colonization of biliary tree. unclear if this still happens but 2017 says can give moxi before and after

highest risk in those with sphincterotomy

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44
Q

When do you need to worry about NSF with gadolinuum

A

When GFR <30 it can be seen (in stage 5 CKD really, and rarely in stage 4)

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45
Q

What are risk factors for graft failure

A

Donor > 60 years
Height
Split/partial graft
sharing outside of region
cold ischemia time
cause of death (CVA/stroke, DCD- both are bad prognosis)

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46
Q

Bedtime snack does what

A

help increase muscle mass

47
Q

What do you do if someone’s native liver is found to have residual Hcc after transplant

A

closer monitoring. you don’t change IS, you dont add mTOR, and you don’t give sorafenib

48
Q

How do you treat GAVE in cirrhosis

A

APC, if no improvement with APC, can do RFA>
TIPS does not work because GAVE is due to vascular proliferation, not to high portal pressure

49
Q

What types of ischemic cholangiopathy has the worse outcomes

A
  1. Those with diffuse peripheral necrosis (highest risk of graft failure and will likely need re-transplant)
    2.multifocal stenosis (intermediate risk of graft failure)
  2. Strictures only at hilum, or start at hilum and then progress to intrahepatic ducts (have the best outcomes)
50
Q

What is a risk factor for placing TIPS for refractory ascites

A

incarcerated hernia if umbilical hernia is present. Thought to be 2/2 to fast reduction ascites and therefore smaller defect, leading to incarceration.

51
Q

What to do if you see gastric varices

A
  1. see if esophageal varices are present.
  2. if no EV present, and isolated gastric varices, get a CT scan to look for splenic vein thrombosis. If splenic vein thrombosis, then can be treated with splenectomy for gastric varices.
    3 If actively bleeding, can try glue. and if re-bleeds, can do TIPS
52
Q

Someone with Bili 5, INR 1.2, ALT 1000, HBV 1 million, what do you do

A

most cases of acute hep b resolve. you should just do serial monitoring in this case.

53
Q

when do you treat acute hep b

A

ALF
protracted symptoms > 4weeks

54
Q

What do you see on biopsy for PHG vs GAVE
Where can both occur
What is salvage therapy

A

PHG- dilated capillaries and venules, can be in SM and colon, salvage is TIPS

GAVE: thrombi, spindle cell proliferation, only in stomach, salvage is antrectomy

55
Q

When do you resect hepatic adenoma

A
  1. > 5 cm
  2. Male gender (any size) because high risk of malignancy transformation
  3. Hemorrage
  4. presence of beta catenin
56
Q

What mass is OCP associated with

A

adenoma, will regress if stop OCP in 80% of cases

57
Q

When do anticoagulant PVT

A
  1. extension into mesenteric system
  2. port-thrombotic state demonstrated
  3. Acute or subacute thrombosis
  4. transplant candidate

** need to consider varices
**heparin if frequent paracentesis is needed

58
Q

DO OCP’s need to be stopped in FNH

A

We generally do not insist that oral contraceptives and other estrogen-containing preparations should be discontinued.

However, it is reasonable to obtain a follow-up imaging study in 6 to 12 months in women with FNH who continue taking these drugs

59
Q

Who can be placed on obeticholic acid in PBC

A
  1. after 1 year of poor response to urso (defined as any elevation in alk phos)
  2. contraindicated in patients wit:
    — decompensated cirrhosis (Child-Pugh class B or C)
    —a prior decompensation event (gastroesophageal varices, encephalopathy)
    — compensated cirrhosis with portal hypertension(ascites, varices, thrombocytopenia) because hepatic decompensation and liver failure have been reported with obeticholic acid use in such patients

can use with or without urso (if unable to tolerate urso)

Response to OCA is defined as alk phos <1.67 x ULN

60
Q

What is side effect of OCA

A

pruritis

61
Q

Can you get acute hep c

A

yes, called fibrosing cholestatic hep c

62
Q

SAAG<1.1. total protein low

A

nephrotic

63
Q

SAAG<1.1, total protein high

A

malignancy TB

64
Q

CA 125 is elevated when?

