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  #1  
Old 05-17-2011
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Liver An appropriate Liver doner is available, would you transplant this patient?

A 28-year-old woman is hospitalized after taking a massive overdose of acetaminophen tablets in a suicide attempt. She has type 1 diabetes mellitus and major depressive disorder refractory to tricyclic antidepressant therapy. Despite appropriate therapy, she develops rapidly progressive hepatic failure and becomes progressively encephalopathic. On the 6th day of hospitalization, she is comatose. A CT scan of the brain shows mild diffuse swelling. An appropriately cross-matched, size-appropriate donor liver is available. Which of the following is the most appropriate course of action regarding transplantation?

A ) Do not proceed with the transplantation because diabetes mellitus is a contraindication
B ) Do not proceed with the transplantation because hepatic function is likely to return over the next week
C ) Do not proceed with the transplantation because major depressive disorder places the patient at risk for another suicide attempt
D ) Do not proceed with the transplantation because the onset of encephalopathy and CT findings suggest bacterial meningitis
E ) Proceed with the transplantation
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  #2  
Old 05-17-2011
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Default hey

Correct answer is E.
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  #3  
Old 05-18-2011
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eeeeeeeeeeeeeeeeee
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  #4  
Old 05-18-2011
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Transplant - dont see any reason not to, except ofcourse the "hepatic contraindication to operation" is present , in the presence of bilirubin >2 or albumin < 3 or encephalopathy the mortality due to operations approaches 40-50% and more depending on number of such factors.. (source kaplan surgery).

So.....
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Old 05-18-2011
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Question E

I l go with E.
Is this an NBME question? I hope it isn't.
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  #6  
Old 08-27-2011
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Warning! Contraindications for liver tranplantation

Quote:
Originally Posted by drarnab View Post
Transplant - dont see any reason not to, except ofcourse the "hepatic contraindication to operation" is present , in the presence of bilirubin >2 or albumin < 3 or encephalopathy the mortality due to operations approaches 40-50% and more depending on number of such factors.. (source kaplan surgery).

So.....
I found that one of the contraindications for liver transplantation is "Uncontrolled psychiatric disorder" as presents in this patient.
http://www.umm.edu/transplant/liver/indliver.htm

However, I am not sure about C. Maybe E is correct.

Any comments is appreciated.
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  #7  
Old 08-27-2011
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Quote:
Originally Posted by mle guy View Post
I l go with E.
Is this an NBME question? I hope it isn't.

Answer should be C as explained by the above mentioned link.

Heads up....

This is an NBME question. Plz at least have the courtesy of mentioning it in the title.
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Last edited by step1an; 08-28-2011 at 02:46 PM.
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  #8  
Old 08-27-2011
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I would go for C.
I wouldn´t for for the transplant for 2 reasons: 1. not controlled psychiatric illness (if patient doesn´t take her meds than the transplant is not going to be of any good, and will be rejected), 2. extense comorbidities for surgery that puts this patient at an extreme high risk (although probably her only chance to survive).
So, what is the correct answer, and why?
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  #9  
Old 08-27-2011
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I think I would also go for C because:
1) The patient has to be able to comply with treatment regimens post transplant, and if her psychiatric condition is uncontrolled she may not be able to do that.
2) She has severe brain damage, which is a life limiting/ threatening condition that the transplanted liver won't fix.

Would love to know the answer...
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  #10  
Old 08-28-2011
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Warning!

Quote:
Originally Posted by heights View Post
I think I would also go for C because:
1) The patient has to be able to comply with treatment regimens post transplant, and if her psychiatric condition is uncontrolled she may not be able to do that.
2) She has severe brain damage, which is a life limiting/ threatening condition that the transplanted liver won't fix.

Would love to know the answer...

I found in the other forums the following explanation. This question was actually an NBME question:


Answer is C.

Patients who are going to have transplants shouldn't have any psychiatric disorders. Besides, they should be very reliable and compliant with medications and follow-ups.
With immunosuppressive medications, there's no fooling around. If the patient is not the compliant and reliable type, delays filling them or forgets them (dementia for example), then this would be a disaster for sure.
If the patient can't follow-up with the clinic on a regular basis (no transportation for example), then he's not a candidate.
The patient above tried to commit suicide. Liver transplants are expensive and are not easy to find. Why waste a transplant on a patient who's likely to commit suicide again? This transplant should be saved to save the life of a patient who is more reliable and is expected to live longer.
Also, if the patient is going to die within 6 months (for example), then what's the point?

Makes sense?

http://www.usmleforum.com/files/forum/2010/2/522454.php
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  #11  
Old 08-29-2011
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Answer is C....DM is not a contraindication to transplantation..>BUt the suicide attempt is because its gonna end up being wasted.
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