1. Case Conference 報告者： R3 蕭景中 指導老師：方基存醫師 報告日期：2012/03/28

2. Patient's Profiles • Age: 48 • Gender: male • Ethnic: Taiwanese • Marital status: married • Occupation:房地產 before • Travel history: no travel history in recent 3 months

3. Chief Complaints • High blood pressure with headache for 2-3days

4. The 48year-old male sufferred from high blood pressure with SBP about 200mmHg for 2-3 days • Bitemporal headache,decreased appetitie and bilateral lower leg edema was also noted • Drank 味增魚湯 every day during Chineses year for one month Present Illness

5. No nasuea,vomiting,shortness of breath,blurred vision,decreased urine output • No fever, cough, dysuria,abdominal pain,tarry stool • Admitted 2011/10/14-2011/10/20 due to acute pyelonephritis • Visit ER once 2012/01/14 due to right ankle swelling r/o gout, discharge after symptomatic relief Present Illness

6. Visit ER 02/02,hypertension (245/114mmHg)and renal function deterioration • (3.34(01/11)11.97(02/02)) noted • Under the impression of acute on chronic renal failure,he was admitted Present Illness

7. Past history • Hepatocellular carcinoma,T1N0M0,s/p partial hepatectomy and TACE,s/p cadaver liver transplantation 2009/05,under MMF and tacrolimus • Liver cirrhosis,child C,HCV related,s/p interferon-alpha and ribavirin 2009/07-2010/02 • Chronic kidney disease,stage IV

8. Past history • Moderate aortic stenosis and aortic regurgication,EF:57%,no surgical indication • Diabetic mellitus under OHA • Recurrent urinary tract infection(6-7 times in current two years) • Spleen rupture due to traffic accident s/p splenectomy 26years ago • Gout

9. Personal history • Allergy: no known allergy to drugs or food • Alcohol :social but quitted now • Smoking:1PPD*21years,quitted now • Betelnut :social but quitted now

10. 78 78 Family history DM Old CVA,bedridden 48 46 HCC,HCV,DM

11. Medication history • Immunosupressant: 2009/05:tacrolimus 1-2mg Q12h MMF:1mg Q12h • HCV: 2009/07-2010/02: interferon-alpha and ribavirin

12. Physical examination (02/02 at Taipei ER) • T:36/℃ P:70/min R:18/min BP:245/114mmHg • 身高:176CM (20120204) 體重:84.3KG (20120204) BMI:27.2 • GENERAL APPEARANCE: Fair looking • CONSCIOUSNESS: Clear, E 4 V 5 M 6 • HEENT: • Sclera: not icteric • Conjunctiva:not pale • NECK: • Supple • No jugular vein engorgement • No lymphadenopathy

13. CHEST: Smooth breath pattern Bilateral symmetric expansion Breathing sound: bilateral clear • HEART: Regular heart beat without audible murmur No audible S3; No audible S4

14. ABDOMEN: Soft and distended No tenderness, No rebounding pain Normoactive bowel sound Operation scar 7cm over midline,12cm over RUQ and LUQ • BACK:no bilateral knocking pain • EXTREMITIES: Freely movable grade II leg edema • SKIN: No rash, no petechiae, no purpura uvula swelling, no erythema or tenderness

15. admission

16. admission

17. admission

18. 1.acute on chronic renal failure, RIFLE:F, Suspected acute urate nephropathy or malignant hypertension related, r/o RPGN 2.Post transplantation diabetic mellitus 3.Hepatocellular carcinoma,T1N0M0,s/p partial hepatectomy and TACE,s/p cadaver liver transplantation 2009/05,under MMF and tacrolimus 4.Moderate aortic stenosis and aortic regurgication,EF:57%,no surgical indication 5.gout Initial impression

21. Kidney Sonography 2012/02/03 Left Kidney Length: 11.9 cm Right Kidney Length: 11.8 cm There is focal calyceal dilatation in the upper pole of the right kidney. There are two echo-free lesions (1.3 x 1.3 cm in the pelvis and 1.3 x 1.1 cm in the lower pole) with posterior wall enhancement over the left kidney. No renal mass, or stone is noted. IMP:1. Parenchymal renal disease. 2. Left renal cysts.

