Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
How does the use of checkpoint inhibitors for treatment of HCC impact timing of liver transplant and subsequent immunosuppression?
This is a challenging issue with concerns for checkpoint inhibitor/immunotherapy (IO) resulting in rejection of a transplanted organ. In our practice, we have a local protocol based on our consensus that at least 6 weeks of washout for IO prior to transplantation. Post-transplantation, IO is not use...
How do you approach treatment options for patients with fibrolamellar HCC compared to "normal" HCC?
Fibrolamellar HCC is a very rare cancer, reported to account for 1% of all primary liver cancers, and it has distinct differences compared to normal HCC. Patients with fibrolamellar are younger (20s - 30s) than patients with HCC and do not have underlying chronic liver disease, and often present wit...
How does the identification of a hepatic adenoma in a male patient affect your management and evaluation?
Hepatic adenomas (HCA) are benign liver tumors that nonetheless carry risks of hemorrhage and malignant transformation. There are several molecular subtypes of HCA, including: HNF-1α–inactivated HCA Inflammatory HCA β-catenin–activated HCA Unclassified HCA Of these, β-catenin–activated HCA is of p...
How much do you factor in a patient's frailty in selection for transplant if the underlying driver for their debility is their underlying liver disease itself?
It really depends on your LT program's level of comfort with rehabilitating a frail patient post-LT, and whether the patient has shown engagement with physical therapy/rehabilitation prior to transplant. In my opinion, a resilient and well-motivated patient who has shown engagement in some form or r...
What would be the right patient profile and experience for someone who may have (operational) tolerance and how do you approach immunosuppresison management (or withdrawal) in this patient?
We try our very best to minimize immunosuppression (IS) in all patients. A very small subset of patients post-liver transplant (LT) can stop all IS, unlike other solid organ transplants. We don't actively discontinue all IS in patients, but have several patients who have done so on their own, remain...
How do you determine which patients are good candidates to have their organ receive machine perfusion therapy before implantation?
Machine perfusion is being used more and more for DCD grafts resulting in less incidence for ischemic cholangiopathy, thus allowing more DCD organs to be considered and used. Transplant programs are using machine perfusion for more complicated surgical cases such as retransplants and in order to uti...
How do you determine when you would treat an identified spleno-renal shunt and how?
It is important to remember that the typical reason portal hypertension develops is to try and accommodate the increased resistance across the cirrhotic liver. A spleno-renal shunt is a congenital malformation that is often noted when a patient develops portal hypertension. Prior to TIPS, these were...
Do you find there is any benefit to giving N-acetyl-cysteine in non-acetaminophen related acute liver failure?
Yes, we believe there is a modest benefit for non-APAP patients. The Acute Liver Failure Study Group did a placebo controlled double blind study of NAC use in non-APAP ALF. Here is the reference. This is not FDA-approved. They wanted a second study but this one took about 6 or 7 years to complete!Le...
When would you decide to pursue plasma exchange in a patient in acute liver failure due to sinusoidal obstruction syndrome?
I have not used plasma exchange in the treatment of SOS. The Plex may transiently decrease the hyperbilirubinemia associated with SOS, but to my knowledge, it does not address the underlying pathophysiology.
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...