Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
How do you decide whether ordering a 5' nucleotidase or a GGT is the most appropriate option in the evaluation of an elevated alkaline phosphatase?
GGTP is the obvious choice; every elevated alkaline phosphatase needs a GGTP.
What is your clinical approach to the evaluation of cytopenias in patients with end-stage liver disease?
Cytopenias may be the new normal for a patient with cirrhosis. However, they may not be. If a patient has isolated thrombocytopenia and a large spleen, I am typically going to monitor labs on the standard labs with each visit. Isolated mild leukopenia is the same pattern as well. Anemia requires a w...
How do you approach the use of viscoelastic assays (ex: TEG, ROTEM) in patients with identified coagulopathy in the peri-procedural period?
Coagulopathy requires consideration, but not necessarily action. The usual way it is invoked is by an elevated INR result - but this does not imply auto-anti-coagulation (as coumadin on INR). PVT is very common in PHTN/cirrhosis. Thus, in many cases, it depends on the procedure and the proceduralist...
When would you consider use of EUS guided liver biopsy over percutaneous and/or transjugular?
If data (labs, imaging) are not entirely compelling for a primary parenchymal or biliary issue, then EUS liver biopsy can be an efficient approach in addition to ERCP (saving the need for separate biopsy in the event that ERCP is non diagnostic).
Would you refer a patient for kidney only or kidney and liver transplantation if they develop advanced chronic kidney disease secondary to primary hyperoxaluria type 2?
Now that the data suggesting a benefit for nedosiran for PH2 is very disappointing, I think we have to say simultaneous liver and kidney. I have this one experience. My PH2 patient had kidney only because I was thinking that nedosiran would be effective. Ultimately, the kidney failed after about 5 y...
How do you rule out spontaneous bacterial peritonitis in a patient with minimal ascites that is not amenable to paracentesis?
You can’t, unfortunately. You either need to keep looking for a good pocket (move patient to each side, etc.) or use clinical judgement and decide whether or not to treat empirically.
When giving albumin challenge, for acute kidney injury with suspected hepatorenal syndrome, do you administer a single dose daily or split the dose of albumin?
The main concern about albumin infusions is the potential risk for pulmonary edema (China et al., PMID 33657293). Therefore, I prefer to have albumin administered in divided doses of 25 grams at a time with a max daily dose of up to 100 grams, and I tend to stop IV albumin if the serum albumin level...
What is your preferred dosing of IV ganciclovir for CMV disease in immunocompromised patients?
For treatment, I usually start with 5 mg/kg IV q 12 hr, and the dose is adjusted for renal function with the help of ID pharmacists. I can consider going to 7.5 mg/kg if there is a concern for very severe disease or low-level resistance, but to be honest, I don't think I've ever done that, given the...
How do you manage oxaliplatin-induced splenomegaly?
Oxaliplatin can lead to sinusoidal obstructive syndrome (SOS), which will result in portal hypertension. Splenomegaly is one of the portal hypertension signs.The SOS is correlated with cumulative oxaliplatin dose, and cumulative dose >1000 mg/m2 is considered a potential threshold (Overman et al., P...
Under which circumstances is there a role for reduction in immunosuppression post-SOT in a patient with recurrent CMV viremia and/or disease?
While the decision regarding immunosuppression is always up to the primary transplant team, as the infectious disease consultant, I always inquire about the ability to reduce immunosuppression during episodes of CMV syndrome or disease even if it is a first episode. This becomes even more important ...