Title: Case Report 1
1Case Report (1)
- Chief Complaint
- Jaundice for two weeks.
- Clinical Course
- A 39-year-old female uremic patient.
- Received allograft renal transplantation on
2001-1-10 in Mainland China (????). - Delayed graft function was noted after
transplantation, and steroid pulse therapy was
given.
2Causes of Acute Renal Failure after Renal
Transplantation
- Prerenal
- Hypovolemia.
- Arterial stenosis or thrombosis.
- Venous thrombosis.
- Renal
- Acute tubular necrosis.
- Hyperacute or acut rejection.
- Nephrotoxicity.
- Postrenal
- Ureteral obstruction, Urinary leak, Hematoma.
3Case Report (2)
- The patient came back to Taiwan with sCr around
1.3 mg/dL. - FK506 2mg po. Bid. Cellcept 500 mg po. Bid.
Prednisolone 20 mg po. QD. were used as
immunosuppressive therapy for 2 months. - Hypertension was treated by Diovan 80 mg po. Qd.
for 1 month.
4Immunosuppressive Therapy
- Cyclosporin
- Inhibits IL-2 secretion from helper T cells.
- FK506 (Tacrolimus)
- Inhibits IL-2 secretion by helper T cells.
- Mycophenolate Mofetil (Cellcept)
- Inhibit GTP synthesis in activated immune cells.
- Steroids
- Inhibits cytokine secretion from immune cells.
5Case Report (3)
- The First Admission
- On 2001-3-12.
- FK506 was replaced by cyclosporin (CsA) due to
hyperglycemia. - Diabetes was noted before hemodialysis.
- Family History ().
- Cyclosporin (Sandimmun Neoral) 100mg po. Bid. was
given after discharge.
6Case Report (4)
- The First Admission
- Very high C2 levels were noted.
- Glurenorm was used for hyperglycemia.
- No liver function test was done during this
admission. - The patient was discharged on 2001-3-19.
7Serum C2 Levels
8Target C2 Levels in Renal Transplant Recipients
(BioDrugs 200115(5)279-290)
9Case Report (5)
- Medications at discharge
- Cyclosporin 100 mg Bid.
- Cellcept 500 mg Bid.
- Prednisolone 15 mg Qd.
- Diovan 1 Qd.
- Glurenorm 1.5 Bid.
- Glucophage 1 Qd.
10Case Report (6)
- OPD on 90-4-12
- Impaired liver function was noted.
- SGOT 80 U/L, SGPT 124 U/L.
- Cr 1.5 mg, Glucose AC 150 mg.
- BP 150/96 mmHg.
- Stopped Diovan.
- Doxaben 0.5 Bid. was added.
11Case Report (7)
- OPD on 90-5-3
- SGOT 48 U/L, SGPT 79 U/L.
- Cr 1.7 mg.
- BP 160/110 mmHg
- Cellcept dosage was increased to 1000 mg Bid.
- Tenormin 100 mg Bid. was added.
12Case Report (8)
- OPD on 90-5-31
- SGOT 45 U/L, SGPT 63 U/L.
- Cr 1.5 mg. T. Bil 1.3
- BP 120/80 mmHg.
- Anti-HCV (), HBsAg(), Anti-HBsAb(-).
- Insulin injection was given (unknown dosage).
13Case Report (9)
- OPD on 90-6-28
- SGOT 107 U/L, SGPT 151 U/L.
- Cr 1.6 mg/dL, T. Bil 5.2 mg/dL
- BP 130/90 mmHg.
- Anti-HCV (), HBsAg(), Anti-HBsAb(-).
- Jaundice(), Dyspnea().
- Admitted on 90-7-2.
14Case Report (10)
- The Second Admission (90-7-2 )
- Generalized weakness and edema.
- UTI with E. Coli infection was noted.
- Markedly prolongation of PT and APTT was also
found. - Sudden onset of leukopenia and thrombocytopenia
occurred on 90-7-3.
15Case Report (11)
- 2001-7-3
- The patient was transferred to ICU due to
impeding hepatic failure. - No active lung lesion.
- Lamivudine was given.
- 2001-7-4
- Conscious disturbance, shock, and high fever
occurred. - The patient expired.
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20Hepatology Profiles
21Major Problems of This Patient
- Acute liver failure.
- Leukopenia.
