Mr. F., a 36-year-old man, was transferred from a community hospital to an academic transplant center with a diagnosis of esophageal varices secondary to a history of autoimmune hepatitis. Initial assessment revealed jaundiced skin and sclera. He was oriented to person, place, and time, but was confused when asked questions about his current situation. His lungs were clear, his heart rate was 96 beats/min with normal sinus rhythm, and his blood pressure was 90/60 mm Hg. Edema (21) was present in the lower extremities. No ascites was evident. Shortly after admission, Mr. F. experienced massive hematemesis and required transfusions with packed red blood cells and fresh frozen plasma. An upper endoscopy was performed with evidence of variceal bleeding requiring banding. His urine was dark in color. Hepatorenal syndrome was suspected.
The liver transplant team was contacted and an evaluation was started with the multiprofessional team. The patient’s Model of End-Stage Liver Disease (MELD) score was calculated to be 35, and Mr. F was listed for a liver transplant. Given the severity of his disease and the high MELD score, a suitable new liver was found just 3 days after listing.
After transplantation, Mr. F. was in the surgical critical care unit; he was extubated within 24 hours and treated in the unit for 2 days. His liver enzymes rose initially but began to fall by the time of his discharge home 16 days later. His mental status was normal at post-op day 6 and the remainder of his hospitalization was uneventful.
Within 7 days after discharge he was readmitted with irritability, fatigue, and right upper quadrant (RUQ) abdominal pain. The abdominal ultrasound was negative as were the magnetic resonance imaging (MRI) and computed tomography (CT) of his head.
A liver biopsy revealed moderate liver rejection requiring treatment with intravenous steroids. He was discharged after 5 days with increases in his maintenance immunosuppression. Discharge laboratory values:
Questions
1. What three tests are used to calculate MELD scores?
2. What symptoms indicate rejection?