We're unable to sign you in at this time. Please try again in a few minutes.
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Special Feature |

Image of the Month—Quiz Case FREE

Amy L. Friedman, MD; Marc I. Lorber, MD; Dennis Cooper, MD
[+] Author Affiliations

From the Section of Organ Transplantation and Immunology, Department of Surgery (Drs Friedman and Lorber), and the Section of Medical Oncology and Surgery, Department of Internal Medicine (Dr Cooper), Yale University School of Medicine, New Haven, Conn.

Section Editor: Grace S. Rozycki, MD

More Author Information
Arch Surg. 2003;138(9):1025. doi:10.1001/archsurg.138.9.1025.
Text Size: A A A
Published online

A 52-YEAR-OLD man underwent living unrelated donor renal transplantation for treatment of end-stage renal disease caused by congenital obstructive disease. Immunosuppression was initiated with 2 doses of simulect and maintained with cyclosporine microemulsion, mycophenolic acid, and prednisone. The allograft functioned immediately, and there were no rejection episodes. Thirteen months later, the patient complained of severe itching, malaise, and anorexia. Physical examination revealed diffuse excoriations and deep jaundice. Laboratory values included awhite blood cell count of 5.4 × 103/µL, serum creatinine level of 1.9 mg/dL (158 µmol/L), total bilirubin level of 15.2 mg/dL (260 µmol/L), direct bilirubin level of 12.4 mg/dL (212 µmol/L), alanine aminotransferase of 270 U/L, aspartate aminotransferase of 329 UL, and alkaline phosphatase of 1090 U/L. Images from the computed tomography and magnetic resonance imaging scans are shown in Figure 1 and Figure 2.

Place holder to copy figure label and caption
Figure 1.
Graphic Jump Location

Place holder to copy figure label and caption
Figure 2.
Graphic Jump Location


A. Arrange hospice care since this patient's liver disease is incurable.

B. Place the patient on the emergent liver transplant list.

C. Stop cyclosporine since it has been associated with choledocholithiasis, and start tacrolimus.

D. Obtain a biopsy specimen of the hepatic mass.

Corresponding author and reprints: Amy L. Friedman, MD, Yale University School of Medicine, FMB 112, 333 Cedar St, New Haven, CT 06520 (e-mail: amy.friedman@yale.edu).


Place holder to copy figure label and caption
Figure 1.
Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Graphic Jump Location




Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment


Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles