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Transplant Hep Boards > Autoimmune and Cholestatic > Flashcards

Autoimmune and Cholestatic Flashcards

1
Q

How do you treat Hep D?

A

Per IFNalpha for 12 months/ until undetectable HDV RNA/ALT normalization

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2
Q

What happens in liver transplant and HDV?

A

HDV confection is a risk factor for HepB viral replication, So need to give both HBIG and NA

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3
Q

What is treatment for Hep E

A

ribavirin

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4
Q

How do you test immunocompetent vs immunocompromised patients for Hep E?

A

immunocompetent: start with anti HEV IgM and IgG and RNA

immunocompromised, started with HEV RNA

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5
Q

What are extrahepatic manifestations of Hep E?

A

Mostly neurologic and renal:
Guillan Barre
Meningoencephalitis
Myosisitis

Renal complications: IgA nephropathy, membranoproliferazive

So if you see these and elevated LFTS, think Hep E

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6
Q

What is Harvoni?

A

sofo+led
genotype 1,4,5,6

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7
Q

What is epclusa

A

sofo+velpa
pangenotypic

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8
Q

what Is mayvret

A

glecaprevir+ pibrentsavir
pangenotypic
Can’t use in decompensated

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9
Q

What are options for HCV without cirrhosis?

A

Mayret (Glec +pib) 8 weeks
Epclusa (sof +vel) 12 weeks

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10
Q

How do you treat HCV in decompensated cirrhosis?

A

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

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11
Q

What is the definition of ALF?
What is the UNOS criteria for ALF?

A

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

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12
Q

What are factors that influence outcome of ALF?

A
  • early recognition
  • administration of NAC
  • transfer to liver transplant center
  • listing for liver transplant
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13
Q

What are the kings college criteria for ALF due to Tylenol?

A

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

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14
Q

What is the kings criteria for ALF not due to Tylenol

A

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

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15
Q

What are favorable etiologies of ALF? And what are unfavorable etiologies of ALF?

A

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

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16
Q

Can lactulose be used in ALF HE?

A

no role, just causes ileum and bowel edema

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17
Q

What are predictors of cerebral edema in ALF?

A
  • persistent ammonia >150-200
  • younger age - decreased free space within cranium
  • hyper acute ALF phenotype
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18
Q

What are non - invasive methods of monitoring ICP

A

trans-cranial doppler
optic nerve sheath diameter
pupillometry

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19
Q

What are general management for elevated ICP

A
  • 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

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20
Q

When can charcoal be given in Tylenol overdose?

A

For patients with known or suspected tylenol overdose within four hours of presentation, given activated charcoal just prior to starting NAC

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21
Q

How to manage ALF from mushroom poisoning?

A

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

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22
Q

When is liver biopsy recommended in AIH and ALF?

A

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

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23
Q

How do you treat seizures in ALF?

A

phenytoin and benzodiazepines with short half lives, prophylactic phenytoin is not recommended

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24
Q

What type of PH is portal vein thrombosis and what hepatic vein pressure measurements do you see?

A

prehepatic
Free: normal
Wedged: normal
Gradient/HVPG: normal

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25
Q

What type of portal hypertension is heart failure or SVC?

A

post hepatic
Free: elevated
Wedged: elevated
HVPG: normal

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26
Q

What type of ph is seen in cirrhosis? pressure measurements?

A

Sinuoidal (intrahepatic PH)
Free: normal
Wedged: Elevated
Gradient: Elevated

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27
Q

What type of PH Is seen in cholestatic cirrhosis or schisto?

A

Intrahepatic, pre-sinusoidal
Free: normal
Wedged: normal
Gradient: normal

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28
Q

What type of portal hypertension is seen in sinusoidal obstruction syndrome?>

A

Intrahepatic, post sinusoidal
Free: normal
Wedged: elevated
Gradients: elevated

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29
Q

What does free hepatic vein measure?

A

pressure in hepatic vein

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30
Q

what does wedged pressure measure?

