Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
When treating with SBRT and immunotherapy for unresectable HCC, how do you sequence the treatment?
Great question. No great data in this space regarding optimal sequencing. In general, I would sequence SBRT first, followed by initiation of immunotherapy. Some data suggest that SBRT may best prime IO if administered prior to IO. Additionally, if the IO regimen preferred is atezolizumab/bevacizumab...
Can tamoxifen be safely prescribed for breast cancer patients with cirrhosis?
Tamoxifen would definitely not be my preferred endocrine agent in a patient with cirrhosis. I have had many cases of tamoxifen-induced liver injury. The incidence of MASH due to tamoxifen is really underreported in the literature. In a case of pre-existing MASH or other liver disease, I switch to an...
How does the presence of porto-mesenteric vein thrombosis impact a patient's transplant candidacy?
This is nuanced and depends if the portal vein thrombosis (PVT) is acute vs chronic with cavernous transformation. Main PVT is not necessarily an absolute contraindication to liver transplant. Current guidelines recommend anticoagulation for acute main PVT in patients who are (or may be) transplant ...
How do you decide which patient and with which device to pursue machine perfusion for the organ of a liver transplant recipient?
In general, these are the principles I consider to pump livers prior to transplant: Patient comorbidities: Even if the donor is ideal and the surgery is not expected to be challenging, minimizing the risk of reperfusion injury and early allograft dysfunction is important in patients with coronary a...
How will the recent withdrawal of Ocaliva for the treatment of PBC impact your therapeutic and management plan for these patients?
It was unfortunate to lose a drug that was effective for many PBC patients but the FDA approved 2 new PBC drugs last year. These are PPAR agonists (elafibranor and seladelpar) and are well-tolerated and have been effective in reducing ALP in PBC. These are second-line add-on drugs to UDCA (should be...
What is your strategy to manage peri-procedural bleeding risk in patients with cirrhosis?
We use TEG primarily here and mostly ask our colleagues to routinely check TEGs to guide transfusion strategies. It remains a challenging situation to monitor and manage because of the unique profile and difficulty in accurately assessing what is truly needed. Certainly, no empiric FFP for specific ...
How would you workup a patient who develops ascites AFTER liver transplantation?
Challenging patient population. TTE to try to exclude cardiac etiology - HFpEF is often a significant factor, particularly with cardiorenal physiology. Sometimes, a hepatic venogram is needed to confirm no outflow obstruction. Good CTA to assess for portal vein stenosis - in the post-transplant sett...
How do you approach restarting immunotherapy in a patient with metastatic melanoma who previously developed immune-mediated hepatitis (Grade 3), with liver enzymes now back to baseline levels?
I prefer to rechallenge when the irAE is back to grade 0. It depends on how long the hepatitis took to revert to a normal level. If it goes back to normal quickly (within 4 weeks), I keep patients on 8 mg methylprednisolone when rechallenging patients. If they do well, I wean them off at the second ...
How do you decide whether or not to pursue inpatient workup of an incidental liver mass?
When deciding whether to pursue inpatient evaluation of an incidentally discovered liver lesion, I ask two key questions:Is the lesion plausibly related to the clinical syndrome I’m treating now?Are there patient- or system-level barriers that would make outpatient follow-up unreliable or unsafe?Cli...
Can tacrolimus in a transplant patient be used during radiation and concurrent chemoradiation?
Patients with solid organ transplants present unique challenges in management and risk of infectious complications, among others. The short answer is that tacrolimus can be used in the lowest dose possible, along with concurrent chemoradiation and close coordination with the transplant team. If the ...