359.3 🏥 內科專科考前版

359.3.1 Mechanistic Deep Dive

359.3.1.1 MELD-Na Calculation

  • Bilirubin + INR + creatinine + sodium
  • 90-day mortality predictor
  • Replaced wait-time system 2002

359.3.1.2 MELD 3.0 (2023)

  • Adds female sex coefficient
  • Albumin
  • Better discrimination
  • Used by UNOS

359.3.1.3 Acute-on-Chronic Liver Failure (ACLF)

  • Cirrhosis + acute precipitant
  • Multi-organ failure
  • High mortality
  • ICU + LT evaluation
  • CLIF-C scoring

359.3.2 Recent Trials & Updates

359.3.2.1 Machine Perfusion

  • Normothermic + hypothermic
  • DBD + DCD expansion
  • Improved outcomes

359.3.2.2 Early LT for Severe AH

  • Mathurin 2011
  • US protocols (ELITAH)
  • Strict psychosocial
  • 6-month rule challenged

359.3.2.3 DCD Liver Transplant

  • Donation after circulatory death
  • Comparable outcomes in select donors
  • Increasing utilization

359.3.2.4 HBV Post-Transplant

  • Antivirals + HBIG combination
  • Recurrence reduced to < 5%
  • Lifelong therapy

359.3.2.5 Xenotransplantation

  • Pig liver early trials 2024
  • Multiple gene edits
  • Limited duration so far

359.3.3 High-Yield Specialist Points

359.3.3.1 Tacrolimus Practical

  • Trough 8-10 ng/mL early, 5-8 long-term
  • CYP3A4 metabolism (interactions)
  • Side effects: nephrotoxicity, neurotoxicity, hyperglycemia, hyperkalemia, tremor, hyperestrogenism

359.3.3.2 MMF Side Effects

  • Diarrhea
  • Leukopenia
  • Anemia
  • Use mycophenolic acid (Myfortic) for GI intolerance

359.3.3.3 mTOR Inhibitors

  • Sirolimus, everolimus
  • For CNI nephrotoxicity, HCC recurrence prevention, CAV
  • Side effects: edema, hyperlipidemia, mouth ulcers, wound healing

359.3.3.4 CMV Tissue Invasive

  • Esophagitis, gastritis, colitis, hepatitis, pneumonia, retinitis
  • Treatment: ganciclovir IV 5 mg/kg q12h × 2-3 weeks → valganciclovir oral

359.3.3.5 EBV + PTLD Monitoring

  • Monthly EBV PCR first year
  • Reduction of IS first-line
  • Rituximab for CD20+
  • Chemo for aggressive

359.3.3.6 Skin Cancer Post-LT

  • SCC most common
  • UV protection essential
  • Annual dermatology
  • Voriconazole ↑ SCC risk

359.3.3.7 Liver-Specific Drug Interactions

  • Tacrolimus + azoles (↑ levels — fluconazole, voriconazole, itraconazole)
  • Tacrolimus + macrolides (↑ levels)
  • Tacrolimus + CCBs (diltiazem ↑)
  • Grapefruit ↑ levels
  • Rifampin ↓ levels
  • Phenytoin ↓ levels
  • St. John’s wort ↓ levels

359.3.3.8 Vaccinations Post-LT

  • Inactivated only
  • Annual flu, pneumococcal, COVID, RSV
  • Avoid live (MMR, varicella, yellow fever, shingles live)
  • Hepatitis A + B if susceptible

359.3.3.9 Pregnancy After LT

  • Generally OK after 1-2 yr stable
  • IS adjustment (avoid MMF — teratogenic)
  • Higher pre-eclampsia, preterm risks
  • Multidisciplinary

359.3.3.10 Cardiovascular Risk Post-LT

  • Top cause of late mortality
  • Aggressive management of HTN, lipids, DM
  • Statins, ACE/ARB liberally

359.3.3.11 Renal Function Decline

  • CNI nephrotoxicity
  • 25-30% develop ESRD
  • mTOR inhibitor switch for some

359.3.4 Pearls

  • MELD-Na or MELD 3.0 for allocation
  • Milan Criteria for HCC
  • Mayo Protocol for hilar CCA
  • Tacrolimus + MMF + prednisone standard
  • CMV, EBV, PCP important infections
  • HCV curable post-LT with DAAs
  • HBV prevented with antivirals + HBIG
  • PSC recurrence 30%+; PBC 20-30%; AIH common
  • Outcomes: 1-yr 90%, 5-yr 75%, 10-yr 60%
  • Living donor predominant in Taiwan