Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
How do you distinguish portopulmonary hypertension from group 3 or mixed-etiology PH in liver transplant candidates with COPD/ILD and elevated mPAP—what additional testing (PFTs/DLCO, CT, V/Q, ABG, repeat RHC maneuvers) or hemodynamic interpretation do you rely on before listing?
Certainly, PFTS and Chest CT help decide if another (possible group 3) major issue is evolving along in the setting of suspected or proven portopulmonary hypertension (POPH) by right heart cath. In my experience, the severity of the pulmonary hypertension (mPAP and PVR) is helpful. Rarely have I see...
What is your approach to liver transplantation candidacy in those with decompensated cirrhosis who have been treated for a solid-organ malignancy, such as oral SCC?
This is an important consideration as patients who receive a solid organ transplantation will be on significant immunosuppression, which can result in significant proliferation of an underlying malignancy and have worse treatment outcomes compared to non-immunosuppressed patients. Furthermore, patie...
In cirrhosis with suspected HRS-AKI and baseline CKD or chronically elevated creatinine, how do you define a clinically meaningful ‘improvement’ during an albumin trial (over 24–48 hours) to distinguish HRS-AKI from volume-responsive AKI?
If the acute rise in serum creatinine returns to the pre-AKI level, the patient has volume-responsive AKI.
Would you consider the use of prophylactic antibiotics in patients admitted with decompensated cirrhosis with AKI with Cr>1.2, with ascitic fluid protein <1.5 without SBP and/or hyponatremia/Bili >3?
Is this in generalized cases or cases of GIB? If GIB, yes, I would consider it. In just generalized cases, there is no real role for empiric antibiotics.
In patients with MASLD and F2–F3 fibrosis, would you initiate Resmetirom even if they are not making active lifestyle changes?
Yes, many patients had an underlying metabolic disorder that is difficult/impossible to address with lifestyle interventions alone and will go on to progress in their liver disease if left alone. Now with the approval of Semaglutide in August 2025 by the FDA and the approval of Resmetirom, we have t...
In patients with MASLD, would you consider management with off-label metformin, pioglitazone (despite weight gain risk), GLP-1 RA, or simply intensify lifestyle and monitor?
In 2025, we should be assessing if patients are developing F2-F3 fibrosis especially with the use of non-invasive assessments (FIB-4 score, transient elastography, or MRI elastography), and then offering either Semaglutide or Resmetirom for these individuals w/ F2-F3, which are the only FDA approved...
In what scenario do you screen patients with hepatitis B for hepatitis D co-infection?
I routinely screen every patient once at an initial diagnosis of chronic hepatitis B.
Pending final results, but in what scenario would you select bepirovirsen as opposed to established therapy for hepatitis B patients (ex: TAF or TDF)?
Bepe looks like the first drug that will be approved for the functional cure of hepatitis B. All patients with hepatitis B are potentially eligible for treatment. However, it is much more likely to be successful if the quantitative s Ag is below 3,000 or 1,000 IU. This is very good reason to start d...
How do you decide between empiric carvedilol versus obtaining HVPG to confirm CSPH when noninvasive markers suggest CSPH but there is limited hemodynamic/renal reserve (borderline MAP and/or CKD)?
May be reasonable to consider EGD to assess for varices and/or band high risk especially if the patient ultimately cannot tolerate carvedilol.
What risk factors in a cirrhotic patient would predispose them to the development of sarcopenia and how do you address these risk factors?
The most common risk factor for sarcopenia in cirrhosis is recurrent large ascites/diuretic refractory ascites requiring regular large volume paracentesis every 1-2 weeks. 4 L of ascites contains as much as 60 grams of protein. Additionally, at the decompensated stage of liver disease (hepatic encep...