- Thrombocytopenia.
22Causes of Acute Hepatic Failure (1)(J
Gastroenterol Hepatol 200015480-8)
- Viral
- Hepatitis A, B(D), C, E. ?
- Haemorrhagic fever viruses. ?
- Cytomegalovirus. ?
- Herpes simplex viruses. ?
- Adenovirus. ?
23Causes of Acute Hepatic Failure (2)(J
Gastroenterol Hepatol 200015480-8)
- Drugs/Toxins
- Acetaminophen
- Carbon tetrachloride
- Amanita phalloides poisoning
- Bacillus cereus (???) emetic toxin.
- Cyanobacteria microcystins.
- Isoniazid, halothane, troglitazone.
- Herbal medicines.
- Idiosyncratic reactions.
24Drugs Inducing Idiosyncratic Liver Injury (1)
- Infrequent Causes
- Isoniazid
- Valproate
- Halothane
- Phenytoin
- Sulfonamides
- Propylthiouracil
- Amiodarone
- Disulfiram
- Dapsone
25Drugs Inducing Idiosyncratic Liver Injury (2)
- Rare Causes
- Carbamazepine
- Ofloxacin
- Ketoconazole
- Lisinopril
- Niacin
- Labetalol
- Etoposide (VP-16)
- Imipramine
- Interferon alfa
- Flutamide
26Causes of Acute Hepatic Failure (3)(J
Gastroenterol Hepatol 200015480-8)
- Metabolic/Genetic
- Galactosaemia.
- Fructose intolerance.
- Tyrinosaemia.
- Neonatal iron storage disease.
- Wilsons disease.
- Alpha-1-antitrypsin deficiency.
- Neoplastic
- Lymphoma, metastatic malignancies.
27Causes of Acute Hepatic Failure (4)(J
Gastroenterol Hepatol 200015480-8)
- Pregnancy-related
- Acute fatty liver of pregnancy.
- HELLP syndrome (haemolysis, impaired liver
function, low platelet) - Heat stroke
- Vascular
- Budd-Chiari syndrome.
- Veno-occlusive disese.
- Ischemic shock liver.
28Possible Causes of AHF
- Viral infection
- Hepatitis virus B or C.
- Haemorrhagic fever viruses.
- Cytomegalovirus.
- Herpes simplex viruses.
- Adenovirus.
29Long-Term Impact of Hepatitis B, C Virus
Infection on Renal Transplantation(Am J Nephrol
200121300-306)
- 477 patients from 1984 to 1999.
- Age 6-67 years old.
- Follow-up period 4 months to 15 years.
- Cyclosporin-based immunotherapy.
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31Prevalence of Chronic Liver Disease
32Prevalence of Hepatoma
33Prevalence of Liver Cirrhosis/Hepatic Failure
3410-year Patient Survival Rate
3510-year Graft Survival Rate
36Lamivudine Therapy for Severe Acute Hepatitis B
Virus Infection after Renal Transplantation(Trans
plantation Proceedings 2001332948-2949)
- 56 positive outcome in immunosuppressed
patients. - Higher positive outcome in patients with renal
transplantation. - Should be given as early as possible.
- Long time treatment is reasonable.
- No risk of rejection.
37HCV Transmission by Organ Transplantation
- 96 in 26 organ recipients. (N Eng J Med
1992327910-915) - 56 in 37 kidney recipients. (Transplantation
199457826-813) - 0 in 6 kidney recipients. (Transplantation
199455674-675) - 57 in 14 kidney recipients. (Nephron
199571249-253)
38Hepatitis C Progression after Renal
Transplantation (1)
- Liver disease is more aggressive in RT recipients
who acquire HCV at the time of transplantation. - 12 jaundice patients in 15 RT recipients during
21?12 months. (NDT 1998133103-3107) - 6 of 14 RT recipients died. (Kidney Int
199751981-999)
39Hepatitis C Progression after Renal
Transplantation (2)
- Chronic hepatitis and cirrhosis occurred more
frequently in RT recipients with HBV and HCV
coinfection than those with HCV alone. - 26 vs 10 (NDT 1995(suppl 6)10S122-S124)
- 50 vs 25.5 (NDT 199510125-128)
- No difference in the death rate from liver diease.
