Case Presentation
A 47 year old Caucasian woman presented with recent progressive fatigue, bloating
feeling, and occasional midepigastric pain, without radiation and unrelated to food intake
or exertion. Temp. 36C, HR 78, BP 102/60mmHg, ht. 63in, wt. 152lbs. Examination of
the oropharynx, neck, lungs, heart, and abdomen were unremarkable. The liver edge
could not be palpated, but there was a small amount of ascites noted. A spleen tip was
palpated 3cm below the left costal margin. The skin was normal with trace pretibial
edema. Neurologically, the patient was alert and oriented. As a result of her lab values
and symptomology the patient was referred to a local hepatologist for further evaluations
(Table 1). An ultrasound was performed which showed cirrhosis and splenomegaly. A
liver biopsy confirmed cirrhosis and the presence of Chronic Hepatitis C (HCV). The
patient was placed on Lasix 20mg QD, Aldactone 50mg QD, and Prilosec 20mg QD and
referred to a liver transplant center to be evaluated.
After meeting with a hepatologist, transplant surgeon, social worker, and a CEP, her case
was discussed at the weekly liver transplant selection conference. The patient is a wife of
20 years and a mother of three teenage daughters. She has been a second grade school
teacher for 25 years. Her father died of a heart attack in his 50’s; he was a heavy smoker.
A sister and brother both have Diabetes Mellitus Type II. She has never smoked
cigarettes and has no known allergies. She has no history of heavy alcohol use and
hasn’t used drugs apart from some marijuana in her youth. She reported having less than
10 drinks over the last 5yrs. She walks the family dog every night about 1 mile, enjoys
gardening on weekends, and hiking with her family when on vacations. Her first delivery
was breech, required a cesarean section and the subsequent blood loss required a blood
transfusion. The HCV transmission was assumed to occur with this blood transfusion.
Her Childs-Turcotte-Pugh score (CTP) was seven, and therefore met minimum listing
criteria for the United Network for Organ Sharing (UNOS). The decision was to list her
with UNOS as a status 3 based on her liver function and CTP score. In the meantime, she
was to abstain from all alcohol, undergo further cardiovascular studies, and complete
routine abdominal ultrasounds and alpha-fetoprotein levels to screen for hepatocellular
carcinoma (HCC -increased risk associated with HCV). In addition, she should complete
routine liver functions and attend liver transplant clinic every three months for follow-up.
Questions:
1.) Define underlined terms
2.) Do you understand the physical exam?
3.) Table 1., what are these labs looking at & what are normal values?
4.) What are this woman’s risk factors for CVD?
5.) How would you evaluate this patient’s physical functioning?
6.) What do you think some special considerations will be?
You guys are doing great, but unfortunately the patient is not…
Over the next two years the patient gradually decompensated in physical functioning and
liver dysfunction. She began working half days at school, but eventually had to go on
full disability due to fatigue, worsening edema and ascites, and the beginning symptoms
of encephalopathy. Her exercise regiment had been reduced to one or two bouts of 10
min. walks/day when she felt she had enough energy.
Six months after leaving work and almost three years after her initial liver transplant (ltx)
evaluation the patient underwent an orthotopic liver transplant (ltx). Two days after an
uncomplicated ltx, a physical therapist had the patient performing ROM exercises in the
ICU. On post-op day 4, the patient had progressed to unassisted ambulation and physical
therapy referred the exercise therapy to a CEP.
Questions:
1.) Define underlined terms
2.) What would you do with this patient?
Keep plugging away…
The patient was discharged on post-op day 6 with the following post tx pharmacological
therapies: prednisone taper (200mg QD to 5mg QD over the next six weeks), tacrolimus
2mg BID, mycophenolate mofetil 1000mg BID, acyclovir 800mg QID,
trimethoprim/sulfamethoxazole 80mg/400mg TIW, omeprazole 20mg BID, and
magnesium 300mg TID. She was told to obtain biweekly blood draws at her local lab,
with results to be faxed to the liver transplant office so her liver functions could be
assessed regularly. She was also instructed to attend liver transplant clinic weekly for the
first month. The CEP also gave her a written exercise prescription and exercise logs for
adherence and motivation.
Questions:
1.) Define underlined terms
2.) Now, what would you kind of exercise prescription would you send this patient home
with and what is your next plan of action for this patient?
Time marches on…
Three months post transplant, the patient was seen at the liver transplant clinic for routine
follow-up. Her liver function tests were elevated again. A liver biopsy was performed to
differentiate between HCV recurrence and organ rejection. The histology report
confirmed acute rejection and her immunosuppressive medications were recycled. The
patient met with the CEP and reported increased duration and intensity of exercise and
“feeling stronger every day”.
Questions:
1.) Define underlined terms
2.) What would you discuss at this patient at this visit?
Very sad, but true…
At six months post transplant, she had been released to begin working part-time and also
to resume driving. After working for one week, she received a call from the liver
transplant center informing her that her LFT’s were elevated again. Another biopsy was
performed which revealed HCV recurrence. Interferon and ribavirin therapy was
initiated. Over the next few weeks, exercise phone follow-up calls were not returned to
the CEP and there was also no response via postal mail. Ten months post transplant, the
patient attended clinic to have a physician complete disability leave papers for work. The
patient was placed on an antidepressant. The patient told the CEP that she has no energy
to exercise and feels that she must conserve her energy just for routine errands and
childcare and that she’ll contact the CEP when she feels strong enough to resume her
exercise program.
Questions:
1.) Define underlined terms
2.) Now what will you do?
.
Table 1. Laboratory Values – Pre transplant
Creatinine
0.6 mg/
Alk Phos
BUN
20.2 mg/dL
AST
Hgb
11.1 g/dL
ALT
Hct
33.1 %
Bili, t
WBC
6.9 thous/mcl
PT
Sodium
138.0 mmol/L
Potassium
2.9 mmol/L
Normal range values vary between laboratories
148.0 U/L
69.0 U/L
77.0 U/L
1.2 mg/dL
14.0 sec