Ascites, SBP, HRS Flashcards
When should fluid restriction be employed?
When there is hyponatremia (Na<125), should restrict fluid to 1L a day
Having ascites without hyponatremia does not require fluid restriction
What weight loss per day is recommended in someone with peripheral edema and someone without?
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
How can you use 24 hour urinary sodium to guide therpay in ascites?
if Na excretion is lower than the intake –> insufficient diuresis dose
Persistent ascites despite adequate urinary sodium excretion –> dietary indiscretion
How can you use the urinary Na/K ratio to help guide therapy?
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”
What is max dose of spironolactone and lasix in ascites?
Spironolactone max dose is 400/day
Lasix ís 160
What can be used for muscle cramping in cirrhosis?
baclofen 10mg/day up to 30 mg/day
Albumin 29-40/week
What is first line treatment of moderate ascites (grade 2)
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
What is half life of aldactone? What are alternatives to aldacone due to gynecomastia
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
What is treatment of grade 3 ascites
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
What drugs should be avoided in cirrhosis and ascites?
Any drug that can further reduce the effective arterial volume and renal perfusion and nephrotoxins
Ace inhibitors
NSAIDS
Aminoglycosdes
IV contrast is ok
When do you give albumin after a paracentesis and how much?
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
When is the risk of post paracentesis circulatory dysfunction the highest?
When >8L is removed. So shouldn’t really remove more than 8L at a time
How do you use NSSB in ascites?
Mixed data, but not necessarily contraindicated in patients with ascites. But cation should be taken in patients with hypotension, HYPONATREMIA and AKI.
Correction of which electrolyte helps with hyponatremia?
hypokalemia
How do you manage hypoNa of 126-135?
if no symptoms and cirrhosis, can monitor and start fluid restriction to 1500cc/day
how do you manage hypoNa of 120-125 in cirrhosis?
water restriction to 1L/day and cessation of diuresis
How do you manage hypoNa of 120?
more severe water restriction with albumin infusion
Can you use vaptans in cirrhosis and hypoNa?
yes, but should be used with caution and short term (<30 days)
How fast can you correct chronic hypoNa in cirrhosis
increase Na by 4-6 mEq/24 hour, not to exceed 8 mEq in 24 hours to decrease rate of ODS
What are MELD exceptions points for HH?
- At least 1 thora >1 L weekly in last four weeks
- Pleural fluid is trasudative by pleural albumin-serum albumin gradient of at least 1.1
- No evidence of heart failure
- culture negative on 2 separate occasions
- pleural cytology is benign on 2 separate occasions
- There is a contraindication to TIPS
- Diuretic refractory
What do you do for someone with positive culture but PMN<250?
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
When do you need to do a repeat para for SBP?
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
What do you do with NSBB in SBP?
only need to be held in patients who develop hypotension (MAP <65) or AKI. otherwise can continue
What are requirements for primary SBP prophylactic?
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
What is the goal of NE in HRS?
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
All patients with cirrhosis and AKI should have what?
a LT eval given the high short term mortality even in responders to vasocontrictor therapy
What are criteria for SLK?
1, AKI:
a. dialysis at least once every 7 days for six weeks
b. GFR <25 once every 7 days for six weeks
- 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 - metabolic disease
a. atypical HUS with mutation
b. methylmalonic acid
c. oxaluria - 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
How is AKI in cirrhosis defined?
Rise in SCr ≥ 50% from the baseline or rise in SCr ≥ 0.3 mg/dL in <48 hours
What is the major cause of renal failure in cirrhosis?
Infection, followed by hypovolemia, followed by HRS
those with renal failure associated with infections and HRS had the lowest 3-month survival probabilities
What is post paracentesis circulatory dysfunction?
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
How much albumin is given with vasoconstrictors in HRS?
Concomitant administration of albumin and vasoconstrictor drugs (1 g/kg of body weight on day 1 followed by 20–40 g/day).
When to use hypertonic saline in hyponatremia?
Hypertonic saline is rarely used in the stable patient without evidence of severe symptoms such as seizures due to the risk of rapid correction
How long before and after should anti-platelets be held prior to liver biopsy?
