LIVER TRANSPLANT RECIPIENT DEMOGRAPHY

Patient Demographics (Please fill up in capital letters)

Name / Age/Sex:
Blood Group
Address / Contact Numbers:
Primary (Mobile)
Attendant (Mobile)
Local contact
Home
email: / Diagnosis
For office use
Hospital No / Height / Cms
weight / Kgs
MELD / CTP / BMI / DOA
Referring doctor name, address & contact nos.

DEPARTMENT OF SURGICAL GASTROENETEROLOG

JIPMER, PONDICHERRY-9.

LIST OF INVESTIGATION TO BE DONE

S.no / Departments / Reports collected / Pending reports
1 / Microbiology
2 / Immunology
3 / Biochemistry
4 / Nuclear Medicine
5 / Pulmonary Medicine
6 / Cardiology
7 / Radiology
8 / Virology
9 / Pathology
10 / Transfusion Medicine
11 / General Medicine

MULTIDISCIPLINARY REPORT SUMMARY CHECKLIST

S.No / Multidisciplinary Team / Name of the Member / Fitness / Remarks
1 / Microbiology / Dr.Hidendran
Dr.Rahul
2 / Biochemistry / Dr.Nivedita
3 / Pathology / Dr.S.K.Varma
4 / Radiology / Dr.Ramkumar
5 / Nuclear Medicine / DR.Dhanapathihalnaik
6 / Cardiology / Dr.SanthoshSatheesh
7 / Pulmonology / Dr.ManjuRajaram
8 / Hepatology / Dr.Palanivel
9 / Dentist / Dr.Krishnan
10 / Psychiatry / Dr VikasMenon
11 / Anesthetist / Dr.Leninbabu
Dr.Sathyaprakash
12 / Dietician
13 / Physiotherapy
14 / OBG / Dr Veena
15 / Nephrology / Dr.Priyamvada
16 / Clinical Pharmacology / Dr.Adithan
17 / Endocrinology / Dr.Jayaprakash
18 / Transfusion / Dr.RajendraKulkarni
19 / Co-ordinator / Mrs. Subalaxmi
20 / Billing/Insurance
21 / Consent

Clinical Data

Presenting complaints/ Reason for referral to transplant centre:

Specific complaints related to liver disease:

  1. Jaundice- Yes/No.If yes, then
  2. Whether it was cholestatic
  3. Was it associated with cholangitis
  4. Encephalopathy- Yes/No. If yes, then
  5. Severity; Slowing/slurring of speech, loss of consciousness
  6. Number of episodes
  7. Whether hospital admission was required
  8. Grade
  9. Ascites- Yes/No. If yes, then
  10. Whether it required diuretics
  11. Whether it required paracentesis If yes no: of: episodes:
  12. Was there any complication to the above medication/procedure
  13. Spontaneous Bacterial Peritonitis- Yes/No. If yes, then
  14. Number of episodes
  15. Last episode
  16. Upper Gastrointestinal Bleed- Yes/No. If yes, then
  17. Number of episodes
  18. Severity of episodes
  19. Treatment;
  20. Medical
  21. Endoscopic(Banding/Sclerotherapy, sessions)
  1. Hepatitis diagnosed previously- Yes/No. If yes, then
  2. Hepatitis B or C
  3. Viral characterization;
  4. Viral load
  5. Genotype
  1. Any other complaints

Review of systems (Please include treatment details)

