Show notes
Episode four follows a patient across the whole transplant arc, organized by two clocks: the allocation score that triages who is sickest, and time itself, which orders both the drop in immunosuppression intensity and the shift from acute risk to cumulative toxicity. The calculated score does the primary triage with its sex and albumin corrections fixing real undervaluation, the workup confirms the operation can succeed medically, infectiously, and psychosocially, and the exception points cover the diseases the labs cannot see. Donor type then sets the complication profile, immunosuppression intensity organizes the early timeline of rejection and opportunistic infection with CMV dominant, and cumulative toxicity organizes the late timeline. The original disease returns in a pattern specific to its cause, which is why surveillance continues indefinitely.
Topics covered
Allocation score components and corrections
Referral triggers and the score-of-fifteen threshold
The three-question workup
Exception points for undervalued diseases
Donor types and their complication signatures
Immunosuppression stepping down over time
The complication timeline by era
Acute and antibody-mediated rejection
CMV and recurrent disease patterns
Key decisions
The allocation score uses capped creatinine, bilirubin, INR, and sodium, adds points for female sex to correct the lower creatinine of lower muscle mass, and subtracts points across the low albumin range to capture catabolic decompensated disease.
List for transplant on decompensation, meaning variceal bleeding, ascites, encephalopathy, HCC, or hepatorenal dysfunction, or on a score of fifteen or higher, the point where the operation stops being a net loss versus medical management.
Exception points cover diseases the score misses: HCC within criteria gets a regional median score after a six-month wait, hepatopulmonary syndrome qualifies at an arterial oxygen under sixty, and portopulmonary hypertension qualifies with a mean pressure under thirty-five after vasodilators while a mean over fifty is an outright contraindication.
Donation after circulatory death carries higher ischemic cholangiopathy and primary non-function from longer warm ischemic time, mitigated by normothermic machine perfusion, and living donor grafts carry higher biliary complication rates but serve high-symptom, low-score patients.
Immunosuppression steps down from high-dose induction steroid, through the first months of triple therapy with steroid taper, mycophenolate, and a calcineurin inhibitor, to calcineurin-inhibitor monotherapy after about a year.
Acute cellular rejection occurs in about a third of transplants, usually in the first six weeks, needs biopsy showing the triad of portal inflammation, bile duct injury, and endothelial inflammation, and is treated with intravenous methylprednisolone five hundred to a thousand milligrams daily for three days.
Tacrolimus is metabolized by CYP3A4, so azole antifungals, macrolides, diltiazem, verapamil, and amiodarone raise its level and cause toxicity, while rifampin, isoniazid, phenytoin, carbamazepine, and St John's wort lower it and risk rejection.
For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com.
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