Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
When using vasoconstrictors for HRS-AKI, what MAP target do you use in practice (absolute MAP vs ΔMAP), and how do you adjust that target in patients with chronic hypertension, cirrhotic cardiomyopathy, or very low baseline MAP?
Aim for a mean arterial pressure (MAP) at least 10 mmHg higher than baseline when treating with norepinephrine. For terlipressin, it is not necessarily titrated to a MAP, but you will see an increase in MAP as a response.
Do you continue semiannual HCC surveillance after HBsAg loss in a non-cirrhotic patient with additional risk factors (e.g., first-degree family history of HCC and ongoing alcohol use), and what criteria drive that decision?
No
How do you decide on the timing and urgency of transplant evaluation when a patient recovering from alcohol-associated hepatitis has rapid biochemical improvement (MELD falls into the low teens) but persistent portal-hypertension features and frailty/sarcopenia?
This is a great question, but it needs to be individualized. First: What is the time interval since presentation till MELD drop? Second: What is the patient's age, and what other comorbidities may require attention before or for a transplant evaluation, in particular risks of coronary disease and he...
What is your approach to peri-operative risk stratification and optimization in patients with cirrhosis?
The VOCAL-Penn score is one piece of information that I use for risk stratification in patients with cirrhosis. I usually treat symptomatic decompensated cirrhosis first (hepatic encephalopathy, ascites, hepatic hydrothorax, hepatorenal syndrome, variceal bleeding), because the risk scores usually c...
How do you pragmatically approach a conversation about "liver detox"/"liver cleansers" when patients bring up this topic?
It's important to keep an open mind with the use of these products, as often people will want to take them despite what you might say. Having some experience with the use of these products (or at least their ingredients) will give the patient a comfort level with freely discussing their use with you...
Do you add elafibranor or seladelpar to UDCA within the first year of treatment in a patient with primary biliary cholangitis who has an inadequate alkaline phosphatase response but no symptoms of pruritus?
I usually will wait for a year with the first line agent, ursodiol, if it is well-tolerated and there are no symptoms, before declaring inadequate alkaline phosphatase response and moving on to a second line agent for primary biliary cholangitis.
What clinical features would raise your suspicion for IgG-4 related disease?
IgG4-related disease can affect multiple organs, leading to varied presentations. In the abdomen, patients can have symptoms secondary to pancreatitis and or biliary obstruction. In the liver, patients can present with a PSC-like picture (jaundice, cholangitis, ductal strictures/dilatation) that, un...
In healthy living liver donors with a persistent postoperative bile leak, what leak- and patient- specific thresholds (e.g., drain output trend, biloma size, systemic inflammatory signs, duct anatomy) push you to early ERCP rather than continued percutaneous drainage and observation?
Typically, a bile leak would be noted because there are some objective findings which prompt an abdominal imaging study, i.e., fever, pain, rising liver chemistry tests, bilious output in Jackson-Pratt drains. A collection suspicious for a bile leak should be drained in order to avoid infection. Cut...
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...
Does your working phenotype for ‘new PAH after LT’ (occult POPH vs PAH unmasked after HPS resolution vs distinct post-LT vasculopathy) change what you actually do—specifically, who you screen more aggressively and when you initiate PAH therapy?
In pre-liver transplant patients with known hepatopulmonary syndrome (HPS), we do pay greater post-transplant attention to those considered to have "large intrapulmonary shunts," marked lung-brain uptake with technetium-99m macroaggregated albumin (⁹⁹ᵐTc-MAA) scanning (>30%) or poor response to 100%...