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hyperbilirubinemia Post liver Transplant

Hello, My father had Liver transplant on 4th April.He is still in ICU due to constant increase in Bilirubin.
Below is is today's report.

BILIRUBIN(TOTAL)    29.86       mg/dL       (0.20-1.00)     Diazo assay
BILIRUBIN(DIRECT)   21.80       mg/dL       (0.00-0.20)     Diazo assay
TOTAL PROTEIN       4.30        gm/dL       (6.60-8.70)     Biuret assay
ALBUMIN             2.36        gm/dL       (3.50-5.00)     BCP
GLOBULIN            1.94        gm/dL       (1.80-3.60)     Calculated
A/G RATIO           1.22            2:1                     Albumin / Globulin
AST/SGOT            48.00       IU/L        (0.00-42.00)    UV kinetic
ALT/SGPT            73.00       IU/L        (0.00-60.00)    UV kinetic
ALK PHOSPHATASE     56.00       IU/L        (39.00-117.00)  AMP PNP
GGT                 26.00       IU/L        (0.00-64.00)    Enzymatic Kinetic

Doctors are not sure what is going wrong, since post transplant all the liver functioning test were good(Doopler test, CT Scan).Acute rejection happened on 3rd day post transplant, which was controlled by giving dose of steroid.

Is it curable?
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517301 tn?1229797785
unfortunately i think that he may require retransplantation.  Typically rejection doesnt occur this early after transplantation but he may have antibody mediated rejection or another complication related to the dsurgery itself
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Avatar universal

Surgical Gastroenterology & Liver transplantation
     Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi – 110060
                        Liver Transplant Unit

Dr. Naimish N. Mehta     Dr. Shailendra              Dr. Vivek                Dr. S. Nundy         
MBBS, MS, FACRSI                      MBBS, MS, DNB(GI Surg), MNAMS       MBBS, MS, MCh(AIIMS)   MA,MChir,FRCS,FRCP      
Consultant                        Consultant                                   Consultant   Consultant   

Name: Jai Prakash Jha Age / Sex: 60 Y/Male Hospital No: 1427731
Admission Date: 27/03/2014                                                             Date of Transplant: 21/02/2014
Address:  A-20, Police Colony, Anisabad, Patna-2
Phone: 9835096389
Diagnosis: Cryptogenic Chronic Liver Disease with Ascites with portal hypertension with Umbilical hernia with scrotal swelling.

60 yrs old male is a known case of Cryptogenic Chronic Liver Disease with Ascites with portal hypertension for last 6 years. Underwent living donor liver transplant (left lobe orthotopic liver transplant) on 04/04/2014. GRWR was 0.8. Post operatively he was shifted to liver ICU and he was extubated on 7/4/14. His inotropic support gradually tapered. On ABG lactate became normal. Post operatively his enzymes were normal till postoperative day one. On postoperative day two his enzymes were elevated & bilirubin levels were also increased. Urgent USG Doppler was done which showed normal arterial and portal vein flow. He underwent CT angio which showed normal artery, portal vein and hepatic veins. On postoperative day three his enzymes further went up. His procalcitonin was 6.6 so antibiotics were upgraded. His enzymes continued to rise (SGOT 2179 and SGPT 2403 and bilirubin was 20). He was treated with pulse therapy with methyl predinsolone and his enzymes showed downtrend and gradually it became normal in next 5 days. His bilirubin continued to rise and reached upto 29.86. His INR continue to be high (between 2.6 to 4.5). His drain output was high initially but gradually started coming down upto 2300 ml. Presently he is in ICU and on minimal inotropic support  (noradrenalin 2ml/hour). He is on oral and RT feed. He is requiring intermittent BIPAP support. He is maintaining his urine output and creatinine is normal. All cultures are negative till date. Transjugular liver biopsy done on 16/04/2014 suggestive of massive hepatic necrosis with marked ductal proliferation.  
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