ACUTE ON CHRONIC LIVER FAILURE – case presentation

Dr Karan Jain – Hepatologist

Dr Rela Institute & Medical Centre

BACKGROUND

• A 26-year-old gentleman from Chennai
• Index presentation: Lower limb swelling, jaundice, fever, and blood vomiting.
• Admitted else-where managed with EVL banding for esophageal varices, IV antibiotics, FFP transfusion.
• Etiology work up: Negative AI profile, viral markers, and normal Ceruloplasmin.
• Came to RIMC for further evaluation.
• Diagnosis: Cirrhosis of the liver, cause unknown, Portal hypertension/ variceal bleed/ no AKI/ no HCC/ no HE diagnosed in October 2023

​

Diagnostic Findings:

• Endoscopy (30/10/23): Grade III Esophageal varices, EVL performed.
• CECT abdomen (11/2023):chronic liver disease, portal hypertension, splenomegaly and moderate ascites

Admission for Decompensation and ACLF Diagnosis:

• Admitted with fever, altered sensorium, vomiting, and abdominal pain.
• Hepatic encephalopathy grade II, MELD 33, no comorbidities.
• Investigations showed hematological and biochemical abnormalities.
• Managed in the liver medical ICU with antibiotics, volume resuscitation, and anti-HE measures.
• ACLF GRADE: 2
• AARC SCORE : 10

Transplant Evaluation and Management:

• Shifted to ward post-stabilization with a plan for early liver transplant.
• Had grossly elevated INR.
• Reviewed by Prof Rela for ABO-incompatible LDLT.
• Admitted for rituximab administration and plasma exchange pre-transplant.

​

​

• Initial Status (Pre-Plasma Exchange): ABO isoagglutinin titre: IgM 1:64, IgG 1:256.
• Treatment Plan: Rituximab 300mg IV (375mg/m² BSA)1 week prior to fixed transplant date, Scheduled for 2 cycles of plasma exchange before transplant.
• Plasma Exchange Dates: Conducted on 25th and 27th.
• Post-Plasma Exchange Status: ABO titre reduced to IgM 1:4, IgG 1:8, IgM-1:8.

​

RITUXIMAB

Liver Transplantation and Postoperative Course:

• ABOi Compatible LDLT performed on 28.02.2024.
• Shifted to liver transplant ICU post-surgery, started on higher antibiotics and supportive medications.
• Extubated on POD 1, started on oral sips, and gradual escalation of feeds.
• Explant showed: Chronic hepatitis with mixed nodular cirrhosis, cholestasis ? Metabolic etiology ?crytogenic. Whole exome studies awaited.
• Discharged on POD 20 with Immunosuppression regimen and discharged on 19.03.2024

​

Post-Transplant Follow-Up

• Post-transplant individual under regular follow-up.
• Medication Regimen: Tacrolimus 1mg twice daily, Myfortic 360mg twice daily, Wysolone 15mg.
• Tacrolimus Level: Maintained at 7.
• ABO Titres Progression:
• 25-03-2024: IgM 1:2, IgG 1:16
• 29-03-2024: IgM 1:4, IgG 1:8
• 09-04-2024: IgM 1:64, IgG 1:128
• Observing increasing ABO titres post-transplant despite immunosuppressive regimen.
• Requires close monitoring and potential adjustment of therapy to prevent rejection.

​

POD 1

Thank you!!!