22. GS 02/04 02/05 02/06 02/07 02/08 02/09 02/10 02/11 24hour urine TP Cardiac echo HD OPH BUN 125.8 114.3 106.1 12.22 Cr 11.94 12.18 Hydration:IVF 40cc/hr+allopurinol 0.5pc qd

23. 02/12 02/13 02/14 02/15 02/16 02/17 02/18 02/19 HD HD HD Serum 50.9 60.8 64.1 BUN 8.98 Cr 10.59 8.84

24. 02/23 02/20 02/21 02/22 02/24 02/25 02/26 02/27 HD HD HD HD 60.8 46.2 41.2 BUN 8.84 7.73 9.49 Cr Kidney biopsy

25. 03/02 02/28 02/29 03/01 03/03 03/04 03/05 03/06 HD HD HD 33.9 BUN 65.5 7.2 9.52 Cr TCC

26. 03/14 03/07 03/08 03/09 03/10 03/11 03/12 03/13 HD HD HD BUN 18.7 Cardiac echo 3.78 Cr

27. 03/15 03/16 03/17 HD HD BUN Cr

28. Final impression 1.Acute on chronic renal failure reaching End stage renal disease, diabetic nephropathy related Aggravating factor: hypertension, NSAID, Immunosuppressant, heart failure, gout Under maintanence hemodilaysis Q246 2.Post transplantation diabetic mellitus 3.Hepatocellular carcinoma,T1N0M0,s/p partial hepatectomy and TACE,s/p cadaver liver transplantation 2009/05,under MMF and tacrolimus 4.Congestive heart failiure, Fc III,favored valular heart related,EF:46%

29. Outline • Early and chronic renal dysfunction after liver transplantation • Early renal dysfunction after liver transplantation • Early kidney dysfunction predict chronic kidney disease • Chronic renal failure after liver transplantation • Post transplantation diabetic mellitus • Definition,impact and risk factor • HCV and PTDM • Immunosupressant and PTDM

30. Methods: 246 LDLT recipients,to review postoperative renal dysfunction • Results: Intraoperative blood loss and preoperative serum creatinine were significant independent risk factors for the development of early renal dysfunction Patients who required RRT had a lower survival rate

33. Methods:181 liver transplantation in which recipient was alived during followed up(2.7years),Renal dysfunction defined as Cr>2 • Results: PRT-DM and early postoperative acute renal dysfunction predict chronic kidney disease

35. Methods: 69,321 persons who received nonrenal transplants in the United States between 1990 and 2000.To estimate the cumulative incidence of chronic renal failure and association of death

36. Results: The five-year risk of chronic renal failure varied according to the type of organ transplanted — from 6.9% among recipients of heart–lung transplants to 21.3% among recipients of intestine transplants.

39. Results: increased risk of chronic renal failure was associated with age, female sex, pretransplantation GFR and hepatitis C infection, hypertension,diabetes mellitus, postoperative acute renal failure

42. Results: The occurrence of chronic renal failure significantly increased the risk of death Treatment of ESRD with kidney transplantation was associated with a five year risk of death that was significantly lower than that associated with dialysis (relative risk, 0.56; P=0.02).

45. Post transplantation DM • Metabolic complication after solid organ transplantation • Increased cardiovascular mortality and morbidity in transplantation recipients • Multiple risk factors related to develop of PTDM

46. Incidence of PTDM • Often underestimated due to lack of standard definition • Confounded by patient with diabetics before transplantation • Variable incidence due to different steroid regimen and immunosuppressants

47. Definition

48. Impact of PTDM(graft) • Diabetes mellitus after renal transplantation. Transplantation 65:380 –384, 1998 • Outcome of patients with new-onset diabetes mellitus after liver transplantation compared with those without diabetes mellitus Liver Transpl 8:708 –713, 2002 • increasing the risk of graft-related complications such as graft rejection, graft loss,and infection

49. Outcome of Patients With New-Onset Diabetes Mellitus After Liver Transplantation Compared With Those Without Diabetes Mellitus

50. Cumulative CV events