LIVER TRANSPLANT AVOIDANCE
CONSULTATION REPORT from UCLA liver transplant team
Date of Consultation: 11-16-94
Reason for Consultation: Evaluation for possible orthotopic liver transplantation.
History of Present Illness: The patient is a 43 year old man with chronic hepatitis B who is now being evaluated for possible liver transplantation. The patient has had known hepatitis B since 1988; in addition, was drinking heavily at that time as well and was working as a golf course supervisor. He is had cessation of alcohol since that time and was treated briefly with interferon for hepatitis B in 1992. It is uncertain why he did not complete totally his treatment. He denies intravenous drug abuse and has been basically with increasing liver decompensation over the past 6 months’ time with increasing jaundice, worsening hepatic function and ongoing active hepatitis B with coagulopathy and systemic complaints. His hepatic tests recently – bilirubin 15, ALT 270, AST 569, alkaline-phosphatase 157. Prothrombin time 20 seconds. Albumin was 2.8. He was admitted to the Dominican Hospital in 8/94 with dysuria, evidence of urinary tract infection and atrial fibrillation. In addition, he has had progression of ascites and edema since 1989 and is beginning to exhaust standard medical management.
Current Medications: Aldactone. Lactulose. Zaroxolyn. Cardiac medications of which he is currently uncertain.
He was admitted to the hospital and found to be in atrial fibrillation in addition to having findings of advanced chronic liver disease. He was treated with intravenous metoprolol for supraventricular tachycardia which was felt to be on the basis of possible pulmonary hypertension and regurgitation. An outpatient echocardiogram showed tricuspid regurgitation with pulmonary hypertension with estimated pulmonary pressures of approximately 45 mmHg. A hyperdynamic left ventricle was noted as well. He is now being evaluated for liver transplantation because of ongoing general compromise of his clinical status, with worsening hepatic function.
Physical Exam: A chronically ill, jaundiced man with obvious stigmata of chronic liver disease visible on inspection. Blood pressure 100/70, respirations 18. HEENT: There is marked icterus. There bitemporal wasting and multiple spider angiomata over the skin of the face, anterior chest wall and back. There are malar telangiectasias. Oropharynx: Teeth are in poor repair. Neck is supple, there is no adenopathy. Chest is clear to percussion and auscultation. The heart has a regular rhythm with a hyperdynamic precordium, soft systolic murmur along the left sternal border, without rubs, gallops or adventitial sounds. Abdomen is distended with ascites, increased venous pattern. Liver is felt 3 cm below the xiphisternum, 2 cm below the right costal margin with an approximate span of 10 cm, midclavicular The spleen is easily felt at the left costal margin. There are no rubs, bruits or murmur. There is bilateral edema with brawny changes of his lower extremities up to the thighs. There is no clubbing. There is palmar redness. Neurologically he is alert, oriented, without fetor, asterixis or focal neuropathological abnormalities.
Diagnosis: Chronic active hepatitis B, decompensated with: A. Systemic complaints. B. Poor synthetic function. C. Portal hypertension. Perhaps early encephalopathy, intermittent. D. Pulmonary hypertension ?.
Discussion: This patient has advancing chronic hepatitis B from the time of is presentation in 1988 when the disease was already established. He in addition has evidence for cardiac disease, perhaps mediated by pulmonary hypertension. Pulmonary hypertension may be problematic for him as it makes these patients extremely hazardous relative to anesthesia and intraoperative events involving reperfusion of the liver and the early postoperative care as well. The mechanism of pulmonary hypertension is uncertain but may relate to vasoactive substance which bypasses the liver via collaterals and in the pulmonary circulation causes vasoconstriction and elevation of pulmonary pressures. This same substance in the peripheral bed leads to vasodilation of hyperdynamic circulation and perhaps a combination of hyperdynamic circulation and the elevated pulmonary resistance compound the problem leading to eventual cardiac compromise and worsening of liver failure in that setting. Liver transplantation, once these cardiac concerns are resolved, would be his best option for long term care. His hepatitis B should not be problematic relative to use of high titer hepatitis B immune globulin and the standard protocol to prevent the recurrence of hepatitis B and has been noted by groups both in the United States and the recent trial from France.
