Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
In patients with MASLD, would you consider management with off-label metformin, pioglitazone (despite weight gain risk), GLP-1 RA, or simply intensify lifestyle and monitor?
In 2025, we should be assessing if patients are developing F2-F3 fibrosis especially with the use of non-invasive assessments (FIB-4 score, transient elastography, or MRI elastography), and then offering either Semaglutide or Resmetirom for these individuals w/ F2-F3, which are the only FDA approved...
In what scenario do you screen patients with hepatitis B for hepatitis D co-infection?
I routinely screen every patient once at an initial diagnosis of chronic hepatitis B.
How do you decide between empiric carvedilol versus obtaining HVPG to confirm CSPH when noninvasive markers suggest CSPH but there is limited hemodynamic/renal reserve (borderline MAP and/or CKD)?
May be reasonable to consider EGD to assess for varices and/or band high risk especially if the patient ultimately cannot tolerate carvedilol.
What risk factors in a cirrhotic patient would predispose them to the development of sarcopenia and how do you address these risk factors?
The most common risk factor for sarcopenia in cirrhosis is recurrent large ascites/diuretic refractory ascites requiring regular large volume paracentesis every 1-2 weeks. 4 L of ascites contains as much as 60 grams of protein. Additionally, at the decompensated stage of liver disease (hepatic encep...
How do you choose between resmetirom and semaglutide in the treatment of MASH?
I write a disclaimer to start, because use of resmetirom ($5,000 per month) and semaglutide ($1,600 per month) at this time cannot be used across the board with any patient with hepatic steatosis. It's important to highlight how we characterize a patient's metabolic dysfunction associated steatotic ...
In suspected portopulmonary hypertension with high cardiac output where mPAP is elevated but PVR is acceptable, do you base liver transplant candidacy primarily on PVR (and RV function) rather than mPAP, and how do you operationalize that in your listing decisions?
The short answer is yes. The key parameters of PVR and right heart function by transthoracic echo (mainly RV free wall strain, Fractional area change, and TAPSE in combination) are discussed by pulmonary and anesthesia colleagues at our selection conference. Specifically, we follow the current Inter...
How has the move away from a strict 6 month period of sobriety impacted your patient selection criteria for transplant of patients with alcohol associated liver disease?
The "sixth-month rule" was applied by many transplant programs years ago as a method of minimizing recidivism post-liver transplant. The evidence that this approach improves outcomes is sparse, and most programs have moved toward applying other criteria toward transplant decisions for these patients...
Should a patient who requires definitive treatment for prostate cancer as a pre-transplant requirement be strictly required to complete their course prior to transplant/initiation of immunosuppression?
To help address this complex question, I would like to call your attention to a review of the topic by Al-Adra et al., PMID 32969590. It covers several types of malignancies, including prostate cancer (Table 4). Treating this patient will require close collaboration with the transplant surgeon, urol...
For how long would you treat a patient with latent TB before allowing them to proceed with a liver transplant?
There are a few ways to look at the answer to this question. If the individual is stable enough to complete the Latent TB Infection (LTBI) therapy without need for a liver transplant, then treat the LTBI to completion. If the individual may need the transplant during the treatment course, then start...
How do you use objective sarcopenia/frailty measures during liver transplant evaluation to decide between expedited listing versus a defined period of prehabilitation before listing?
At our center, we screen everyone with the liver frailty index (LFI). In those found to have frailty, we refer them to a prehabilitation clinic where, apart from providing physical literacy, personalized exercise and dietary prescriptions, we monitor LFI, 6MWT, and phase angle at every visit. This a...