Autoimmune and Cholestatic Flashcards
How do you treat Hep D?
Per IFNalpha for 12 months/ until undetectable HDV RNA/ALT normalization
What happens in liver transplant and HDV?
HDV confection is a risk factor for HepB viral replication, So need to give both HBIG and NA
What is treatment for Hep E
ribavirin
How do you test immunocompetent vs immunocompromised patients for Hep E?
immunocompetent: start with anti HEV IgM and IgG and RNA
immunocompromised, started with HEV RNA
What are extrahepatic manifestations of Hep E?
Mostly neurologic and renal:
Guillan Barre
Meningoencephalitis
Myosisitis
Renal complications: IgA nephropathy, membranoproliferazive
So if you see these and elevated LFTS, think Hep E
What is Harvoni?
sofo+led
genotype 1,4,5,6
What is epclusa
sofo+velpa
pangenotypic
what Is mayvret
glecaprevir+ pibrentsavir
pangenotypic
Can’t use in decompensated
What are options for HCV without cirrhosis?
Mayret (Glec +pib) 8 weeks
Epclusa (sof +vel) 12 weeks
How do you treat HCV in decompensated cirrhosis?
Ribavirin eligible:
Epclusa +ribavirin for 12 weeks
Harvoni + ribavirin for 12 weeks (1,4,5,6 only)
Ribavirin ineligible:
HArvoni (1,4,5,6) for 24 weeks
Epclusa for 24 weeks
Avoid protease inhibitors (previr) and interferon
What is the definition of ALF?
What is the UNOS criteria for ALF?
Definition: INR >1.5, encephalopathy (any degree), without pre-existing liver disease, duration of illness <26 weeks
UNOS criteria for 1A:
-HE within 8 weeks of the first symptoms of liver disease
-absence of pre-exisiting liver disease
-must be in the ICU
- must have life expectancy of less than 7 days
- must have one of the following
—ventilator dependence
—dialysis
— INR >2.0
What are factors that influence outcome of ALF?
- early recognition
- administration of NAC
- transfer to liver transplant center
- listing for liver transplant
What are the kings college criteria for ALF due to Tylenol?
It is a prognostic model to help identify those who should be referred to transplant. There is a criteria by etiology (Tylenol vs non Tylenol)
For Tylenol ALF:
List for OLT if
- pH<7.3 after resuscitation and >24 hours post ingestion
or
- lactic >3 after IVF
Strongly consider listing if
- Lactic >3.5 after IVF
List if all three occur within 24 hour period
1. HE>grade 3
2. Cr >3.4
3. INR>6.5
What is the kings criteria for ALF not due to Tylenol
INR>6.5 and HE present
OR three of the following 5 criteria
- indeterminate etiology, non acetaminophen drug induced, unfavorable etiology
- IND >3.5
- Interval from jaundice to encephalopathy >7 days
- Bilirubin >17
- Age <10 or >40
What are favorable etiologies of ALF? And what are unfavorable etiologies of ALF?
Favorable:
- Tylenol
- Pregnancy associated
- Hep A
- ischemic hepatitis
Unfavorable:
- wilson- won’t recover if presents with alf without transplant
- non-a viral hepatitis- majority will recover with supportive care but 1% present with alf and need transplant even if on antiviral
- mushroom intoxication- can treat with penicillin g and nac, but still need lt
- budd chiari syndrome
- yellow phosphorus
- non acetaminophen drug induced
- Indeterminate
Can lactulose be used in ALF HE?
no role, just causes ileum and bowel edema
What are predictors of cerebral edema in ALF?
- persistent ammonia >150-200
- younger age - decreased free space within cranium
- hyper acute ALF phenotype
What are non - invasive methods of monitoring ICP
trans-cranial doppler
optic nerve sheath diameter
pupillometry
What are general management for elevated ICP
- HOB elevation to 30
- Avoidance of excessive stimulation
- avoidance of unnecessary or routine tracheal suctioning
- avoidance of fever
- clamping of serum sodium to 140-145
sustained elevation:
- hypertonic saline 23.4% bolus
- mannitol - in those without renal dysfunction
-indomethicin
- mechanical ventillation- only as rescue
Per AASLD:
- in ICP, can give mannitol bolus as first line therapy, but prophylactic administration is not recommended
- in ALF patients at highest risk for cerebral edema (ammonia >150, HE, acute renal failure, vasopressors), prophylactic induction of hypernatremia with hypertonic saline to a sodium level of 145-155 is ok
When can charcoal be given in Tylenol overdose?
