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Old 09-28-2012
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Arrow Gyrus Daily Questions; Internal Medicine #34

A 55-year-old male with cirrhosis is seen in the clinic to follow up a recent hospitalization for spontane-ous bacterial peritonitis. He is doing well and finishing his course of antibiotics. He is taking propranolol and lactulose; besides complications of end-stage liver disease, he has well-controlled diabetes mellitus and had a basal cell carcinoma resected 5 years ago. The cirrhosis is thought to be due to alcohol abuse, and his last drink of alcohol was 2 weeks ago. He and his wife ask if he is a liver transplant candidate. He can be counseled in which of the following ways?
A. He is not a transplant candidate as he has a history of alcohol dependence.
B. He is not a transplant candidate now, but may be after a sustained period of proven abstinence from alcohol.
C. Because he has diabetes mellitus he is not a transplant candidate.
D. Because he had a skin cancer he is not a transplant candidate.
E. He is appropriate for liver transplantation and should be referred immediately.
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Old 09-28-2012
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B. He is not a transplant candidate now, but may be after a sustained period of proven abstinence from alcohol.
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Answer B
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Old 09-29-2012
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The answer is B.

The patient has advanced cirrhosis with a high risk of mortality as evidenced by his episode of spontaneous bacterial peritonitis. His diabetes and remote skin cancers are not absolute contraindications for liver transplantation, but active alcohol abuse is. The other absolute contraindications to transplantation are lifethreatening systemic disease, uncontrolled infections, preexisting advanced cardiac or pulmonary disease, metastatic malignancy, and life-threatening congenital malignancies. Ongoing drug or alcohol abuse is an absolute contraindication, and patients who would otherwise be suitable candidates should immediately be referred to appropriate counseling centers to achieve abstinence. Once that is achieved for an acceptable period of time, transplantation can be considered. Indeed, alcoholic cirrhosis accounts for a substantial portion of the patients who undergo liver transplantation.
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