Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
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...
How do you choose between resmetirom and semaglutide in the treatment of MASH?
I write a disclaimer to start, because use of resmetirom ($5,000 per month) and semaglutide ($1,600 per month) at this time cannot be used across the board with any patient with hepatic steatosis. It's important to highlight how we characterize a patient's metabolic dysfunction associated steatotic ...
In suspected portopulmonary hypertension with high cardiac output where mPAP is elevated but PVR is acceptable, do you base liver transplant candidacy primarily on PVR (and RV function) rather than mPAP, and how do you operationalize that in your listing decisions?
The short answer is yes. The key parameters of PVR and right heart function by transthoracic echo (mainly RV free wall strain, Fractional area change, and TAPSE in combination) are discussed by pulmonary and anesthesia colleagues at our selection conference. Specifically, we follow the current Inter...
How has the move away from a strict 6 month period of sobriety impacted your patient selection criteria for transplant of patients with alcohol associated liver disease?
The "sixth-month rule" was applied by many transplant programs years ago as a method of minimizing recidivism post-liver transplant. The evidence that this approach improves outcomes is sparse, and most programs have moved toward applying other criteria toward transplant decisions for these patients...
Should a patient who requires definitive treatment for prostate cancer as a pre-transplant requirement be strictly required to complete their course prior to transplant/initiation of immunosuppression?
To help address this complex question, I would like to call your attention to a review of the topic by Al-Adra et al., PMID 32969590. It covers several types of malignancies, including prostate cancer (Table 4). Treating this patient will require close collaboration with the transplant surgeon, urol...
For how long would you treat a patient with latent TB before allowing them to proceed with a liver transplant?
There are a few ways to look at the answer to this question. If the individual is stable enough to complete the Latent TB Infection (LTBI) therapy without need for a liver transplant, then treat the LTBI to completion. If the individual may need the transplant during the treatment course, then start...
What is your approach to secondary prophylaxis and post-discharge planning after an acute esophageal variceal bleed in a patient with ongoing alcohol use disorder and major social barriers (uninsured, homeless)?
Obviously, these questions are moot in the setting of an acute variceal bleeding when a life-saving TIPS becomes necessary; we then deal with these issues afterwards. We frankly go as far as we can with medical/endoscopic therapy before considering TIPS as an option for repeated bleeding episodes, w...
How do you use objective sarcopenia/frailty measures during liver transplant evaluation to decide between expedited listing versus a defined period of prehabilitation before listing?
At our center, we screen everyone with the liver frailty index (LFI). In those found to have frailty, we refer them to a prehabilitation clinic where, apart from providing physical literacy, personalized exercise and dietary prescriptions, we monitor LFI, 6MWT, and phase angle at every visit. This a...
What is your approach to the use of GLP-1 agonists in older adults with diabetes with or at risk of sarcopenia?
This is an important question to keep an eye on, given the broadening use and effectiveness of GLP-1 agonists for various conditions, especially diabetes, and for weight loss. Unfortunately, as is so often the case, major clinical trials in this area do not reflect the heterogeneity of older adults ...
How do you approach HCC screening in patients with advanced fibrosis e.g., F3 on FibroScan?
We should first understand the underlying principles that defined the various cut-offs that resulted in this recommendation (eg, cost-effectiveness threshold for HCC screening, cut-offs for advanced fibrosis) and then go from there. Among patients with cirrhosis, the cost-effectiveness threshold wa...