Held for several to 10 days before, restarted 48-72 hours after
When should warfarin be held and restarted after liver biopsy?
held 5 days before, restarted the day following biopsy
Someone with Crohn’s, presents with ascites but synthetic function is preserved. What do you think
NRH from AZA
non cirrhotic form of portal HTN
NRH also associated with hematologic malignancy (myelodysplastic syndrome, PV, essential thrombocytosis, hypercoagu states like factorV
What do you see on biopsy for NRH
alternating regions of atrophic liver with no inflammation or firbosis
CK7
stain for bile ducts
What is reversal for dabigatran
idarucizumab
daba is a thrombin inhibitor
What is protamine
reversal for heparin
What are TEG parameters for transfusion
if max amplitude is <30 mm, can give platelets
If reaction time >40 min, given FFP
When does ablation lead to curative response
usually when tumor is < 3cm
Does use or sirolimus decrease recurrence of HCC
one study in SRTR showed less recurrence if sirolimus used, but not statistically significant
Which HCC treatment can cause hepatic abscesses
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
When do you need to worry about NSF with gadolinuum
When GFR <30 it can be seen (in stage 5 CKD really, and rarely in stage 4)
What are risk factors for graft failure
Donor > 60 years
Height
Split/partial graft
sharing outside of region
cold ischemia time
cause of death (CVA/stroke, DCD- both are bad prognosis)
Bedtime snack does what
help increase muscle mass
What do you do if someone’s native liver is found to have residual Hcc after transplant
closer monitoring. you don’t change IS, you dont add mTOR, and you don’t give sorafenib
How do you treat GAVE in cirrhosis
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
What types of ischemic cholangiopathy has the worse outcomes
- Those with diffuse peripheral necrosis (highest risk of graft failure and will likely need re-transplant)
2.multifocal stenosis (intermediate risk of graft failure) - Strictures only at hilum, or start at hilum and then progress to intrahepatic ducts (have the best outcomes)
What is a risk factor for placing TIPS for refractory ascites
incarcerated hernia if umbilical hernia is present. Thought to be 2/2 to fast reduction ascites and therefore smaller defect, leading to incarceration.
What to do if you see gastric varices
- see if esophageal varices are present.
- 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
Someone with Bili 5, INR 1.2, ALT 1000, HBV 1 million, what do you do
most cases of acute hep b resolve. you should just do serial monitoring in this case.
when do you treat acute hep b
ALF
protracted symptoms > 4weeks
What do you see on biopsy for PHG vs GAVE
Where can both occur
What is salvage therapy
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
When do you resect hepatic adenoma
- > 5 cm
- Male gender (any size) because high risk of malignancy transformation
- Hemorrage
- presence of beta catenin
What mass is OCP associated with
adenoma, will regress if stop OCP in 80% of cases
When do anticoagulant PVT
- extension into mesenteric system
- port-thrombotic state demonstrated
- Acute or subacute thrombosis
- transplant candidate
** need to consider varices
**heparin if frequent paracentesis is needed
DO OCP’s need to be stopped in FNH
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
Who can be placed on obeticholic acid in PBC
- after 1 year of poor response to urso (defined as any elevation in alk phos)
- 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
What is side effect of OCA
pruritis
Can you get acute hep c
yes, called fibrosing cholestatic hep c
SAAG<1.1. total protein low
nephrotic
SAAG<1.1, total protein high
malignancy TB
CA 125 is elevated when?
cirrhotic or non cirrhotic liver disease
cholangitis
can be as high as 700-800 in those with ascites
those without ascites usually 100-200
C2Y282 homozygote
Ferritin normal
What do you do
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
What do you see in IgG4 biopsy
lymphocytic infiltrate
What are indications for treating Hep B when starting DAA in Hep C
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
What is UCSF
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
What are drugs that increase tac toxicity
Inhibitors (↑ drug level)
•Erythromycin
•Clarithromycin
•azole
•Verapamil
•Ritonavir
What are things that decrease tac level
Phenytoin
•Rifampin
•Chronic alcohol use
•Phenobarbital
What type of surgery does not require v-v echmo
piggyback so less AKI
What are risk factors for primary non function
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
What are risks for HAT
- pediatric tx
- split liver/living donor
- arterial reconstruction
- hx of locoregional therapy
How does PVT present if acute vs chronic
acute: labs go up abruptly
chronic: more pHTN related complicated
What is the most important risk factor for post transplant NAFLD
post LT BMI
Pre and post ETOH use
post LT HLD
post LT DM
How much weight loss to decrease steatosis, steatohepatitis, and fibrosis
5%- steatosis
7% steatohepatitis
10% fibrosis
Where are each IS drugs absorbed?