A

cirrhotic or non cirrhotic liver disease
cholangitis
can be as high as 700-800 in those with ascites
those without ascites usually 100-200

65
Q

C2Y282 homozygote
Ferritin normal
What do you do

A

serial testing, do not need to start phlebotomy is ferritin is normal and no iron on MRI, even if you are a homozygote

Start therapy if homozygote if ferritin is elevated

c282Y homozygote:
1. if ferritin >1000, OR, LFTs elevated –> biopsy –> phlebotomy
2. if ferritin is <1000 AND normal LFTs –> phlebotomy
3. if ferritin is normal, LFT’s normal –> watch

66
Q

What do you see in IgG4 biopsy

A

lymphocytic infiltrate

67
Q

What are indications for treating Hep B when starting DAA in Hep C

A

same as standard indications

if on DAA and HBV DNA positive at baseline, monitor closely, Start anti-viral tx if HBV DNA level increases >10x or is >1000 IU/mL in a pt w/ undetectable or unquantifiable HBV DNA prior to DAA treatment

68
Q

What is UCSF

A

Milan (also UNOS)
•1 lesion ≤ 5 cm
•3 lesions ≤ 3 cm
•No vascular invasion or extrahepatic metastases

Expanded (UCSF)
•1 lesion ≤ 6.5 cm
•2-3 lesions
–largest ≤ 4.5 cm
–total < 8 cm
•No vascular invasion or extrahepatic metastases

69
Q

What are drugs that increase tac toxicity

A

Inhibitors (↑ drug level)
•Erythromycin
•Clarithromycin
•azole
•Verapamil
•Ritonavir

70
Q

What are things that decrease tac level

A

Phenytoin
•Rifampin
•Chronic alcohol use
•Phenobarbital

71
Q

What type of surgery does not require v-v echmo

A

piggyback so less AKI

72
Q

What are risk factors for primary non function

A

Donor:
1. longer hospital stay
2. Age >49
3. Long preservation time
4. steatosis
5. Small for size
6. hyperNa

Recipient
1. young age
2. need for RRT

73
Q

What are risks for HAT

A
  1. pediatric tx
  2. split liver/living donor
  3. arterial reconstruction
  4. hx of locoregional therapy
74
Q

How does PVT present if acute vs chronic

A

acute: labs go up abruptly
chronic: more pHTN related complicated

75
Q

What is the most important risk factor for post transplant NAFLD

A

post LT BMI
Pre and post ETOH use
post LT HLD
post LT DM

76
Q

How much weight loss to decrease steatosis, steatohepatitis, and fibrosis

A

5%- steatosis
7% steatohepatitis
10% fibrosis

77
Q

Where are each IS drugs absorbed?

A
  1. tac and mtor in duodenum
  2. mmf in stomach
78
Q

how are IS affected by bariatric surgery

A

mmf affected by RYB and gastric sleeve (both will remove stomach)

tac and mtor affected by ryb because no duodenum

79
Q

statins and CNI

A

CNI will inhibit statin metabolism, safest is pravastatin

80
Q

What are concerns with GLP1agonits and SGLTi post transplant

A

GLP1 agonists (tides) cause delayed gastric emptying, so will need to watch IS levels

SGLTi inhibitors can cause UTI in immunosuppressed patients (flozin)

81
Q

What is an important risk factor for recurrence post surgery in CCA

A

LN involvement,
LNs beyond the hepatoduodenal and gastrohepatic ligament are
contraindications for surgery, and upfront chemotherapy is preferred

82
Q

What should be done post surgery for all patients with CCA

A

capcetibine

83
Q

Who gets screened for HCC

A

cirrhosis
Asian male with Hep B >40
Asian woman with Hep B >50
Young africans with Hep B
family hx of bcc