A

portal and sinusoidal pressure

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31
Q

What are the cutoff for LSM of CSPH?

A

LSM>25 alone
LSM 20-25 + Plt <150
LSM 15-20 +plts <110

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32
Q

Who needs a screening EGD at time of diagnosis of cirrhosis?

A

everyone unless LSM <20 and Plts >150 (these have a very low probability of having high risk varices (<5%)

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33
Q

When should someone with compensated cirrhosis get a repeat screening endoscopy for prophylaxis?

A
  1. At time of diagnosis
  2. No varices –> 2 (with ongoing liver injury) to 3 years (if liver injury is quiescent)
  3. Small varices –> 1 to 2 years
  4. at time of decompensation
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34
Q

When should someone with decompensated cirrhosis be screened for varices?

A

yearly and at time of decompensation

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35
Q

How do you give propranolol for varices?

A

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

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36
Q

How do you give nadolol for varices?

A

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

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37
Q

How to give carvedilol for varices?

A

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

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38
Q

How often do you do EGD for EVL?

A

Every 2-8 weeks until eradication of varices
First EGD is 3-6 months after eradication and every 6-12 months thereafter

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39
Q

What does the new Baveno guidelines say re use of co-reg?

A

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

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40
Q

How do you treat patients with compensated cirrhosis and mild pH?

A

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

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41
Q

What type of portal hypertension in seen in PBC

A

pre-sinsuoidal
free: normal
Wedged: normal
Gradient: normal

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42
Q

Why is coreg better than other NSBB

A

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)

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43
Q

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

A

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

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44
Q

How long should you continue antibiotics with GIB?

A

max of 7 days, consider stopping once hemorrhage has resolved and vasoactive drugs discontinued
ceftriaxone 1g/24 hr

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45
Q

When should vasoactive be started in a bleed

A

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

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46
Q

When should EGD be performed for VH?

A

within 12 hours of admission and once stable

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47
Q

When is early/pre-emptive TIPS recommended?

A

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

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48
Q

Once someone is banded for VH, how long to keep vasoactive on? When to start NSBB?

A

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

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49
Q

How do you treat GOV 1? What about prophylactic?

A

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

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50
Q

Treatment for GOV2 or IGV1?

A

NSBB
GOV 2= extension of EV along great curve

IGV1 = gastric varies along fundus

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51
Q

What is treatment of bleeding GOV1?

A

EVL if feasible or glue

Can do combination of EVL and NSBB for prevention of re-bleed

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52
Q

What is treatment of GOV2 and IGV1?

A

TIPS

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53
Q

What do you do with NSBB in someone who has bleed from varices and has ascites or SBP?

A

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

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54
Q

Which are better to prevent shunt dysfunction in TIPS? Bare metal or PTFE covered stents?

A

PTFE covered lowers the risk

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55
Q

Can TIPS be used to prevent rebreeding in patients who have bled only once from EV? GV?

A

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

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56
Q

What are absolute contraindications to TIPS?

A
  1. Primary prevention of variceal bleeding
  2. CHF
  3. Multiple hepatic cysts
  4. Uncontrolled systemic infection or sepsis
  5. Unrelieved biliary obstuction
  6. Severe pulmonary hypertension
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57
Q

What are the indications for status 1a for adults?

A
  1. 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
  2. Anheptic
  3. 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
  4. HAT
    – AST>/= 3000 AND one of the following
    - INR >/= 2.5
    –arterial pH /= 4
    ** all labs must be from same lab draw
  5. Acute decompensated Wilson disease
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58
Q

What are indications for pediatric 1A status?

A
  1. 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
  2. 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
  3. 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
  4. acute decompensated Wilson disease
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59
Q

What are indications for pediatric status 1B?

A
  1. hepatoblastoma (biopsy proven) without metastatic disease
    - no size limit
  2. Organic academia or urea cycle defect AND approved exception for >/= 30 days
  3. 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
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60
Q

What are component of MELD-Na

A

Cr
INR
Bili

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61
Q

What is max Cr in MELD score

A

Cr set to 4 when
- cr >/=4
- two or more dialysis treatments in last 7 days
- 24 hours of CVVHD in last 7 days

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62
Q

Which is used for candidates with MELD

A

MELD

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63
Q

When is MELD-NA used? Why is it used?

A

when MELD>/= 12
-wait list mortality higher in those with hyponatremia

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64
Q

When is PELD score used?

A

for candidates <12 years old

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65
Q

What are components of PELD?

A

age

Bili
albumin
INR
***eventually Cr will be added
growth failure = 2 standard deviations below expected growth for age and gender

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66
Q

How are MMAT calculated for adults and Peds?

A

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

67
Q

What is meld exception for CCA

A

MMAT-3

68
Q

What is meld exception for CF

A

MMat -3

69
Q

What is meld exception for HAT that is not STATUS 1a

A

MELD 40

70
Q

What is mmat for primary hyperoxaluria

A

MMAT (not -3)

71
Q

What is meld exception for HCC

A

MMAT-3 after six month delay

72
Q

What is meld exception for primary hyperuxaluria for Peds?

A

MMAT +3

73
Q

What is hcc exception for 12-17 and <12

A

MELD 40
PELD 40

74
Q

What is criteria for HAT meld exception in adults if not status 1A

A

<14 days, if not status 1a, then will get MELD 40

75
Q

What are requirements for adult meld exception for primary hyperoxaluria

A

SLK (excess oxalate damages kidney)
biopsy or mutation proven
GFR

76
Q

What are requirements for FAP meld exception points in adults?

A

EF>40%
ambulatory
biopsy proven or mutation identified

will get MMAT -3

77
Q

What are requirements for CF meld exception in adults?

A

MMAT-3 if FEV1<40%

78
Q

What are requirements for HPS in adults for meld exception?

A

evidence of shunt
PaO2<60
no underlying primary lung disease
clinical evidence of portal hypertension

MMAT-3

79
Q

What are requirements of portopulmonary hypertension in adults for MELD exception?

A

post treatmetn MPAP <35
post treatment PVR<400 dynes

MMAT-3

80
Q

What diseases are different between Peds and adults for Meld exceptions

A

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

81
Q

What is safety net for kidney requirements?

A

for recipients who do not undergo Renal recovery after OLT
- GFR <20 between 60 and 365 days after Ltx

82
Q

What are CKD requirements for SLK allocation?

A

Diagnosis to qualify:
- GFR<60 for 90 or more days
Must have ONE of:
- regular scheduled RRT
- GFR <30 at the time of listing

83
Q

What are AKI requirements for SLK?

A

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

84
Q

What are requirements for metabolic disease for SLK allocation?

A

Hypooxaluria
Atypical HUS

85
Q

How do opportunistic infections affect HIV transplantation?

A

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

86
Q

Can you transplant a liver in someone with COPD

A

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

87
Q

Why does sarcopenia matter in LT?

A

-better assessment of nutrition than BMI
- Predicts pre-transplant survival, post OLT infection, LOS
- failure to improve after transplant predicts mortality

88
Q

Which frailty tool should be used and how often?

A

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)

89
Q

How can one assess for muscle loss?

A

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

90
Q

Role of inflammation in malnutrition?

A

inflammation can make frailty and sarcopenia worse, so inflammatory conditions that can lead to cirrhosis (HCV, insulin resistance, obesity, Alcohol) should be treated

91
Q

Can TIPS be placed for sarcopenia?

A

not an indication, but if placed for standard indication, it may offer an indirect benefit of improving muscle mass

92
Q

is frailty or sarcopenia an absolute contraindication or indication for transplant?

A

cannot be recommended specifically for treatment of frailty or sarcopenia

do not recommend using frailty as an absolute contraindication against transplant

93
Q

What are calorie needs for non obese vs obese patients?

A

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

94
Q

What is goal protein intake for critically ill vs not?