For patients with known or suspected tylenol overdose within four hours of presentation, given activated charcoal just prior to starting NAC
How to manage ALF from mushroom poisoning?
Amanita phalloides
No blood test
look for severe GI symptoms (nausea, vomiting, diarrhea, abdominal cramping)
Tx: penicillin G and NAC
Patients with ALF from mushroom poisoning should be listed for transplantation as this procedure is often the only lifesaving option
When is liver biopsy recommended in AIH and ALF?
when AIH is suspected as cause of ALF and autoantibodies are negative.
Can still treat with steroids but need to start workup for transplant, while getting steroids
How do you treat seizures in ALF?
phenytoin and benzodiazepines with short half lives, prophylactic phenytoin is not recommended
What type of PH is portal vein thrombosis and what hepatic vein pressure measurements do you see?
prehepatic
Free: normal
Wedged: normal
Gradient/HVPG: normal
What type of portal hypertension is heart failure or SVC?
post hepatic
Free: elevated
Wedged: elevated
HVPG: normal
What type of ph is seen in cirrhosis? pressure measurements?
Sinuoidal (intrahepatic PH)
Free: normal
Wedged: Elevated
Gradient: Elevated
What type of PH Is seen in cholestatic cirrhosis or schisto?
Intrahepatic, pre-sinusoidal
Free: normal
Wedged: normal
Gradient: normal
What type of portal hypertension is seen in sinusoidal obstruction syndrome?>
Intrahepatic, post sinusoidal
Free: normal
Wedged: elevated
Gradients: elevated
What does free hepatic vein measure?
pressure in hepatic vein
what does wedged pressure measure?
portal and sinusoidal pressure
What are the cutoff for LSM of CSPH?
LSM>25 alone
LSM 20-25 + Plt <150
LSM 15-20 +plts <110
Who needs a screening EGD at time of diagnosis of cirrhosis?
everyone unless LSM <20 and Plts >150 (these have a very low probability of having high risk varices (<5%)
When should someone with compensated cirrhosis get a repeat screening endoscopy for prophylaxis?
- At time of diagnosis
- No varices –> 2 (with ongoing liver injury) to 3 years (if liver injury is quiescent)
- Small varices –> 1 to 2 years
- at time of decompensation
When should someone with decompensated cirrhosis be screened for varices?
yearly and at time of decompensation
How do you give propranolol for varices?
20-40 g orally twice a day
Adjust every 2-3 days until treatment goal (HR of 55-60) is achieved
Max dose is 320 mg/day without ascites or 160 mg/day with ascites
SBP should not fall <90
Continue indefinitely
No need for follow up EGD, but assess HR at every visit
How do you give nadolol for varices?
20-40 mg once a day (not for propranolol is it twice a day)
adjust every 2-3 days until treatment goal is achieved
Max dose is 160 mg/day in patients with ascites, 80 mg/day in patients with ascites
Goal is HR of 55-60
Continue indefinitely, making sure HR
No need for follow up EGD
How to give carvedilol for varices?
Start with 6.25 mg once a day
After three days, increase to 6.5 mg twice a day
Max dose is 12/5 mg/day
Goal is to have SBP not decrease <90
No need for follow up EGD, continue indefinitely
How often do you do EGD for EVL?
Every 2-8 weeks until eradication of varices
First EGD is 3-6 months after eradication and every 6-12 months thereafter
What does the new Baveno guidelines say re use of co-reg?
non selective beta blockers (particularly co-reg) may be considered in patients with compensated cirrhosis with CSPH (remember compensated cirrhosis can be without CSPH or with CSPH i.e presence of varices) to prevent decompensation. So if compensated cirrhosis, and evidence of varices –> can start on co-reg to prevent future decompensation
Once NSBB started, serial endoscopy not needed
How do you treat patients with compensated cirrhosis and mild pH?
objective is to prevent development of CSPH/decompensation and maybe even achieve regression of cirrhosis
NSBB are not as helpful, because they act on portal flow, and at this stage the hyper dynamic circulatory state is not fully developed
What type of portal hypertension in seen in PBC
pre-sinsuoidal
free: normal
Wedged: normal
Gradient: normal
Why is coreg better than other NSBB
has more anti alpha adrenergic vasodilatory properties that contribute to its greater portal pressure reducing effect (**I think it causes systemic vasodilation, which decreased cardiac output and therefore decreases portal pressures)
What do you do if you see medium to large varices on EGD in someone who has not bleed?
