Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
Is there a serum ammonium level for which you recommend initiation of dialysis in a patient with hepatic encephalopathy?
Because there is a very poor correlation between ammonia levels and hepatic encephalopathy, I do not make recommendations based on ammonia levels. My approach is to treat each case individually in consultation with our hepatology colleagues. If a patient has encephalopathy and is not responding to m...
How do you utilize liver assistive devices in the management algorithm of patients with acute liver failure?
In the setting of severe ALF, we use 2 extracorporeal liver support strategies, which include high dose CRRT for the management of hyperammonemia, and plasma exchange as an add on to CRRT if the patient develops shock. The goal of high-dose CRRT (with high dose at our center defined as at least 60 m...
When severe hepatopulmonary syndrome (PaO₂ <50 mmHg) coexists with borderline portopulmonary hemodynamics on therapy (e.g., mPAP high-30s with PVR ~3 WU), how do you sequence optimization and listing strategy, and what physiologic thresholds make you proceed to transplant versus defer for further pulmonary vascular optimization?
This clinical scenario is more common than previously thought. Other than oxygen supplementation for hepatopulmonary syndrome (HPS), there is no other specific therapy. Portopulmonary hypertension (PoPH) needs to be treated to reach the threshold of desired mean pulmonary arterial pressure (mPAP) of...
How do you decide whether to initiate semaglutide for MASH when alcohol intake is near MASLD/MetALD boundary ranges or fluctuates with intermittently positive PEth—specifically, do you require a documented period of reduction/abstinence before treatment, or do you start therapy with a modified monitoring/futility framework?
Typically, my approach is to ensure that alcohol is not contributing to their liver disease before initiating anti-fibrotic therapy. I usually counsel them and monitor their PETH testing serially. Sometimes, cutting out alcohol itself will help reduce their fibrosis level over time and may obviate t...
How do you approach the diagnosis of hepatorenal syndrome in a patient with cirrhosis and AKI who has not responded to albumin resuscitation but has a recent nephrotoxic exposure that could explain the renal dysfunction?
If the nephrotoxic exposure (e.g., aminoglycoside) is known to cause ATN, then the findings of low urinary sodium/fractional excretion of sodium, a bland urinalysis, and no structural abnormalities on renal ultrasound should make one consider HRS as the etiology of the AKI. The findings of granular ...
What antibiotic prophylaxis do you recommend for a cirrhotic patient with an upper GI bleed, if any, in light of the recent meta-analysis published in JAMA Internal Medicine?
This study highlights the lack of high-quality data supporting the recommendation for antibiotic prophylaxis in cirrhosis patients with upper GI bleeding. At my institution, we usually recommend a short course of 3 to 5 days, though some clinicians extend it to 7 days. If there is ongoing bleeding, ...
How would you manage a patient who presents with hair loss that began after they started a GLP-1 inhibitor?
If it fits with telogen effluvium, I recommend monitoring. Many patients will improve after this initial shedding and will not have long-term shedding or long-term thinning. If there is any underlying androgenetic alopecia or pattern hair loss, then starting treatment as you normally would is also r...
How do you adjust transplant-benefit–based decision-making for HCC patients with prior immune checkpoint inhibitor exposure, given the potential for increased peri-transplant rejection or graft loss?
Some programs aim not to proceed with transplantation (LT) for 1 month subsequent to the administration of immunotherapy in order to avoid rejection. However, this is not often feasible, and the reality is that the half-life of these medications can be closer to 50-60 days. My personal opinion is th...
In young, non-cirrhotic HBV–HDV coinfection with minimal fibrosis on elastography, do you perform lifelong 6-month HCC surveillance based on HDV status alone, or do you modulate surveillance intensity based on fibrosis trajectory and treatment response?
It’s quite reasonable to be aggressive with HCC screening in a co-infection like this. It would also depend on whether you’re treating the hepatitis B, which would reduce the chances of HCC. And even more interesting is whether you’re treating the Delta with the new drug expected to be approved on M...
How would you manage a patient with HIV, re-infection of hepatitis C that has not yet been treated, chronic hepatitis B infection on BIC/FTC/TAF with undetectable HIV viral load but HBV viral load consistently >100,000 with normal ALT?
Your concern about HBV reactivation during DAA therapy is real and well-documented, as it can occur in up to 24 of HBsAg-positive patients during or after DAA therapy when not on HBV-active therapy. However, the solution per guidelines is concurrent HBV prophylaxis/treatment, not sequential treatmen...