A

critically ill: 1.2-2.0 g/kg ideal body weight per day

not critically ill: 1.2-1.5g/kg

95
Q

What is protein intake for children?

A

up to 4g/kg ideal body weight

96
Q

Can patients with cirrhosis be told to lose weight?

A

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)

97
Q

How soon should RD consult be placed?

A

within 24 hours in anyone hospitalized with cirrhosis

98
Q

In someone who has varices, can dobhoff be placed?

A

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

99
Q

Are BCAA recommended?

A

insufficient evidence, but because they are naturally occurring, should just get protein intake from diverse protein sources

100
Q

What kind of physical activity based interventions are recommended?

A

aerobic
resistance exercises

101
Q

Is age >70 a contraindication to transplant?

A

if no other significant comorbdiities, age>70 is not a contraindication

102
Q

What to do when RVSP>45?

A

right heart Cath

103
Q

How should you screen for HPS

A

pulse oximetry

104
Q

When do you treat for latent TB?

A

treatment should be initiated pre-LT

105
Q

What vaccines should be given?

A

pneumocccus
influenzae
diphtheria
pertussis
tetanus

Live vaccines: mumps, measles, rubella, and varicella –> should be given early in the evaluation process

106
Q

Can you list someone on methadone?

A

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

107
Q

If transplanted for PSC, and have IBD, how often do you need to do colonoscopy?

A

colonoscopy should be performed annually in patients with PSC and IBD both before and after transplantation due to high incidence of colorectal cancer

108
Q

What lung testing is needed for a1at prior to transplant?

A

screen with PFT’s and chest imaging

109
Q

Should LT be done for those with neuropsychological WIlsons

A

No- because LT does not reliability improve neurologic outcomes. Obvi if decompensated, then should get LT

110
Q

How to approach LT in FAP?

A

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

111
Q

What should AIH patients be screened for

A

Autoimmune Hemolytic anemia
Ibd
Rheumatoid arthritis
Diabetes
Other extrahepatic

112
Q

What is seen in IgG4

A

storiform fibrosis
lymphoplasmacytic infiltrate

can have IBD

113
Q

What labs are seen in Tylenol ALF

A

AST ALT 3500, low bili, no concern for ischemia

114
Q

Can you use penicillamine in ALF from wilson

A

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

115
Q

What patients with ALF are at high risk of high ICP

A

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

116
Q

What is R ratio

A

ALT/ULN divided by ALP/ULN
tells you hepatocellular vs cholestatis

117
Q

how do you manage grade 1 immunotherapy hepatitia

A

ALT>1-3X and/or total bili >1.5
continued therapy with nore frequent labs

118
Q

How do you manage grade 2 IS hepatitis

A

hold IC and start oral steroids

119
Q

What is portal vein embolization in resectinon considered?

A
  • when more than 3 liver segments are involved
  • if future liver remnant is <20% in non cirrhotic or <40% in cirrhotic
120
Q

When do you see fibrolammelar HCC

A

in non-cirrhosis
fibrous strands everywhere
remember trabecular HCC is most common

121
Q

What histologic findings are seen in checkpoint inhibitor toxicity

A

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

122
Q

When do you deliver for ICP
What does urso do

A

deliver at week 37 (not 34)
urso increases bile salt pump and increases placental bile transported

123
Q

Does Hep E cause ALF

A

now
in immunocompromised, genotype 3 can lead to cirrhosis
acute HEC increased mortality in pregnant woman

124
Q

What histologic feature separates GAVE from pht gastropahty

A

thrombi

antral ectasia, spinfle cell proliferation, capillary dilation seen in both

125
Q

what to do with tac when adding protease inhibitor

A

decrease tac

126
Q

what are the cardiac pressures in volume overload vs portopulmonary HTN vs normal cirrhosis

A

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

127
Q

If you see late bubbles on TTE, does that mean you have HPS

A

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

128
Q

What are the criteria for portopulm HTN (definition of this)

and what do you need for MELED exception

A

(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

129
Q

What is posterior, anterior, medial and lateral

A

posterior - 6,7
anterior -5,8
medial 4
lateral 2,3

130
Q

what standard hepatectomy includes segment 4

A

left
if extended right, then 4-8, otherwise right hepatectomy is 5-8

131
Q

When is bariatric surgery ok

A

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.