3/31/95 Progress report by the patient after five NBE treatments.
The only option left with the physicians I was going to was organ transplants (liver and heart). I certainly don’t feel like these transplants are needed at all.
DR. TONG NOTED: This patient presented to us in early 1994 with classic symptoms indicative of liver failure and heart trouble, such as jaundice and scleral icterus, hepatosplenomegaly (enlargement of liver and spleen), large ascites (distended abdomen with accumulation of fluids from liver failure), widespread petechiae and liver spots, intermittent arrhythmia, bilateral 4+ ankle edema, severe shortness of breath, depression and lethargy. The patient was so weak that he could hardly walk up five steps, and had difficulty carrying out a normal conversation.
The patient stated that specialists at UCLA recommended both a liver and heart transplant. However, they hesitated to proceed with the procedures due to their higher risks. On the other hand, they told him that he would not live past Christmas without the transplants.
The patient experienced significant improvement from the very first NBE treatment, especially with the shortness of breath and energy. After five treatments, the ankle swelling was much improved. He was able to walk up four flights of stairs, and make the point of doing so for each appointment with us.
After two and a half months of treatments the patient was mostly symptom free on an occasional diuretic. Unfortunately, he was forced to discontinue treatment due to reimbursement problems from the insurance company. The patient continued to do well for approximately three years, and was lost to follow-up.
CIRRHOSIS OF LIVER, ABDOMINAL PAIN, LOW BACK PAIN, DIABETES
March 8, 1999
After the first treatment, I was able to take deep breaths. Breathing was shallow before. Pain in abdomen where hernia is located has subsided and my stomach is softer. My wife and daughter immediately noticed a great change in my disposition. They said I was my old self, “talking,” “smiling,” “joking.” I usually would wake up in the mornings, shower, eat, then lay back on the couch and fall asleep. I have not done that. I have more energy. I am taking less water pills for my swelling. When we came home after my first session with Dr. Tong, later that evening our daughter said to me, “How are you feeling?” I turned to her and smiled. The entire evening when she saw me I was smiling. She finally said, “Are you high? Did the doctors give you drugs? You sure look and act like you’re on drugs!”
March 15, 1999
Before coming to Dr. Tong for treatments, I was taking 2 types of diuretics for the edema. Now, I have completely stopped one diuretic and I have reduced the dosage of the other diuretic. I have more energy, and my older daughter noticed my skin coloring. She said it looks less yellow and more pink in color. This is my second week without leg cramps and the second week I have not taken Flexirel, a prescription drug to help my leg cramps.
March 17, 1999
I am still able to breathe deep. I had some swelling in my legs and stomach so I started the Lasix again, but I am still taking less diuretics than before Dr. Tong started treating me. I continue to have energy that I didn’t have prior to Dr. Tong’s treatments. I believe I will continue to get better with Dr. Tong’s treatments. If four treatments have helped me, think of how I can feel over a period of time! The staff is the greatest. They are caring, clean, helpful, and they have a great sense of humor! They listen – I do not feel rushed. All my questions and worries are answered.
March 22, 1999
Today is treatment #5. I continue to breathe deeply and with ease. I am able to get up from a lying/sitting position without hesitation. My energy continues to improve. I am not as tired as I was before my first treatment with Dr. Tong. I am not as cold; my electric blanket is set at 4 now instead of 7 or 8. My wife says I am like a heater.
DR. TONG NOTED: This patient initially presented with multiple severe symptoms, such as great difficulty breathing, severe chest and abdominal pain, abdominal distension, extreme weakness and emaciation. There was a remarkable improvement of his overall energy and symptoms in just five NBE treatments. Unfortunately, he had to discontinue therapy because his HMO would not pay for it.