What about small varices with high risk stigmata
can do NSBB or EVL for the prevention of first VH. Should not do both EVL and BB for prophylaxis
Small varices with high risk stigmata is rare, but can do BB. May be too small for EVL
How long should you continue antibiotics with GIB?
max of 7 days, consider stopping once hemorrhage has resolved and vasoactive drugs discontinued
ceftriaxone 1g/24 hr
When should vasoactive be started in a bleed
vasoactive (octreotide 50 micrograms bolus and then continuous infusion of 50 micrograms/hr, SMT, vasopressin, terlipressin) should be initiated as soon as VH is suspected
all is for 2-5 days
When should EGD be performed for VH?
within 12 hours of admission and once stable
When is early/pre-emptive TIPS recommended?
in those with high risk of failure or rebleeding
CTP C
CTP B with active bleeding
TIPS should be within 72 hours from EGD/EVL
Once someone is banded for VH, how long to keep vasoactive on? When to start NSBB?
if no early TIPS performed, then keep vasoactive on for 2-5 days and NSBB started once vasoactive discontinued. Rescue TIPS indicated if hemorrhage can’t be controlled or if bleeding recurs despite vasoactive drug + EVL
If rescue TIPS is performed, vasoactive drugs can be discontinued
How do you treat GOV 1? What about prophylactic?
GOV 1 = extension of EV allow lesser curve
Same as that for EV
Prophy or prevention of first bleeding from GOV1 varices is the same as that for EV
Treatment for GOV2 or IGV1?
NSBB
GOV 2= extension of EV along great curve
IGV1 = gastric varies along fundus
What is treatment of bleeding GOV1?
EVL if feasible or glue
Can do combination of EVL and NSBB for prevention of re-bleed
What is treatment of GOV2 and IGV1?
TIPS
What do you do with NSBB in someone who has bleed from varices and has ascites or SBP?
refractory ascites and SBP are NOT contraindications for treatment with NSBB. Just avoid high doses (over 160 of propranolol and 80 of nadolol)
If the SBP <90 or NA <130, then dose of NSBB should be decreased, or drug temporarily held. NSBB can be re-introduced if circulatory dysfunction improves
Which are better to prevent shunt dysfunction in TIPS? Bare metal or PTFE covered stents?
PTFE covered lowers the risk
Can TIPS be used to prevent rebreeding in patients who have bled only once from EV? GV?
No- its use should only be limited to those who fail pharmacologic and endoscopic therapy
Can be used to prevent rebreeding from gastric varices and is preferred approach for the prevention of rebleeding in this group
What are absolute contraindications to TIPS?
- Primary prevention of variceal bleeding
- CHF
- Multiple hepatic cysts
- Uncontrolled systemic infection or sepsis
- Unrelieved biliary obstuction
- Severe pulmonary hypertension
What are the indications for status 1a for adults?
- Fulminant Liver failure
a. in ICU
b. no pre-exisiting liver disease
c. HE within 56 days of onset AND ONE of the following
–vent dependent
– on HD, CVVH,
– or INR >2.0 - Anheptic
- Primary nonfiction of allograft within 7 day LTx
a. AST>/= 3000 IU/L AND ONE of the following
– INR >/=2.5
– pH /= 4
* all labs must be from same lab draw - HAT
– AST>/= 3000 AND one of the following
- INR >/= 2.5
–arterial pH /= 4
** all labs must be from same lab draw - Acute decompensated Wilson disease
What are indications for pediatric 1A status?
