Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
If you do not have easy access to shear wave elastography (aka Fibroscan), what do you recommend for non-invasive tests to determine if a MASLD patient has clinically significant portal hypertension and risk-stratify them?
Great question. I do magnetic resonance elastography (MRE), and if not possible, shear wave elastography (SWE). If I have access to only blood-based non-invasive liver disease assessment (NILDA), will then order enhanced liver fibrosis (ELF). However, for clinically significant portal hypertension (...
How do you manage symptomatic ascites in a patient with SBP?
In my personal practice, the management of symptomatic ascites in the setting of concurrent SBP is a complex situation and can lead to potential complications. As SBP is a common precipitant of HRS in a cirrhotic patient with ascites, especially if hemodynamically unstable, my answer is IT DEPENDS o...
How do you utilize Cystatin-C as a marker of renal dysfunction in patients with chronic liver disease?
Liver disease is definitely one of those circumstances that results in lower creatinine production. As such, cystatin-C is likely a better marker than creatinine for renal function in those patients, even more than usual.
In patients with Met-ALD, would you still offer the same therapeutic/pharmacologic treatments (ex: GIP/GLP-1 agonists, Resmetirom, ex) for management of their disease as in a "pure" MASLD patient?
We would need to differentiate which is the bigger driver force (alcohol vs metabolic dysfunction) to determine the likelihood that MASH treatment would be effective. Alcohol use can be objectively quantified by phosphatidylethanol, which is a test commonly available in health systems with a liver t...
How do you approach cognitive impairment in the assessment of transplant candidacy?
Three main elements of cognitive impairment in organ transplantation present themselves: Impact on the candidate's ability to qualify for organ listing. Impact on the candidate's future ability to care for themself including adherence to the post-operative immunosuppressant regimen. Ability to cons...
In patients with Met-ALD, how do you approach their treatment plan?
This is a complicated question as Met-ALD is not a homogeneous disease state. This means that some patients will have ethanol-predominant disease, whereas others will have more metabolic issues. However, for all patients whom I suspect have significant alcohol use, I start by asking them to eliminat...
Given that cardiovascular disease is the top cause of morbidity/mortality in patients with MASLD, do you perform any additional screening and/or testing for these patients to minimize this impact?
MASLD should likely be thought of as part of a cardiometabolic disease with a wide spectrum of manifestations. I see my clinic as part of this management, but I do not do a complete cardiac assessment routinely on all my patients. I do not do this simply for the challenge of addressing all these iss...
What cardiac testing do you perform for patients undergoing liver transplant evaluation?
Each institution I am aware of has slightly different approaches to cardiac testing for transplantation candidacy. In our institution, we have patients undergo a TTE with a bubble study at a minimum. However, patients with any risk factor for coronary disease will undergo coronary angiography (CT or...
What graft and patient factors would increase the risk of early graft failure?
Patients who have had previous abdominal surgery, especially in the setting of portal hypertension, might have an increased transfusion requirement and periods of liver hypoperfusion, so may thus be at risk for early raft dysfunction. Any other recipient feature that could be expected to increase th...
Are there any specific guidelines for the transplantation of metastatic disease to the liver or are these institution specific?
For patients with colon cancer metastases to the liver or those having neuroendocrine (NET) metastases to the liver, there are specific UNOS criteria that govern prioritization on the waiting list through MELD exception. The transplant community is closely following graft and patient survival as wel...