Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
How do you decide between immediate liver transplant referral versus a time-limited “recompensation observation” period in patients with alcohol-related cirrhosis who present with a first decompensation and achieve early, verified abstinence?
It can be difficult to differentiate the two, so one never errs on the side of evaluating the patient for a transplant and then getting to know them and their support system a bit better. The more data and time you have to make such a decision, the better it is. Often, the natural history of the dis...
When diuretics or lactulose are newly started or uptitrated at discharge, what clinical factors make you schedule follow-up within 72–96 hours rather than the usual 7–14 days?
In reality, follow-up in 72-96 hours is quite difficult to achieve, so we do rely a bit on nursing check-ins as opposed to clinic follow-up. But clinical factors such as severity of VOL or HE, suspected compliance, out-of-hospital discharge setting (home vs shelter), support structure for patient, a...
In patients with sarcoidosis and persistently elevated liver function tests, when do you consider initiating ursodeoxycholic acid (UDCA)?
In patients with systemic sarcoidosis with predominantly elevated alkaline phosphatase, I would be suspicious for liver involvement of their sarcoidosis. If treatment of the systemic sarcoidosis with immunosuppression (typically initiated by Pulmonology or Rheumatology) are ineffective for improving...
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...
In frail patients with compensated cirrhosis and clinically significant portal hypertension/ascites risk, how do you prioritize protein adequacy versus sodium restriction in practice, and what specific dietary pattern do you prescribe?
I do prioritize protein. I find in particular if you are restricting free water in your patients, the cannot maintain adequate high caloric nutrition. I do still recommend less than 2,000mg/day sodium but also have patients goal for 1.5 mg/kg/day protein and recommend a bed time snack of high protei...
In patients who meet Baveno VII CSPH rule-in by LSM but have potential confounders (e.g., heart failure/congestion, cholestasis, recent alcohol use), how do you decide whether LSM is sufficient to start and follow NSBB versus escalating to spleen stiffness, MRE, or HVPG?
I would like to answer by stating that the Baveno VIII consensus has been published in the Journal of Hepatology. First statement: LSM >10 kPa should be performed in fasting conditions; we use a minimum of 3 hours and complemented by another validated NIT of advanced fibrosis. Second statement: LSM ...
What role, if any, does systemic therapy have in the treatment of HCC amenable to locoregional therapy?
Systemic therapy currently has no established role in patients with hepatocellular carcinoma (HCC) undergoing potentially curative locoregional therapy, including surgical resection or ablation. Active surveillance remains the standard of care after curative-intent treatment, and no perioperative sy...
What is your approach to the management of post-TIPS hepatic encephalopathy?
In general, this will depend on if HE is provoked or unprovoked. Provoking factors such as infection, dehydration, medications (sedatives) or GI bleeding are reversible and often do not require aggressive HE treatment when the underlying trigger is removed. It may be reasonable to consider lactulose...
How do you use IVC caliber and collapsibility to guide decisions about diuresis?
I use IVC caliber in conjunction with my lung exam to assist with the assessment of right and left atrial pressures respectively. The IVC assessment has many caveats in different patient populations, and evaluation with POCUS can be done in two planes to better understand IVC shape.Caveats - IVC siz...
How does HBV/HDV coinfection after liver transplant change your functional cure targets (HBsAg loss/anti-HBs) and your tolerance for residual HBV activity markers (e.g., HBcrAg or pgRNA) compared with HBV monoinfection?
HBV/HDV infection after transplant is no different from pre-transplant. Functional cure is still the goal for HBV, although HBsAg clearance may not clear the Delta virus. There is, however, a treatment for Delta now approved in the US. Core antigen and pgRNA are not available commercially and do not...