- Fulminant liver failure, no pre-existing liver disease
– do not need to be in ICU
- HE within 56 days of onset AND ONE of the following
- vent dependent
- CVVH/HD
- INR >2.0 - Primary non function of allograft within 7 days LTx
– Two of the following
—- ALT>/=2000
— INR >/= 2.5
— Bili >/= 1-
— Acidosis defined by ONE of the following
—– arterial pH <7.3, venous pH<7.25, lactate >4 - HAT within 14 days of LTx
- no defined lab tests for HAT in Peds and note 14 days instead of 7 days as seen in adults - acute decompensated Wilson disease
What are indications for pediatric status 1B?
- hepatoblastoma (biopsy proven) without metastatic disease
- no size limit - Organic academia or urea cycle defect AND approved exception for >/= 30 days
- Sick kid: chronic liver disease with MELD/PELD >/=25 AND ONE of the following
- mechanical ventilation
- GIB ?30 mL/kg RBC in 24 hours
- on HD, CVVH
- glasgow coma score <10 48 hours prior to status 1B
What are component of MELD-Na
Cr
INR
Bili
What is max Cr in MELD score
Cr set to 4 when
- cr >/=4
- two or more dialysis treatments in last 7 days
- 24 hours of CVVHD in last 7 days
Which is used for candidates with MELD
MELD
When is MELD-NA used? Why is it used?
when MELD>/= 12
-wait list mortality higher in those with hyponatremia
When is PELD score used?
for candidates <12 years old
What are components of PELD?
age
Bili
albumin
INR
***eventually Cr will be added
growth failure = 2 standard deviations below expected growth for age and gender
How are MMAT calculated for adults and Peds?
Adult is MMAT-3
Peds is MMAT
**MMAT is calculated for geographic areas every 180 days **note it is around donor hospital, not transplant center
What is meld exception for CCA
MMAT-3
What is meld exception for CF
MMat -3
What is meld exception for HAT that is not STATUS 1a
MELD 40
What is mmat for primary hyperoxaluria
MMAT (not -3)
What is meld exception for HCC
MMAT-3 after six month delay
What is meld exception for primary hyperuxaluria for Peds?
MMAT +3
What is hcc exception for 12-17 and <12
MELD 40
PELD 40
What is criteria for HAT meld exception in adults if not status 1A
<14 days, if not status 1a, then will get MELD 40
What are requirements for adult meld exception for primary hyperoxaluria
SLK (excess oxalate damages kidney)
biopsy or mutation proven
GFR
What are requirements for FAP meld exception points in adults?
EF>40%
ambulatory
biopsy proven or mutation identified
will get MMAT -3
What are requirements for CF meld exception in adults?
MMAT-3 if FEV1<40%
What are requirements for HPS in adults for meld exception?
evidence of shunt
PaO2<60
no underlying primary lung disease
clinical evidence of portal hypertension
MMAT-3
What are requirements of portopulmonary hypertension in adults for MELD exception?
post treatmetn MPAP <35
post treatment PVR<400 dynes
MMAT-3
What diseases are different between Peds and adults for Meld exceptions
most adults will have mmat-3
most Peds will be mmat
HAT
-adults MELD 40 if not status 1a
- Peds same
Primary hyperoxaluria
-adults MMAT
-peds MMAT +3
HCC
-adults MMAT=3 after 6 month delay
- Peds MELD 40, immediately, not delay
What is safety net for kidney requirements?
for recipients who do not undergo Renal recovery after OLT
- GFR <20 between 60 and 365 days after Ltx
What are CKD requirements for SLK allocation?
Diagnosis to qualify:
- GFR<60 for 90 or more days
Must have ONE of:
- regular scheduled RRT
- GFR <30 at the time of listing
What are AKI requirements for SLK?
Diagnosis to qualify:
- no pre-existing GFR requirements
Must have one or combination of both for at least 6 weeks:
- on dialysis at least once every 7 days
- calculated CrCl or GFR <25 every 7 days
What are requirements for metabolic disease for SLK allocation?
Hypooxaluria
Atypical HUS
How do opportunistic infections affect HIV transplantation?