84
Q

What defines CSPH

A

HVPG>10

85
Q

What is definition of CSPH on LSM

A

LSM>20-25 + plts <150
or
LSM >15-20 + plts <110

86
Q

Who gets BB in varices

A

compensated: either no varices or small varices. only do BB if high risk stigmata on small varices

decmopensated: small varices –> BB
medium/large – EVL or BB

87
Q

What is cadence for variceal screening if ELV

A

2-8 weeks until eradication
eradication
first EGD post eradication 3-6 months
then every 6-12 months

88
Q

How frequently do you repeat EGD for varices

A

compensated: no varices –> 2-3 years
small varices:1-2 years

decompensated: if not EVL, then yearly
if EVL: q 2-8 weeks, eradication, 3-6 months, 6-12 months

89
Q

What is RHC in portopulm HTN

A

mPAP >20-25
PCWP <15
PVR>/= 3 or 240 dynes

for MELD exceptin
mPAP<35
PVR,400/5.1

90
Q

What stain is used to distinguish lipufusion from iron

A

Prussian blue, iron will be blue

91
Q

You are a C282Y homozygote, elevated ferritin, but normal labs, what do you do

A

phlebotomy

92
Q

when you do you do phlebotomy in non HFE HH

A

elevated HIC

93
Q

if you have elevated labs, c282y homozygote, elevated ferriting

A

phlebotomy

94
Q

difference in pathophys from type 1 and type 4 HH

A

type 1/HFE: hepcidin deficiency
type 4/FPB: reistance of binding hepcidin to ferroprotin

95
Q

what anticoagulation levels should be replaced in cirrhosis

A

low fibrinogen has been associated with increased bleeding risk in cirrhosis so cryo should be used to replace >100, more so before procedures.

96
Q

What does PVT mean in non transplant and transplant

A

in LT recipients, the presence of PVT at time of transplant is associated iwht increased post transplant mortality.

outside of LT candidates, unknown if it correlates with mortality

97
Q

Do you want to start AC in PVT until varices eradicated

A

not necessarily, can do EGD on AC. Should NOT DELAY ac until varices eradicated or beta blockade achieved

98
Q

Who do you AC for PVT

A

if main PVT, partially occlusive (>50%), thrombosis of mesenteric veins, consider AC

if intrahepatic PV, if main <50%, OR IF chronic with collaterals, can just image q3 months

99
Q

What do you need to do if HCC is suspected in BCS

A

have to biopsy and diagnose histologically because nodules look weird.

remember, BCS will have lots of nodules pop up because of congestion

100
Q

When is RHC indicated with what level of RVSP

A

> 45

101
Q

Is LT a cure for HPS or POPH

A

HPS- almost all improve
POPH- half improve post LT

102
Q

What level of coronary calcium is strongly associated with CAD

A

400 (although this is not the threshold to which you would get LHC)

103
Q

Is systolic or diastolic dysfunction a contraindication to LT

A

diastolic dysfunction should be monitored with q6 month TTE but not a contraindication

EF<40% is a contraindication to LT

104
Q

PNF is secondary to what?

A

ischemic and reperfusin injury, induces an innate immunity mediated injury

105
Q

What is reperfusion injury

A

when the clamps on the IVU are removed, so get a lot of blood back into heart and a lot of K. Includes increase in central venous pressure and pulmonary arterial pressure and decreases mean arterial pressure and peripheral vascular resistance

106
Q

How is median MELD calculated

A

based on recipients hospital location

  • within 150 miles
  • take the MELD score of those transplanted within 365 days
107
Q

how is priority given to those who are status 1A

A

by wait time

108
Q

Who can get status 1B

A

less than 18 years old

109
Q

What is in PELD

A

GABA inhibitor
G- growth
A- albumin
B- bili
A- age
I- INR

110
Q

What is the Final rule

A

allocation policy is objective and measurable medical criteria

most to least medically urgent

111
Q

What BMI is a relative contraindication

A

BMI>40

112
Q

When is cardiac stent needed

A

> 70% occlusion

113
Q

when do you start treatment for latent TB

A

PRE TX

114
Q

is there recurrence of A1AT post tx

A

no- you get the donor’s phenotype and levels within several weeks

Transplant Hep Boards (7 decks)

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