CCTC CERTIFICATION REVIEW

CCTC CERTIFICATION REVIEW Absolute Contraindications for liver transplant - ✔✔Severe cardiopulmonary disease, uncontrolled HIV, poorly controlled Psych illness, noncompliance, anatomical abnormalities precluding adequ ...

CCTC CERTIFICATION REVIEW Absolute Contraindications for liver transplant - ✔✔Severe cardiopulmonary disease, uncontrolled HIV, poorly controlled Psych illness, noncompliance, anatomical abnormalities precluding adequate surgical reconstruction Reason for not accepted for liver TX - ✔✔Hepatocellular Carcinoma (HCC) outside Milan Criteria What is NAFLD? - ✔✔Nonalcoholic Fatty Liver Disease- caused by obesity, hyperglycemia, elevated serum lipids, and high BP What is NASH? - ✔✔Non-alcoholic steatohepatitis. Can lead to cirrhosis 3rd common indication for liver TX. What is the MELD score? - ✔✔MELD(Model for End Stage Liver Disease) is a predictive model of death within a 3 month period. Ranks your degree of sickness, shows how much you need a liver transplant. The higher the number, the more urgent case is. Score ranges from 6-40. *Score for HCC capped at 34. Calculated using: -INR -Bilirubin -Creatinine -Sodium MELD > 14 needed for liver transplant What can green drainage post liver TX indicate? - ✔✔Bile leakage What can a rise in ALP post liver tx indicate? - ✔✔Can be a sign of biliary complications or cholestasis Lab changes are indicate of graft dysfunction. Which values will be elevated for liver tx? - ✔✔Elevated AST and ALT Target levels for immunosuppressants are based on a number of factors including: - ✔✔Indication for tx, use of induction therapy, kidney function, overall condition of pt. What can lead to metabolic encephalopathy post liver transplant? - ✔✔Renal failure or sepsis What can lead to hypoxic ischemic encephalopathy post liver transplant? - ✔✔Significant perioperative hypotension De Novo seizures can occur post liver transplant and can be caused by what? - ✔✔Electrolyte imbalances, reaction to cyclosporine or tacrolimus, intracranial hemorrhage or cerebral infarction and intracerebral abscesses What can cause a post liver transplant patient whose initial postop neurological course is normal to develop sudden deterioration in neurological status? - ✔✔Intracranial bleed Risk of primary non-function after liver transplant is: - ✔✔4-6% Factors related to primary nonfunction of new liver include: - ✔✔Donor age, prolonged cold ischemic time, prolonged donor hospital stay with periods of hypotension, preservation injury during donor surgery, and donor steatosis(fat in liver) Early Indicators of non functioning liver: - ✔✔decrease in bile production extreme edema of organ Abnormal color of organ upon reperfusion(mottled, gray, pale) lack of reperfusion in OR urine output <30ml/hr hemodynamically unstable glucose, k, and lactate abnormalities Coagulopathy Clinical presentation for hepatic artery stenosis(HAT) - ✔✔Increase in LFTs due to decreased blood flow through the hapatic artery to new organ Delayed bile leak Persistent sepsis of unknown cause What test is the gold standard for HAT diagnosis? - ✔✔Angiography What is treatment for HAT? - ✔✔Immediate return to OR for revascularization of organ Symptoms of bleeding post liver transplant include: - ✔✔Increased swelling in abdomen Pallor Clinical manifestations of hypovolemia Some BP meds may increase cyclosporine or tacrolimus levels, name 2 - ✔✔Diltiazem(Cardizem) Verapamil(Calan) What are causes of cholestasis post liver transplant - ✔✔Rejection Sepsis Drug toxicity Preservation injury Clinical manifestations of cholestasis - ✔✔Cloy or white stools Dark urine Itching Pain in upper right quadrant Jaundice Inability to digest certain foods N&V Locations of bile leaks post liver transplant - ✔✔Anastomosis site T tube exit site Along the t tube tract at time of removal Within the liver as result of bile duct destruction(bile leak) From the cut surface in split liver, living donor transplant, or after biopsy CMV clinical manifestations - ✔✔High fever, rigors, body aches, night sweats CMV prophylaxis - ✔✔Valganciclovir ( valcyte) for 3 months S&S of rejection post liver TX - ✔✔Fever, ictera(yellowing of sclera), jaundice, RUQ pain, fatigue, malaise, pruritis *confirmed by biopsy Lab changes with rejection s/p liver TX - ✔✔Elevated AST, ALT, bilirubin What color should t tube drainage be post liver Tx? - ✔✔Golden brown Types of rejection in transplant - ✔✔Hyperacute acute(cellular and antibody mediated) chronic Signs of acute rejection s/p liver Tx - ✔✔Fever, listlessness, liver pain, loss of appetite, irritability, fatigue, abdominal distention, jaundice, abnormal transaminases What to monitor post liver bx - ✔✔VS, signs of bleeding(tachycardia, hypotension) If has T tube monitor for blood in bile Hgb hct typically check 4 hrs after bx Bed rest 4-6 hrs after bx When should pt notify staff post bx? - ✔✔Severe abdominal pain Dizziness/lightheadedness SOB Bleeding from bx site Calcineurin inhibitors - ✔✔Tacrolimus(prograf) Cyclosporine(neoral or gengraf) Antiproliferative agents - ✔✔Azathioprine (imuran) Mycophenolate mofetil(cellcept) Mycophenolic Acid(myfortic) Corticosteroids - ✔✔Methylprednisolone (solu-medrol), or IV or Oral prednisone Which medication causes increased cholesterol levels? - ✔✔Sirolimis(rapamycin/rapamune) Why are induction agents given pre- or intraoperatively in transplant? - ✔✔Decrease incidence of acute rejection delay first rejection delay use of calcineurin inhibitors due to their nephrotixicity Side effects of calcineurin inhibitors(tacrolimus and cyclosporine) - ✔✔Tremors, headaches, HTN, nephrotoxicity, high glucose levels, hair growth or loss, increased risk of cancer Side effects of corticosteroids - ✔✔DM, HTN, high cholesterol, weight gain, fluid retention, indigestion, bone loss(long term use), Azathioprine(imuran) side effects - ✔✔Leukopenia, joint pain, n&v, dizziness, stomach upset Sirolimus(rapamycin/rapamune) side effects - ✔✔Leukopenia, thrombocytopenia, anemia, HTN, rash, acne, diarrhea, poor wound healing *dyslipidemia is a long term complication* Mycophenolate mofetil (CellCept) side effects - ✔✔Low white cells(especially neutrophils), diarrhea(splitting dose may help), vomiting, headaches, HTN Basiliximab (Simulect) side effects - ✔✔Abdominal pain, sore throat, tremors, vomiting, swelling of ankles body face lower legs, loss of energy Daclizumab (zenapex) side effects - ✔✔Dizziness, n&v, tachycardia, chest pain, tremors, swelling of feet or lower legs Alemtuzumab (Campath) side effects - ✔✔Fever and chills shortly after infusion