CD4>200 WITH prior history of resolved OI
CD4>100 without hx of OI
Undetectable HIV viral load or expectation of undectable HIV viral load after LTx
Documented compliance with ART regimen
Absence of chronic wasting/malnutrition
—-BMI<21 –> poor outcome
Hope act permits HIV + organs into HIV + recipients at qualified centers
Can you transplant a liver in someone with COPD
NO guidelines about COPD
- presence of obstructive or restrictive Lung disease associated with longer intubation and ICU but not post op mortality
- prob best to have FEV1>30% prior to transplant
Why does sarcopenia matter in LT?
-better assessment of nutrition than BMI
- Predicts pre-transplant survival, post OLT infection, LOS
- failure to improve after transplant predicts mortality
Which frailty tool should be used and how often?
no data to recommend a specific frailty tool, but should use one depending on efficiency and objectivity
in compensated- annual assessment is fine
in decompensated- more frequent (i.e q 3-6 months)
How can one assess for muscle loss?
Skeletal muscle index assessed by CT is them most consistent and reproducible. MRI has not been validated in cirrhosis, but theoretically provides the same information on muscle mass as CT
because of radiation, use of CT solely for muscle mass is not recommended, but quantification of skeletal muscle mass should be considered when CT is ordered as part of clinical care
Role of inflammation in malnutrition?
inflammation can make frailty and sarcopenia worse, so inflammatory conditions that can lead to cirrhosis (HCV, insulin resistance, obesity, Alcohol) should be treated
Can TIPS be placed for sarcopenia?
not an indication, but if placed for standard indication, it may offer an indirect benefit of improving muscle mass
is frailty or sarcopenia an absolute contraindication or indication for transplant?
cannot be recommended specifically for treatment of frailty or sarcopenia
do not recommend using frailty as an absolute contraindication against transplant
What are calorie needs for non obese vs obese patients?
non obese- at least 35 kcal/kg today weight/day
obese:
- BMI 30-40: 25-35 kcal/kg/day
- BMI>40: 20-25 kcal/kg/day
What is goal protein intake for critically ill vs not?
critically ill: 1.2-2.0 g/kg ideal body weight per day
not critically ill: 1.2-1.5g/kg
What is protein intake for children?
up to 4g/kg ideal body weight
Can patients with cirrhosis be told to lose weight?
if medically required, then yes. but caution in decompensated cirrhosis
and target protein and physical activity are needed to reduce loss of muscle contractile function (frailty) and muscle mass (sarcopenia)
How soon should RD consult be placed?
within 24 hours in anyone hospitalized with cirrhosis
In someone who has varices, can dobhoff be placed?
yes, presence of varices is not an absolute contraindication to placement of enteric feeding tube. But if recent banding, then should have close monitoring for signs of rebreeding if an enteric tube is required
Are BCAA recommended?
insufficient evidence, but because they are naturally occurring, should just get protein intake from diverse protein sources
What kind of physical activity based interventions are recommended?
aerobic
resistance exercises
Is age >70 a contraindication to transplant?
if no other significant comorbdiities, age>70 is not a contraindication
What to do when RVSP>45?
right heart Cath
How should you screen for HPS
pulse oximetry
When do you treat for latent TB?
treatment should be initiated pre-LT
What vaccines should be given?
pneumocccus
influenzae
diphtheria
pertussis
tetanus
Live vaccines: mumps, measles, rubella, and varicella –> should be given early in the evaluation process
Can you list someone on methadone?
methadone maintained patients should not be denied transplantation based on methadone use alone, and expectations of methadone reduction or discontinuation should not be a requirement for transplant listing
If transplanted for PSC, and have IBD, how often do you need to do colonoscopy?
colonoscopy should be performed annually in patients with PSC and IBD both before and after transplantation due to high incidence of colorectal cancer
What lung testing is needed for a1at prior to transplant?
screen with PFT’s and chest imaging
Should LT be done for those with neuropsychological WIlsons
No- because LT does not reliability improve neurologic outcomes. Obvi if decompensated, then should get LT
How to approach LT in FAP?
LT should be considered in FAP to eliminate hepatic amyloid production early in the course of disease and particularly prior to the development of cardiac and ocular complications, as these complications are not reliabily improved by LT
What should AIH patients be screened for
Autoimmune Hemolytic anemia
Ibd
Rheumatoid arthritis
Diabetes
Other extrahepatic
What is seen in IgG4
storiform fibrosis
lymphoplasmacytic infiltrate
can have IBD
What labs are seen in Tylenol ALF
AST ALT 3500, low bili, no concern for ischemia
Can you use penicillamine in ALF from wilson
Treatment to acutely lower serum copper and to limit further hemolysis should include albumin dialysis, continuous hemofiltration, plasma- pheresis, or plasma exchange.
