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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
MELD
CTP
Referring doctor name,
address & contact nos.
BMI
Height
Cms
weight
Kgs
DOA
DEPARTMENT OF SURGICAL GASTROENETEROLOG
JIPMER, PONDICHERRY-9.
LIST OF INVESTIGATION TO BE DONE
S.no
Departments
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
Reports collected
Pending reports
MULTIDISCIPLINARY REPORT SUMMARY CHECKLIST
S.No
Multidisciplinary Team
Name of the Member
1
Microbiology
Dr.Hidendran
Dr.Rahul
2
Biochemistry
Dr.Nivedita
3
Pathology
Dr.S.K.Varma
4
Radiology
Dr.Ramkumar
5
Nuclear Medicine
DR.Dhanapathi halnaik
6
Cardiology
Dr.Santhosh Satheesh
7
Pulmonology
Dr.Manju Rajaram
8
Hepatology
Dr.Palanivel
9
Dentist
Dr.Krishnan
10
Psychiatry
Dr Vikas Menon
11
Anesthetist
Dr.Lenin babu
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.Rajendra Kulkarni
19
Co-ordinator
Mrs. Subalaxmi
20
Billing/Insurance
21
Consent
Fitness
Remarks
Clinical Data
Presenting complaints/ Reason for referral to transplant centre:
1.
2.
3.
Specific complaints related to liver disease:
1. Jaundice- Yes/No.If yes, then
a. Whether it was cholestatic
b. Was it associated with cholangitis
2. Encephalopathy- Yes/No. If yes, then
a. Severity; Slowing/slurring of speech, loss of consciousness
b. Number of episodes
c. Whether hospital admission was required
d. Grade
3. Ascites- Yes/No. If yes, then
a. Whether it required diuretics
b. Whether it required paracentesis
If yes no: of: episodes:
c. Was there any complication to the above medication/procedure
4. Spontaneous Bacterial Peritonitis- Yes/No. If yes, then
a. Number of episodes
b. Last episode
5. Upper Gastrointestinal Bleed- Yes/No. If yes, then
a. Number of episodes
b. Severity of episodes
c. Treatment;
i. Medical
ii. Endoscopic(Banding/Sclerotherapy, sessions)
6. Hepatitis diagnosed previously- Yes/No. If yes, then
a. Hepatitis B or C
b. Viral characterization;
i. Viral load
ii. Genotype
7. Any other complaints
Review of systems (Please include treatment details)
1. Respiratory:
a. Asthma
b. COPD
2. Cardiovascular:
a. Hypertension
b. Coronary artery disease
3. Performance status:
a. Good (Can walk 500 meters or a flight of stairs without stopping or getting
breathless)
b. Average (Able to walk but needs support or to stop in between)
c. Poor (Unable to walk independently)
4. Nutritional status:
a. Good (Intake normal or nearly normal, no significant loss of weight)
b. Average (Intake less than usual, weight loss present but not significant)
c. Poor (Poor intake, loss of more than 10% of pre-illness weight over the last 6
months)
5. Gastrointestinal:
a. Appetite
b. Bowel movements
6. Genitourinary:
a. Urinary complaints: Urine output, burning, bleeding
7. Gynaecological
a. Menstrual history, menopause, HRT, breakthrough bleeding
8. Medical History:
a. Diabetes mellitus
b. Tuberculosis
c. Cancer
9. Surgical History:
a. Prior surgeries
b. Anesthesia
c. Complications
d. Blood transfusions
10. Alcohol intake:
a. Duration of intake
b. Amount & type of alcohol
c. History of recidivism
d. Duration of abstinence
11. Personal History:
a. Smoking
b. Intravenous drug abuse
c. Indigenous systems of medication used
12. Family History:
a. Any history of liver disease
b. History of malignancy
c. Married
d. Children
e. Type of Family: Nuclear/Joint
f. Support system: Strong/Weak
g. Evaluation and vaccination status of spouse and children in Hepatitis B
13. Allergies
a. To medication
b. To foodstuff
c.
14. Medications
INVESTIGATIONS
MICROBIOLOGY
S.no Investigation
Results
S.no
Investigation
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
Toxoplasma Ig 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
Results
MICROBIOLOGY CULTURES
SPECIMEN
DATE
ORGANISM
ANTIBIOTIC
COUIRSE
BLOOD
URINE
SPUTUM
ASCITIC
FLUID
IMMUNOLOGY
S.no Investigation
Results
S.no
Investigation
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
Results
BIOCHEMISTRY
S.no
INVESTIGATIONS
1
Liver Function Test
REPORTS
S.no INVESTIGATIONS
5
Thyroid profile
T.Bilirubin
FT3
Direct
FT4
REPORTS
Indirect
Total protein
TSH
6
Tumour Markers
Albumin
AFP
Globulin
CA 125
AST
CA19.9
ALT
7
Alpha-1-anti-trypsin
levels
2
3
GGT
8
Blood urea
Alkaline phosphatase
9
Serum creatinine
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
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
1
DTPA Scan
2.
HIDA Scan
3.
Bone Scan
Report
PULMONARY MEDICINE
S.no Investigation
1
Sweat chloride
2.
Pulmonary Function
Test
CARDIOLOGY
S.no Investigation
1
ECG
2
Echo
3
Cardiac
Catheterization
Report
Report
4
Micro bubble Echo
cardiography
5
DSA
6
Hepatic/mesenteric
Angiography
RADIOLOGY
S.no Investigation
1
X-ray
2
USG Abdomen
Report
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 Ostium stenosis:
Any other:
5
MRI
6
MRCP
PATHOLOGY
S.no Investigation
1
HistopathologyBowel, 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
Report
TRANFUSION MEDICINE
S.no
Investigation
1
Blood group
2
Cross matching
3
Auto antibody
Screen
4
Direct and indirect
Coomb’s test
Reports
GENERAL MEDICINE
S.no Investigation
1
Reports
HbA1C
ENDOCRINOLOGY
S.no Investigation
1
Reports
Bone densitometry
Dental assessmentOPG
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
Endoscopy
OGD
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