  1. Respiratory:
  2. Asthma
  3. COPD
  4. Cardiovascular:
  5. Hypertension
  6. Coronary artery disease
  7. Performance status:
  8. Good (Can walk 500 meters or a flight of stairs without stopping or getting breathless)
  9. Average (Able to walk but needs support or to stop in between)
  10. Poor (Unable to walk independently)
  11. Nutritional status:
  12. Good (Intake normal or nearly normal, no significant loss of weight)
  13. Average (Intake less than usual, weight loss present but not significant)
  14. Poor (Poor intake, loss of more than 10% of pre-illness weight over the last 6 months)
  15. Gastrointestinal:
  16. Appetite
  17. Bowel movements
  18. Genitourinary:
  19. Urinary complaints: Urine output, burning, bleeding
  20. Gynaecological
  21. Menstrual history, menopause, HRT, breakthrough bleeding
  1. Medical History:
  2. Diabetes mellitus
  3. Tuberculosis
  4. Cancer
  5. Surgical History:
  6. Prior surgeries
  7. Anesthesia
  8. Complications
  9. Blood transfusions
  10. Alcohol intake:
  11. Duration of intake
  12. Amount & type of alcohol
  13. History of recidivism
  14. Duration of abstinence
  15. Personal History:
  16. Smoking
  17. Intravenous drug abuse
  18. Indigenous systems of medication used
  19. Family History:
  20. Any history of liver disease
  21. History of malignancy
  22. Married
  23. Children
  24. Type of Family: Nuclear/Joint
  25. Support system: Strong/Weak
  26. Evaluation and vaccination status of spouse and children in Hepatitis B
  27. Allergies
  28. To medication
  29. To foodstuff
  30. Medications

INVESTIGATIONS

MICROBIOLOGY

S.no / Investigation / Results / S.no / Investigation / Results
1 / Ig M Anti-HAV / 14 / CMV IgG
2 / HbsAg(Screening) / 15 / CMV Ig M
3 / Anti HCV / 16 / HSV 1&2 Ig M Ab
4 / HCV RNA Quantitative assay / 17 / Herpes Zoster Ig G
5 / HCV Genotype / 18 / Herpes Zoster Ig M
6 / Anti-HBs / 19 / HIV screening
7 / HBV DNA Quantitative / 20 / ToxoplasmaIg G
8 / Hbe Ag / 21 / EB Virus
9 / Anti-Hbe / 22 / Stool opportunistic infection
10 / Ig M –Anti HBc / 23 / MRSA Screen
11 / Ig G- Anti HBc / 24 / Throat swab
12 / Rubella Ig G
13 / Rubella Ig M

MICROBIOLOGY CULTURES

SPECIMEN / DATE / ORGANISM / ANTIBIOTIC / COUIRSE
BLOOD
URINE
SPUTUM
ASCITIC FLUID

IMMUNOLOGY

S.no / Investigation / Results / S.no / Investigation / Results
1 / ASCA IgA / 7 / ANCA (P&C)
2 / ASCA IgG / 8 / SMA
3 / ANA by IFA / 9 / Anti-LKM
4 / AMA / 10 / Anti-thyroid antibody
5 / Serum Immunoglobulin profile / 11 / HLA typing
6 / Serum IgG4 estimation

BIOCHEMISTRY

S.no / INVESTIGATIONS / REPORTS / S.no / INVESTIGATIONS / REPORTS
1 / Liver Function Test / 5 / Thyroid profile
T.Bilirubin / FT3
Direct / FT4
Indirect / TSH
Total protein / 6 / Tumour Markers
Albumin / AFP
Globulin / CA 125
AST / CA19.9
ALT / 7 / Alpha-1-anti-trypsin levels
GGT / 8 / Blood urea
Alkaline phosphatase / 9 / Serum creatinine
2 / Lipid profile / 10 / Blood ammonia
Total cholesterol / 11 / Iron&Copper studies
Triglycerides / Serum Iron
HDL-Chol / TIBC
LDL-Chol / Serum Ferritin
VLDL-Chol / Serum copper
3 / Serum electrolytes / Ceruloplasmin
Sodium / 12 / Serum Zinc Level
Potassium / 13 / PT/INR
Chloride / 14 / S.fibrinogen
Calcium / 15 / Creatinine Clearance
Phosphorus
Magnesium
4. / Blood Glucose HbA1C
BIOCHEMISTRY- ABG:

NUCLEAR MEDICINE

S.No / Investigation / Report
1 / DTPA Scan
2. / HIDA Scan
3. / Bone Scan
PULMONARY MEDICINE
S.no / Investigation / Report
1 / Sweat chloride
2. / Pulmonary Function Test