132
Q

Sertraline causes increased risk of what

A

bleeding

133
Q

What are the main things to do for intracranial hypertesion

A
  1. remove fluid- dialysis or mannitol (diuretic)
  2. cerebral venous drainage (elevation of head of bed, head in midline) vs Pressors increase cerebral perfusion pressure by increasing the mean arterial pressure.
  3. Minimization of stimuli via sedation
  4. permissive hypothermia
  5. hypocapnia (hyperventilation)
  6. hypertonic Saline - Increases serum osmolality to decrease intracellular volume
134
Q

post operative ascites is associated with which technique

A

piggy back (But piggyback shortens anhepatic phase and venous return is preserved)

135
Q

What are risk factors for small for size

A
  1. graft to recipient weight ratio (GRWR) of <0.8%
  2. donor age ≥48 years
  3. and recipient’s model for end-stage liver disease (MELD) score of ≥19.

All of these INCREASE risk

136
Q

How to diagnose PRES

A

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

137
Q

Does pioglitazone cause weight gain or weight loss

A

weight gain

138
Q

Who is NAFLD progresses to cirrhosis

A

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%

139
Q

HOw high will AST and ALT go to in biliary obstruction with stone passage

A

can be as high as 1000

140
Q

What are teh risks of mom and baby in ICP

A

mother mortality is same as general public
baby mortality is higher

141
Q

What is seen on path for NRH and waht is HVPG

A

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.

142
Q

What is NRH associated wiht

A

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.

143
Q

What is seen in chronic AMR

A

-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.

144
Q

Which IS do you reduce first in HEV

A

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

145
Q

Who is at risk for infection/abcess post TACE

A

those who have had a biliary spinchterotomy

146
Q

What reverses or doesn’t reverse post transplant for amyloid

A

cardiac dysfunction and neuropathy do not reverse

147
Q

what is risk of graft failure if donor is:
1. age 65
2. death by stroke
3. outside region

A

40% in three years

148
Q

how long can urine etg detect ETOH

A

5-7 days

149
Q

what is rate of recurrence of HCC post transplant

A

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.

150
Q

creation of a renal portal bypass increases risk of what

A

ascites

151
Q

what is the most common disease to cause BCS

A

myeloproliferative, which can be screened with JAK2

152
Q

What is a hint it is Igg4

A

look for multiple organs involved

153
Q

what is treatment for massive bleeding from rectal varices

A

TIPS&raquo_space;> banding (not sure of right answer here, 2015 questions)

154
Q

what trimester can cholecystectomy be done

A

any

155
Q

What is the dx when normal/low TS, but high ferritin+ anemia

A

ferroportin
kupper cells with iron
AD

156
Q

hilar CCA- what do you have to ask

A

PSC –> tx
non-PSC –> can it be resected, cirrhosis present?

157
Q

What is associated with infantile hepatic hemangioma and what should be started

A

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

158
Q

can OCA be used in pregngnacy

A

no- there is no data

159
Q

how to treat variceal bleed in pregnancy

A

same way, octreotide, EVL, BB are all safe. Just do not use terlipressin

160
Q

how do you treat Hep E in pregnancy

A

cannot use interferon or ribavirin, supportive care, close monitoring

161
Q

what happens to LFT’s in hyperemesis once vomiting resolves and hydration give

A

LFTs should improve, if they dont seeka naother cause

162
Q

what pruritus meds are safe in pregnancy

A

urso
rifampin
cholecstramine
SAMe

163
Q

when should delivery in HELLP pccurs

A

around 37 weeks

164
Q

what to do with tacro levels in pregnancy

A

nothing, goals should stay the same, just need close monitoring

Transplant Hep Boards (7 decks)

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