40Hepatitis C Progression after Renal
Transplantation (3)
- 10-year patient survival rate was 91 in 16
HCV-positive recipients. - (Transplant Proc 1998302100-2101)
- The use of azathioprine, antilymphocyte globulin,
and anti-CD3 antibodies (OKT3) is linked wih more
frequent liver disease. - (N Eng J Med 1991325454-460)
41Viral Hemorrhagic Fevers(D.Amstrong Infectious
Disease,1999)
- An acute onset of high fever.
- High mortality rate.
- Bleeding tendency.
- Prolonged APTT.
- Pulmonary edema.
- Thrombocytopenia.
- Impaired liver function, AST/ALT gt 1.
- Death due to shock or ARDS.
42RNA Viruses Causing VHF
43Viral Hemorrhagic Fevers(Infectious Disease,
Donald Amstrong,1999)
- Diagnosis
- Isolating the virus from serum.
- Demonstrating a 4-fold rise in antibody titer.
- Demonstrating high-titer IgG antibody with
virus-specific IgM antibody in association with
compatible clinical disease.
44Key Clinical Features of VHF
45Yellow Fever
- Mosquito-mediated.
- The 1st phase
- Lasts for 72 hours.
- Headache, malaise, weakness, nausea, vomiting.
- The 2nd phase
- No symptoms for 24 48 hours.
- The 3rd phase
- High fever, bradycardia, bleeding.
- Hepatic failure, renal failure.
46Hantavirus Infection
- Febrile phase
- High fever, chills, headache, malaise, myalgia,
elevated WBC, rising hematocrit. - Hypotensive phase
- Hypotension, shock, hemorrhage, pulmonary edema,
thrombocytopenia, renal failure.
47Dengue Hemorrhagic Fever
- No classical progressive phases in adult
patients. - May have a stormy and fatal course.
- Elevated liver enzymes.
- Hypotension.
- Gastrointestinal bleeding.
48Posttransplantation Viral Infection
- Cytomegalovirus (the most common).
- Herpes Simplex Virus.
- Varicella Zoster
- Epstein-Barr Virus.
- Human Immunodeficiency Virus.
49Cytomegalovirus (CMV) Infection
- Asymptomatic
- Positive CMV culture.
- More than 4x rise in anti-CMV antibody titer.
- Symptomatic
- Fever. Usually between 4th and 10th weeks.
- Neutropenia, Splenomegaly.
- Pneumonia, Hepatitis, pancreatitis.
- Arthralgia, Myalgia.
- Gastrointestinal ulceration.
- Chorioretinitis. (4 6 months later)
50Anti-CMV Ab in This Patient
- CMV antibody 1 16 (). (2000-9-7)
- CMV IgM antibody negative. (2000-9-7)
51Types of CMV Disease
52Herpes Simplex Virus (HSV) Infection
- Oropharyngeal ulceration.
- Epidermal infection.
- Gastrointestinal tract disease.
- Fulminant hepatitis.
- Pneumonia.
- Encephalitis.
53 - Varicella Zoster Infection
- Localized zoster.
- Epstein-Barr Virus Infection
- Acute lymphoproliferative syndrome.
- Human Immunodeficiency Virus
- Persistent leukopenia.
54Neutropenia
- Definition
- Neutrophil count lt 1,500/cumm.
- Etiology
- Bone marrow injury.(radiation, drugs, hepatitis,
malignancies) - Maturation defects (poor nutrition).
- Increased margination (endotoxin)
- Accelerated consumption. (severe sepsis)
- Accelerated destruction. (Drugs, immune
mechanisms)
55Thrombocytopenia (1)
- Definition
- Platelet count lt 70,000/cumm.
- Etiology
- Congenital.
- Acquired (decreased production).
- Aplastic anemia.
- Marrow infiltration.
- Radiation toxicity
- Chemotherapy.
- Drug toxicity (thiazides, alcohol, estrogens)
56Thrombocytopenia (2)
- Nutritional deficiency.
- Viral infection.
- Splenic problem.
- Increased platelet destruction
- Infection.
- Disseminated intravascular coagulation (DIC).
- Drug-induced.
- Posttransfusion.
57Final Diagnosis
- Acute liver failure due to Viral Infection
- Hepatitis B or/and C virus.
- Hantavirus, Dengue virus, Cytomegalovirus, Herpes
simplex virus, Adenovirus. (??????)