Station 1.5: The liver transplant patient

Question 1

Clinical signs

What are the clinical signs?

The liver transplant patient

Please examine this patients abdomen

Answer 1

• Scars

‘Mercedes–Benz’ or roof–top scar
Liver transplant

• Evidence of chronic liver disease

Question 2

Clinical signs

What are the reasons for liver transplantation?

The liver transplant patient

Please examine this patients abdomen

Answer 2

*  Slate‐grey pigmentation - Haemochromatosis
*  Other autoimmune disease - PBC
*  Tattoos and needle marks - Hepatitis B, C

Question 3

Clinical signs

What is evidence of immunosuppressive medication?

The liver transplant patient

Please examine this patients abdomen

Answer 3

*  Ciclosporin: gum hypertrophy and hypertension
*  Steroids: Cushingoid appearance, thin skin, ecchymoses

Question 4

Dicussion

Top three reasons for liver transplantation?

The liver transplant patient

Please examine this patients abdomen

Answer 4

*  Cirrhosis
*  Acute hepatic failure (hepatitis A and B, paracetamol overdose)
*  Hepatic malignancy (hepatocellular carcinoma)

Question 5

Discussion

What is success rate of liver transplantation?

The liver transplant patient

Please examine this patients abdomen

Answer 5

*  80% 1‐year survival
*  70% 5‐year survival

Question 6

Discussions

What are the causes of gum hypertrophy?

The liver transplant patient

Please examine this patients abdomen

Answer 6

*  Drugs: ciclosporin, phenytoin and nifedipine
*  Scurvy
*  Acute myelomonocytic leukaemia
*  Pregnancy
*  Familial

Question 7

Discussions

What are the skin signs in (any) transplant patients?

The liver transplant patient

Please examine this patients abdomen

Answer 7

* ** Malignancy**
⚬ Dysplastic change (actinic keratoses)
⚬ Squamous cell carcinoma (100 × increased risk and multiple lesions)
⚬ Basal cell carcinoma and malignant melanoma (10 × increased risk)

* ** Infection**:
⚬ Viral warts
⚬ Cellulitis

Question 8

Clinical signs

What are the clinical signs?

The renal patient

Please examine this patients abdomen

Answer 8

*  Stigmata:
⚬ Arms: arteriovenous fistula(e) – currently working (thrill), being used (thrill and
dressings), or failed
⚬ Neck: tunneled dialysis line (or previous lines; scars in the root of the neck and over
the chest wall)
⚬ Abdomen:

Flank scar: Nephrectomy (polycystic kidney disease, renal malignancy)

Peritoneal dialysis – catheter, or
scars from previous catheter (below umbilicus, insertion; lateral to umbilicus, exit site)

Iliac fossa scar: Kidney transplant

*  Fluid status (leg oedema

Question 9

Clinical signs

What are three things to consider in all renal patients?

The renal patient

Please examine this patients abdomen

Answer 9

1. Underlying reason for renal failure
   *  Polycystic kidneys: ADPKD
   *  Visual impairment, fingerprick marks, injection sites/pump, etc.: diabetes
   *  Sclerodactyly, typical facies: systemic sclerosis
   *  Rheumatoid hands, nodules: rheumatoid arthritis
   *  (Hepato)splenomegaly: amyloidosis
   *  Other organ transplantation (liver/heart/lungs): calcineurin inhibitor nephrotoxicity
   *  Ungual fibromata, adenoma sebaceum, polycystic kidneys: tuberous sclerosis
2. Current treatment modality
   *  Haemodialysis: working fistula, tunneled neck lines, arteriovenous grafts
   *  Peritoneal dialysis: abdominal catheter
   *  Functioning transplant: no evidence of other current dialysis access (in use)
3. Complications of past/current treatment
   *  Side effects of treatment for the underlying disease: Cushingoid appearance from
   steroids (glomerulonephritis)
   *  Side effects of immunosuppressive treatment in transplant patients:
   ⚬ Fine tremor (tacrolimus)
   ⚬ Steroid side effects
   ⚬ Gum hypertrophy (ciclosporin)
   ⚬ Hypertension (ciclosporin, tacrolimus)
   ⚬ Skin damage and malignancy (especially ciclosporin and azathioprine)
   *  Scars from previous access for dialysis, failed transplant(s)

Question 10

Clinical signs

What are things to consider in all Kidney‐pancreas transplantation patients?

The renal patient

Please examine this patients abdomen

Answer 10

Consider if:
*  Lower midline abdominal incision, with a palpable kidney in an iliac fossa (but no
overlying scar)
*  Evidence of previous diabetes (e.g. visual impairment)
*  Patients are often younger (most commonly transplanted in 30s–40s

Question 11

Discussion

What are top three causes for renal transplantation?

The renal patient

Please examine this patients abdomen

Answer 11

*  Glomerulonephritis
*  Diabetic nephropathy
*  Polycystic kidney disease (ADPKD)

Question 12

Discussion

What are problems following transplantation?

The renal patient

Please examine this patients abdomen

Answer 12

  Rejection:** acute or chronic
**  Infection secondary to immunosuppression:
⚬ Pneumocystis carinii
⚬ CMV
  Increased risk of other pathology**:
⚬ Skin malignancy
⚬ Post‐transplant lymphoproliferative disease
⚬ Hypertension and hyperlipidaemia causing cardiovascular disease
**  Immunosuppressant drug side effects/toxicity:
⚬ Ciclosporin nephrotoxicity
*  Recurrence of original disease
*  Chronic graft dysfunction

Question 13

Discussion

What is the success rate for renal transplantation?

The renal patient

Please examine this patients abdomen

Answer 13

*  90% 1‐year graft survival
*  50% 10‐year graft survival (better with live‐related donor grafts)