Liver Transplantation

Patient Care

Goals and Objectives

  1. Interpret the results of focused clinical evaluations (history, physical examination, laboratory data) performed on patients undergoing assessment for liver transplantation to
    1. Identify patients who are candidates for liver transplantation
    2. Identify the findings that constitute contraindications to proceeding with liver transplantation
      1. Cardiac risk factors
      2. Infectious risk factors
      3. Risk of rejection
      4. Risk of recurrence of disease, hepatocellular carcinoma, hepatitis B and C
    3. Perform evaluations on patients with end-stage liver disease being assessed for liver transplantation, and identify those findings consistent with liver disease.
  2. Interpret the results of focused clinical evaluations (history, physical examination, laboratory data) in postoperative liver transplant patients to identify and develop treatment plans for the following postoperative changes and complications:
    1. Decreased urine output
    2. Decreased blood pressure
    3. Fever
    4. Hemorrhagic shock
    5. Respiratory failure
    6. Renal failure
    7. Hemorrhage
    8. Rejection
    9. Anastomotic complication
      1. Biliary
        1. Biliary stricture
        2. Leak
      2. Hepatic artery
        1. Stenosis
        2. Thrombosis

Responsibilities & Expectations

  1. Write admission and inpatient orders under the supervision of the NP/fellow/attendings
  2. Attend rounds, and be prepared to present patients in an organized and succinct manner
  3. Update sign out
  4. Implement the clinical decisions made by the team (on rounds, during the day) in a timely manner
    1. Arrange consultations
    2. Check orders
    3. Schedule diagnostic tests
    4. Schedule therapeutic procedures
  5. Notify the fellow/NP if unable to implement the clinical decisions
  6. Communicate the results of consultations, diagnostic tests, and therapeutic procedures to the fellow in a timely manner
  7. Present patients in selection
  8. Write discharge summaries and discharge orders

Medical Knowledge

Goals and Objectives

  1. Describe the evaluation process, including medical and psychosocial components, for the
    1. Live liver transplant donor
    2. Liver transplant recipient
  2. Justify the indications for and contraindications for liver transplantation
  3. Describe the significance of and clinical application of
    1. The Child-Pugh score
    2. The MELD system
  4. Identify immunosuppressive medication
    1. Classes
    2. Mechanisms of action
    3. Toxicities
  5. Describe the anatomy of
    1. The liver
      1. Segmental
      2. Blood supply (normal and aberrant)
    2. Inferior vena cava and hepatic veins
  6. Describe the major steps involved in performing a liver transplant
  7. Describe the anatomic definition of
    1. Right hepatectomy
    2. Left hepatectomy
    3. Left lateral segmentectomy
  8. Describe and compare the treatment options for hepatocellular carcinoma, as well as the criteria for transplant
  9. Analyze common opportunistic infections in transplant recipients in terms of
    1. Presenting signs and symptoms
    2. Treatment
    3. Prevention
  10. Define the course of fulminant hepatic failure and the management of the following complications
    1. Renal failure
    2. Cerebral edema
    3. Hypoglycemia
    4. Coagulopathy
  11. Identify the optimal management for patients with the following complications of end-stage liver disease
    1. Gastrointestinal hemorrhage
    2. Spontaneous bacterial peritonitis
    3. Encephalopathy
    4. Intractable ascites
    5. Hepatocellular carcinoma

Practice-Based Learning And Improvement 

Goals and Objectives

  1. Analyze the common complications of ESLD and liver transplantation 

Responsibilities & Expectations

  1. Participate in the weekly Transplant M&M conference to review and analyze treatment outcomes
  2. Document patient outcomes by maintaining a log of patients treated and their clinical results
  3. Meet with the education representative at least 3 times during the rotation (beginning, midpoint, exit) to review goals & objectives 

Interpersonal And Communication Skills

Goals and Objectives

  1. Communicate effectively as a member of the multidisciplinary team which rounds together
  2. Communicate effectively with patients and families 

Responsibilities & Expectations 

  1. Counsel and educate patients and their families regarding pathology of illness
  2. Communicate daily plan of care with RN, PT, OT and nutrition.
  3. Communicate plan of care to transplant coordinator and outpatient providers as needed. 

Professionalism 

Goals and Objectives

  1. Describe the ethics of organ donation, brain death, withdrawal of support, and the separation of the transplant team from the team caring for the patient who is a potential donor
  2. Describe the ethics of living donation, considering donor health and well-being.
  3. Discuss the ethics of compensation of donor families or living donors.
  4. Discuss the ethics of various organ allocation schemes, emphasizing utility, efficiency, justice.
  5. Discuss the conflicting interests of individual transplant patients vs. the waiting list as a whole 

Responsibilities & Expectations

  1. Attend at least two liver transplant selection conferences 

Systems-Based Practice 

Goals and Objectives

  1. Describe the US system for allocation of livers from deceased donors  
  2. Compare the costs of
    1. A liver transplantation
    2. Immunosuppressive medications with the costs of long-term management of end-stage liver disease
  3. Analyze the impact of recurrent disease
  4. Discuss the ethics of patient selection for liver transplantation, including issues surrounding denial of transplantation
    1. Allocation of a scarce resource (200% mortality, society vs. individual)
    2. Lack of other options
  5. Describe the ethics of living donation, considering donor health and well-being
  6. Discuss the ethics of various organ allocation schemes, emphasizing utility, efficiency, justice 

Responsibilities & Expectations 

  1. Attend at least two liver transplant selection conferences 
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