Initiation of treatment with penicillamine is not recommended in ALF as there is a risk of hypersensitivity to this agent.
Although such copper lowering measures should be considered, recovery is very rare absent transplanta- tion
What patients with ALF are at high risk of high ICP
ammonia >150
grade 3/4 he- patic encephalopathy
acute renal failure, requiring vasopressors to maintain MAP)
the prophylactic induction of hypernatremia with hypertonic saline to a sodium level of 145-155 mEq/L is recommended
What is R ratio
ALT/ULN divided by ALP/ULN
tells you hepatocellular vs cholestatis
how do you manage grade 1 immunotherapy hepatitia
ALT>1-3X and/or total bili >1.5
continued therapy with nore frequent labs
How do you manage grade 2 IS hepatitis
hold IC and start oral steroids
What is portal vein embolization in resectinon considered?
- when more than 3 liver segments are involved
- if future liver remnant is <20% in non cirrhotic or <40% in cirrhotic
When do you see fibrolammelar HCC
in non-cirrhosis
fibrous strands everywhere
remember trabecular HCC is most common
What histologic findings are seen in checkpoint inhibitor toxicity
granulomatous hepatitis
centrilobular necrosis
central vein endothelitis
need to stop the med in most cases +/- steroids
can initiate AIH, so consider liver biopsy to rule out other cause
When do you deliver for ICP
What does urso do
deliver at week 37 (not 34)
urso increases bile salt pump and increases placental bile transported
Does Hep E cause ALF
now
in immunocompromised, genotype 3 can lead to cirrhosis
acute HEC increased mortality in pregnant woman
What histologic feature separates GAVE from pht gastropahty
thrombi
antral ectasia, spinfle cell proliferation, capillary dilation seen in both
what to do with tac when adding protease inhibitor
decrease tac
what are the cardiac pressures in volume overload vs portopulmonary HTN vs normal cirrhosis
normal cirrhosis:
mPAP elevated
SVR low
CO elevated
PCWP normal/low
Fluid overload
mPAP elevated
CO normal
PCWP elevated
TGP normal
pHTN
mPAP very elevated
PCWP normal/low
TPG elevated
TPG is mPAP-PCWP and should be <12
If you see late bubbles on TTE, does that mean you have HPS
not necessarily, just means you have increased pulmonary vasodilation. If you see bubbles late, then dshould get AA gradient. If >15, then you have HPS. If it is <15, then you just have increased pulmonary vasodilation
What are the criteria for portopulm HTN (definition of this)
and what do you need for MELED exception
(mPAP)> 25 mmHg.
(PVR)> 240
Pulmonary arterial occlusion pressure (PAOP) < to 15 mmHg
MELD exception:
mPAP<35
PVR<400 of <5.1 woods
get mmat-3 for adult
get mmat for 12-17
get mpat for <12
What is posterior, anterior, medial and lateral
posterior - 6,7
anterior -5,8
medial 4
lateral 2,3
what standard hepatectomy includes segment 4
left
if extended right, then 4-8, otherwise right hepatectomy is 5-8
When is bariatric surgery ok
BMI 40 or higher, or have a
BMI between 35 and 40 and an obesity-related condition, such as heart disease, diabetes, high blood pressure or severe sleep apnea.
Sertraline causes increased risk of what
bleeding
What are the main things to do for intracranial hypertesion
- remove fluid- dialysis or mannitol (diuretic)
- cerebral venous drainage (elevation of head of bed, head in midline) vs Pressors increase cerebral perfusion pressure by increasing the mean arterial pressure.
- Minimization of stimuli via sedation
- permissive hypothermia
- hypocapnia (hyperventilation)
- hypertonic Saline - Increases serum osmolality to decrease intracellular volume
post operative ascites is associated with which technique
piggy back (But piggyback shortens anhepatic phase and venous return is preserved)
What are risk factors for small for size
- graft to recipient weight ratio (GRWR) of <0.8%
- donor age ≥48 years
- and recipient’s model for end-stage liver disease (MELD) score of ≥19.
