Clinical Case Vignettes

Case 1: “Too Early for Transplant”

Profile: 48-year-old male with alcohol-related cirrhosis
Repeated ascites. MELD 16. Advised transplant elsewhere.

Reassessment showed:

• Severe sarcopenia

• Active infection risk

• Suboptimal nutritional status

Intervention:

• Structured nutrition protocol

• Infection eradication

• Portal pressure control

• Diuretic recalibration

Outcome:
Stabilized. Transplant deferred safely.
Survival benefit preserved.

Lesson: Timing determines outcome. Not fear.

Case 2: “Too Late for Transplant”

Profile: 54-year-old female with ACLF
Rapid bilirubin rise. Renal dysfunction. Encephalopathy.

Referred late.

Immediate action:

• ICU optimization

• Early transplant activation

• Rapid donor coordination

Outcome:
Successful living donor transplant.
Discharged with stable graft function.

Lesson: Delay costs survival. Early escalation saves life.

Case 3: “Cancer Means No Transplant”

Profile: 60-year-old male with hepatocellular carcinoma (HCC)
Told “not eligible.”

Re-evaluation:

• Tumor burden borderline but downstageable

• Preserved performance status

Action:

• Locoregional therapy

• Re-staging

• Transplant listing after successful downstaging

Outcome:
Curative transplant performed.

Lesson: Not all exclusions are permanent.

Case 4: Post-Transplant Renal Failure Risk

Profile: 45-year-old post-transplant patient
Rising creatinine. High tacrolimus levels.

Intervention:

• Immunosuppression recalibration

• Renal protective strategy

• Close trough monitoring

Outcome:
Renal function stabilized. Graft preserved.

Lesson: Surgery gives a liver. Monitoring protects it.

These are not miracle stories.
They are examples of structured hepatology governance.