Question

A 73-year-old man was admitted to the hospital because of recent onset of jaundice and right upper quadrant abdominal pain. The patient had a long history of hypertension and type 2 diabetes mellitus. A renal transplantation had been performed in 2003, 12 years before the current admission, because of end stage diabetic nephropathy. In recent years he had become confused with failing memory. The patient resided in a nursing home for the past five years. Two weeks prior to admission, jaundice was observed accompanied by right upper quadrant abdominal pain, nausea and vomiting. The patient was a retired stock broker. He was a teetotaller and had never smoked. His wife died six years ago of a heart attack. His two daughters who were in good health lived in another state. His medications comprised cyclosporine, azathioprine, atenolol, nifedipine, furosemide and insulin. On examination the patient was moderately jaundiced, confused and itching. A presacral decubitus ulcer was noted. There were obvious signs of wasting as evidenced by reduced muscle bulk and loss of subcutaneous fat. Abdominal examination revealed ascites and a firm, painful, slightly enlarged liver as well as splenomegaly. Spider angiomas, decreased body hair and gynaecomastia were noted and there was evidence of testicular shrinkage. There was 2+ pitting lower limb oedema. Neurological exam revealed a flapping tremor. The stool exam showed evidence of melena. The urine was dark amber and positive for bilirubin (+++). Pertinent laboratory findings are shown in Table 1, 2 and 3.