The Patient for Hepatic Transplantation
A 37-year-old woman was evaluated by the transplant service for acute necrotic hepatitis secondary to antimalarial prophylaxis with sulfadoxinelpyrimethamine (Fansidar®), which she had taken for one year while living in China. At the time of evaluation she was noticeably jaundiced and edematous and complained of nausea and vomiting. Her past history was unremarkable except for hypothyroidism diagnosed at the age of 18, and tonsillectomy performed the same year under general anesthesia. Family and social histories were unremarkable. The patient’s only medication was prednisone 10 mg orally twice a day.
Orthotropic hepatic transplantation was performed without technical complications. The patient did well until the sixth postoperative day, when her temperature rose to 106°F. Acute graft rejection was diagnosed and she was placed on a monoclonal antibody (OKT-3) directed against T lymphocytes. Her liver function continued to deteriorate despite aggressive medical therapy, necessitating a second transplant, which was scheduled for the twelfth postoperative day.
Preoperative evaluation revealed a disoriented, febrile, severely jaundiced woman, with a blood pressure of 150/100 mm Hg and a pulse of 112/min. Chest x-ray demonstrated bilateral basilar atelectasis and a right pleural effusion. Significant laboratory findings included: total bilirubin 41 mg%, prothrombin time (PT) 14.5 sec (normal 12), partial thromboplastin time (PTT) 33 sec (normal 30), blood urea nitrogen (BUN) 98 mg%, and creatinine 2.9 mg%.
Physical examination revealed developing encephalopathy, bilateral basilar râles, and progressive hepatorenal syndrome. Medications at the time of retransplantation included thyroid supplement, tobramycin, ampicillin, cefotaxime, clindamycin, OKT-3, prednisone, cyclosporine, and azathioprine.
KeywordsHepatic Encephalopathy Hepatic Blood Flow Hepatorenal Syndrome Portal Venous Pressure Chronic Persistent Hepatitis
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