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Question 15#

 A 60-year-old man with known hepatitis C and a previous liver biopsy showing cirrhosis requests evaluation for possible liver transplantation. He has never received treatment for hepatitis C. Though previously a heavy user of alcohol, he has been abstinent for over 2 years. He has had two episodes of bleeding esophageal varices. He was hospitalized 6 months ago with acute hepatic encephalopathy. He has a 1-year history of ascites that has required repeated paracentesis despite treatment with diuretics. Medications are spironolactone 200 mg daily and lactulose 30 cc three times daily

On examination he appears thin, with obvious scleral icterus, spider angiomas, palmar erythema, gynecomastia, a large amount of ascitic fluid, and small testicles. There is no asterixis.

Recent laboratory testing revealed the following:

• Hemoglobin = 12.0 mg/dL (normal 13.5-15.0)
• MCV = 103 fL (normal 80-100)
• Creatinine = 2.0 mg/dL (normal 0.7-1.2)
• Bilirubin = 6.5 mg/dL (normal 0.1-1.2)
• AST = 25 U/L (normal < 40)
• ALT = 45 U/L (normal < 40)
• INR = 3.0 (normal 0.8-1.2)

What is the best next step in the management of this patient’s liver failure?

A. Repeat liver biopsy
B. Start treatment with interferon and ribavirin
C. Refer the patient for hospice care
D. Continue to optimize medical treatment for his ascites and hepatic encephalopathy and tell the patient he is not eligible for liver transplantation because of his previous history of alcohol abuse
E. Refer the patient to a liver transplantation center

Correct Answer is E

Comment:

Cirrhosis caused by hepatitis C is the most common cause for liver transplantation in the United States. A previous history of alcoholism is not a contraindication to transplantation, although most transplant centers require abstinence from alcohol for 6 months before transplantation is considered. Three-year survival rate after transplantation in most centers now exceeds 80%. The model for end-stage liver disease (MELD) scoring system is used in the United States to allocate cadaveric livers to potential donors. Patients with complications of cirrhosis (esophageal variceal bleeding, hepatic encephalopathy, and uncontrolled ascites) or who have significantly elevated bilirubin, INR, and serum creatinine are usually made eligible for transplantation. Repeat liver biopsy would be unnecessary and potentially risky due to the patient’s coagulopathy. Patients with end-stage cirrhosis from hepatitis C do not benefit from interferon and ribavirin therapy. Hospice care is inappropriate until the patient is evaluated by a transplant center.