CARDIOLOGY

S.no

/

Investigation

/

Report

1

/

ECG

2

/

Echo

3

/

Cardiac Catheterization

4

/

Micro bubble Echo cardiography

5

/

DSA

6

/

Hepatic/mesenteric Angiography

RADIOLOGY
S.no / Investigation / Report
1 / X-ray
2 / USG Abdomen / Gross status:
IHBR:
3 / Doppler –liver / Portal flow:
HA flow:
Hepatic Venous Flow:
4 / 64 Slice CECT / Status of the liver,spleen:
Portal venous anatomy:
Collaterals:
Leino renal shunt:
Hepatic artery :
Celiac Ostiumstenosis:
Any other:
5 / MRI
6 / MRCP
PATHOLOGY
S.no / Investigation / Report
1 / Histopathology-Bowel, Liver
2 / immunohistochemistry
3 / Frozen section HPE
4 / Luminal pathology for opportunistic infection
5 / Blood group
6 / Complete blood count
7 / Peripheral smear
8 / Coagulation Profile
INR
a PTT.D –dimer
FDP
TRANFUSION MEDICINE
S.no / Investigation / Reports
1 / Blood group
2 / Cross matching
3 / Auto antibody Screen
4 / Direct and indirect Coomb’s test
GENERAL MEDICINE
S.no / Investigation / Reports
1 / HbA1C
ENDOCRINOLOGY
S.no / Investigation / Reports
1 / Bone densitometry
Dental assessment-
OPG
Dental caries / Infectious risk that could cause peri-operative infectious problems
Obstetrics & Gynecology
Mammogram
Gynaecology assessment / Pap smear
Comments
Anaesthetic assessment:
PAH
Malampatti score
Cardiac risk
Pulmonary risk
Coagulopathy
Nutrition risk & Extubation related risks (consider Tri-flometry performance)
Nutritional assessment
Pre-transplant assessment of deficiency
Assess pre-morbid weight
Calculate 125% caloric requirement based on pre-morbid weight
Recommending, pep-talking & monitoring compliance related to the
Recommended diet
Salt restriction (2 / 1 gm salt per day for decompensated CLD)
Water restriction (< 1 lit / day for ascites that may require diuretics)
Physiotherapy assessment
Assess strength and weaknesses of individual muscle groups and girdles.
Teach Isometric limb and girdle exercises in the gym and for at home
Incentive spirometry for gradual improvement up to 4 times a day in the pre-tx
waiting period.
Psychiatric assessment
Motivation status
Cognitive abilities to give informed consent
For alcoholics : insight into the problem
Motivation for quitting
Social / family support
Likelihood of recidivism
Need for formal rehab services
Need for neuro-cognitive assessment scores Fit / not
Hematology
Hemoglobinopathies
Underlying prothrombotic states
Additional assessment : if necessary for pancytopenia
Nephrology
Proteinuria
Underlying chronic renal disease
Hepato-renal syndrome
Potential for long term renal complications secondary to surgical stress & CNIs
Immunization:
Assess viral antibody titres and immune status against, HBV, VZV, CMV, HAV
Advise immunization against HBV and other bacterial infections
Risk & preparation for TB
Help in peri-operative management of prophylaxis & treatment of infectious issues.
Hepatology (Medical) assessment
EndoscopyOGD
Colonoscopy for pts >50 years age (if not done within last 10 years).
Ascites : sampled / not : Comments
Overall assessment with risk factors, indications and urgency
Surgical assessment
Surgical candidacy status
H/O previous surgery / major portal hypertension
Surgical issues (portal vein thrombosis), SOL in Liver
Severity of coagulopathy / presence of ongoing DIC / severity of hypersplenism & pancytopenia
Severity of decompensation, MELD score, Organ suitability (LD /Cad)
Co-Morbidities Nutrition status, overall fitness and timings of LT.
Final Recommendation

Checked by

Hepatologist

Surgeon