- tac and mtor in duodenum
- mmf in stomach
how are IS affected by bariatric surgery
mmf affected by RYB and gastric sleeve (both will remove stomach)
tac and mtor affected by ryb because no duodenum
statins and CNI
CNI will inhibit statin metabolism, safest is pravastatin
What are concerns with GLP1agonits and SGLTi post transplant
GLP1 agonists (tides) cause delayed gastric emptying, so will need to watch IS levels
SGLTi inhibitors can cause UTI in immunosuppressed patients (flozin)
What is an important risk factor for recurrence post surgery in CCA
LN involvement,
LNs beyond the hepatoduodenal and gastrohepatic ligament are
contraindications for surgery, and upfront chemotherapy is preferred
What should be done post surgery for all patients with CCA
capcetibine
Who gets screened for HCC
cirrhosis
Asian male with Hep B >40
Asian woman with Hep B >50
Young africans with Hep B
family hx of bcc
What defines CSPH
HVPG>10
What is definition of CSPH on LSM
LSM>20-25 + plts <150
or
LSM >15-20 + plts <110
Who gets BB in varices
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
What is cadence for variceal screening if ELV
2-8 weeks until eradication
eradication
first EGD post eradication 3-6 months
then every 6-12 months
How frequently do you repeat EGD for varices
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
What is RHC in portopulm HTN
mPAP >20-25
PCWP <15
PVR>/= 3 or 240 dynes
for MELD exceptin
mPAP<35
PVR,400/5.1
What stain is used to distinguish lipufusion from iron
Prussian blue, iron will be blue
You are a C282Y homozygote, elevated ferritin, but normal labs, what do you do
phlebotomy
when you do you do phlebotomy in non HFE HH
elevated HIC
if you have elevated labs, c282y homozygote, elevated ferriting
phlebotomy
difference in pathophys from type 1 and type 4 HH
type 1/HFE: hepcidin deficiency
type 4/FPB: reistance of binding hepcidin to ferroprotin
what anticoagulation levels should be replaced in cirrhosis
low fibrinogen has been associated with increased bleeding risk in cirrhosis so cryo should be used to replace >100, more so before procedures.
What does PVT mean in non transplant and transplant
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
Do you want to start AC in PVT until varices eradicated
not necessarily, can do EGD on AC. Should NOT DELAY ac until varices eradicated or beta blockade achieved
Who do you AC for PVT
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
What do you need to do if HCC is suspected in BCS
have to biopsy and diagnose histologically because nodules look weird.
remember, BCS will have lots of nodules pop up because of congestion
When is RHC indicated with what level of RVSP
> 45
Is LT a cure for HPS or POPH
HPS- almost all improve
POPH- half improve post LT
What level of coronary calcium is strongly associated with CAD
400 (although this is not the threshold to which you would get LHC)
Is systolic or diastolic dysfunction a contraindication to LT
diastolic dysfunction should be monitored with q6 month TTE but not a contraindication
EF<40% is a contraindication to LT
PNF is secondary to what?
ischemic and reperfusin injury, induces an innate immunity mediated injury
What is reperfusion injury
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
How is median MELD calculated
based on recipients hospital location
- within 150 miles
- take the MELD score of those transplanted within 365 days
how is priority given to those who are status 1A
by wait time
Who can get status 1B
less than 18 years old
What is in PELD
GABA inhibitor
G- growth
A- albumin
B- bili
A- age
I- INR
What is the Final rule
allocation policy is objective and measurable medical criteria
most to least medically urgent
What BMI is a relative contraindication
BMI>40
When is cardiac stent needed
> 70% occlusion
when do you start treatment for latent TB
PRE TX
is there recurrence of A1AT post tx
no- you get the donor’s phenotype and levels within several weeks