All of these INCREASE risk
How to diagnose PRES
symmetrical hyperintensities on T2-weighed imaging in the parietal and occipital lobes;
HEadaches, seizures, hemianopsia (inability to see the left or right part of the visual field, weakness in one side of body
Does pioglitazone cause weight gain or weight loss
weight gain
Who is NAFLD progresses to cirrhosis
NAFL have a very slow progression (if any).
- patients with NASH can exhibit histological progression and can develop fibrosis (37%-41%) and cirrhosis (Approximately 5%
HOw high will AST and ALT go to in biliary obstruction with stone passage
can be as high as 1000
What are teh risks of mom and baby in ICP
mother mortality is same as general public
baby mortality is higher
What is seen on path for NRH and waht is HVPG
without cirrhosis, inflammation and fibrosis and obliterative changes of portal vein radicles. Measurement of sinusoidal pressure with WHVP is thus normal, although direct measurement of portal pressure may show elevated portal pressures.
What is NRH associated wiht
associated with hematologic malignancies such as
myelodysplastic syndrome, polycythemia vera, and essential thrombocytosis.
NRH has also been
associated with hypercoagulable states, such as factor V Leiden deficiency, but dont start AC
exposure to drugs
such as didanosine, azathioprine, and 6-mercaptopurine.
It is also sometimes seen following liver
transplantation.
What is seen in chronic AMR
-class TWO DSA
-atypical fibrosis on biopsy
-late-onset acute T-cell mediated rejection
-chronic rejection, and decreased allograft survival.
Histologically, low-grade lymphoplasmacytic portal and perivenular inflammation
accompanied by unusual pattern of fibrosis and variable microvascular C4d deposition.
Which IS do you reduce first in HEV
tacro (in 2017 said mmf was protective for HEV), uptodate says to concomitantly given ribavinr if immunocompromised
if immunocompetent (chronic hep E only happens in immunocompromusedm but immunocompentent can get acute Hep E), supportive care
Who is at risk for infection/abcess post TACE
those who have had a biliary spinchterotomy
What reverses or doesn’t reverse post transplant for amyloid
cardiac dysfunction and neuropathy do not reverse
what is risk of graft failure if donor is:
1. age 65
2. death by stroke
3. outside region
40% in three years
how long can urine etg detect ETOH
5-7 days
what is rate of recurrence of HCC post transplant
Hepatocellular carcinoma (HCC) after liver transplantation (LT)
recurs at a rate of 5% to 10% for patients who undergo LT within Milan criteria and at higher rates for
patients who undergo LT outside of Milan criteria.
creation of a renal portal bypass increases risk of what
ascites
what is the most common disease to cause BCS
myeloproliferative, which can be screened with JAK2
What is a hint it is Igg4
look for multiple organs involved
what is treatment for massive bleeding from rectal varices
TIPS»_space;> banding (not sure of right answer here, 2015 questions)
what trimester can cholecystectomy be done
any
What is the dx when normal/low TS, but high ferritin+ anemia
ferroportin
kupper cells with iron
AD
hilar CCA- what do you have to ask
PSC –> tx
non-PSC –> can it be resected, cirrhosis present?
What is associated with infantile hepatic hemangioma and what should be started
IHH is a tumor comprised of large vascular beds, which require a significant increase in blood flow as the lesion grows. This, in turn, creates an undue burden on the cardiovascular system, leading to high-output HF and potentially, respiratory distress
Start beta blocker, glutathione
can OCA be used in pregngnacy
no- there is no data
how to treat variceal bleed in pregnancy
same way, octreotide, EVL, BB are all safe. Just do not use terlipressin
how do you treat Hep E in pregnancy
cannot use interferon or ribavirin, supportive care, close monitoring
what happens to LFT’s in hyperemesis once vomiting resolves and hydration give
LFTs should improve, if they dont seeka naother cause
what pruritus meds are safe in pregnancy
urso
rifampin
cholecstramine
SAMe
when should delivery in HELLP pccurs
around 37 weeks
what to do with tacro levels in pregnancy
nothing, goals should stay the same, just need close monitoring
