Abnormal liver function tests in the patient transplanted 3 years ago for alcoholic liver disease
✍ Scribed by Nathan M. Bass; Bernard C. Portmann; Michael R. Lucey
- Publisher
- John Wiley and Sons
- Year
- 2006
- Tongue
- English
- Weight
- 297 KB
- Volume
- 12
- Category
- Article
- ISSN
- 1527-6465
- DOI
- 10.1002/lt.20949
No coin nor oath required. For personal study only.
✦ Synopsis
A 27-yr-old Caucasian female dental assistant presented with fatigue, malaise, and nausea, and physical findings of jaundice and hepatomegaly. Total bilirubin was 20.3 mg/dL (direct: 14.6 mg/dL), serum albumin 2.5 gm/dL, aspartate aminotransferase 230 U/L, alanine aminotransferase 58 U/L, alkaline phosphatase 230 U/L, international normalized ratio 2.5 mg/dL, and serum creatinine 1.3 mg/dL. Extensive investigation revealed no viral, autoimmune, metabolic, or genetic etiology for her liver disease. Screening for alcohol and drugs of abuse was consistently negative. Liver biopsy revealed micronodular cirrhosis with considerable steatosis, but no typical features of acute alcoholic hepatitis. She had recently married, and admitted to drinking only up to 2 glasses of wine per week prior to becoming ill. Her history of minimal alcohol consumption was adamantly affirmed by a large, well-educated, close family including her husband. Progressive liver failure with hyperammonemia and altered mental status resulted in orthotopic liver transplant (#1) within 3 months of presentation. The explant showed micronodular cirrhosis with considerable fat and minimal inflammation. Her posttransplantation course was notable for recurrent episodes of nausea, vomiting, and cholestasis, with elevated aspartate aminotransferase and bilirubin. Liver biopsies revealed features of fat, inflammation, and duct injury compatible with mild to moderate acute cellular rejection progressing ultimately to fibrosis and duct loss. Rejection was treated on 2 occasions with OKT3, complicated by aseptic meningitis and cytomegalovirus hepatitis, successfully treated with ganciclovir. Improvement in clinical and biochemical abnormalities was observed during several