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.
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 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.
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...
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...