Clinical Crossroads | Clinician's Corner

A 50-Year-Old Man With Hepatitis C and Cirrhosis Needing Liver Transplantation

Douglas W. Hanto, MD, PhD, Discussant
JAMA. 2003;290(24):3238-3246. doi:10.1001/jama.290.24.3238.
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DR SHIP: Mr G is a 50-year-old man who has had liver disease for about 12 years. He lives near Boston with his wife and children and is a partner in a small industrial firm. He has managed care insurance.

During a routine life insurance evaluation in 1991, Mr G was found to have abnormal liver function test results and was diagnosed with non-A, non-B hepatitis. Liver biopsy showed mild periportal inflammation. In 1995, he was found to have antibodies to hepatitis C. He was treated with interferon and ribavirin but did not improve. A liver biopsy in 2001 revealed grade II to III inflammation, stage IV fibrosis. He was subsequently treated with pegylated interferon and ribavirin and again did not improve. In 2001, he developed transient ascites and encephalopathy, with unsteady gait and forgetfulness. In 2002, Mr G bled from esophageal varices and underwent a transjugular intrahepatic portosystemic shunt (TIPS) procedure, requiring revision 1 week later. Since that time, he has been on the liver transplant waiting list.

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Figure 1. Trends in Liver Transplant Waiting List and Transplantation
Graphic Jump Location
Data from the United Network for Organ Sharing shows the growth in the number of patients on the waiting list for liver transplantation and the number of patients added to the list each year compared with the number of deceased donors and the number of deceased donor liver transplants performed in the United States (1993-2002).10
Figure 2. Reported Deaths and Annual Death Rates: Liver Transplantation Waiting List
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Data from the United Network for Organ Sharing shows that although the number of deaths on the list has increased, reflecting the growth of the waiting list, the death rate per 1000 patient-years at risk has decreased.10
Figure 3. Mechanisms of Action of Immunosuppressive Drugs
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MHC indicates major histocompatibility complex; IL, interleukin. Immunologic events from the time of liver transplantation to the development of rejection are summarized above. The sites of action of several immunosuppressive drugs are noted. Because different sites can be targeted with multidrug regimens, prevention of rejection can be accomplished with lower drug dosages thereby reducing adverse effects.
Figure 4. Prognosis After Liver Transplantation
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Patient and graft survival 1, 3, and 5 years after liver transplantation in all patients compared with patients 50 to 64 years of age.10




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The Rational Clinical Examination
Make the Diagnosis: Cirrhosis

The Rational Clinical Examination
Original Article: Does This Patient With Liver Disease Have Cirrhosis?