Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
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...
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 ...
How long do you treat uncomplicated gram-negative rod bacteremia in solid organ transplant recipients?
My approach to the duration of therapy for GNR bacteremia in SOT patients depends on the source of the bacteremia, the available antibiotics, the patient's net state of immunosuppression, and the organism. There are situations where 7 days of therapy are adequate (One example: E.coli urosepsis in a ...
Should an individual who received the purified protein Hepatitis B vaccine in 1985 receive a booster or have antibody titers checked?
I recommend you ask yourself two questions. How likely has this individual lost humoral immunity? Did they receive B cell deplaning chemotherapy or have CLL, etc? How likely is the individual to be re-exposed? If the answer to both is low, re-vaccination probably provides no benefit.
In a patient with Zieve's Syndrome and alcohol related cirrhosis which antibiotic regimen is safe to treat H. pylori?
I am not concerned about a cirrhotic patient receiving a fluoroquinolone, macrolide, metronidazole, or doxycycline. The drug insert labels do not raise any particular concerns for these drugs’ use, even in Child Pugh class C cirrhosis. Yes, there is a theoretical potential for overdosing patients on...
At what BMI or waist-circumference threshold do you opt to move from Fibroscan to other NILDA for fibrosis assessment?
The XL-validation study found a liver stiffness measurement (LSM) failure of 1% for the XL and 16% for the M probe, in patients with a BMI of 28 or above. In people with a BMI of 40 or above, the XL-probe failure was 5%, and the best predictor of failure was a skin-to-capsule distance (SCD) ≥25 mm (...