Ten days after undergoing liver transplantation, a patient’s levels of gamma-glutamyl transferase (GGT), alkaline phosphatase, and bilirubin begin to rise. Which of the following is the most appropriate next step in diagnosis?
A. Measurement of preformed antibody levels
B. Ultrasound of biliary tract and Doppler studies of the anastomosed vessels
C. Liver biopsy and determination of portal pressures
D. Liver biopsy and more detailed liver function tests
E. Liver biopsy and trial of steroid boluses
Explanation: The correct answer is B. In all other solid organ transplants, deterioration of function 10 days out would suggest an acute rejection episode, and appropriate biopsies would be done to confirm the diagnosis. In the case of the liver, however, antigenic reactions are less common, whereas technical problems with the biliary and vascular anastomosis are the most common cause of early functional deterioration. They are, therefore, the first anomalies to be sought. Preformed antibodies (choice A) are responsible for hyperacute rejection, which would be evident within minutes of establishing blood flow to the graft. Choices C, D, and E are centered on liver biopsy, which would be done only after technical problems have been ruled out.