Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
How do you decide whether ordering a 5' nucleotidase or a GGT is the most appropriate option in the evaluation of an elevated alkaline phosphatase?
GGTP is the obvious choice; every elevated alkaline phosphatase needs a GGTP.
What is your clinical approach to the evaluation of cytopenias in patients with end-stage liver disease?
Cytopenias may be the new normal for a patient with cirrhosis. However, they may not be. If a patient has isolated thrombocytopenia and a large spleen, I am typically going to monitor labs on the standard labs with each visit. Isolated mild leukopenia is the same pattern as well. Anemia requires a w...
How do you approach the use of viscoelastic assays (ex: TEG, ROTEM) in patients with identified coagulopathy in the peri-procedural period?
Coagulopathy requires consideration, but not necessarily action. The usual way it is invoked is by an elevated INR result - but this does not imply auto-anti-coagulation (as coumadin on INR). PVT is very common in PHTN/cirrhosis. Thus, in many cases, it depends on the procedure and the proceduralist...
When would you consider use of EUS guided liver biopsy over percutaneous and/or transjugular?
If data (labs, imaging) are not entirely compelling for a primary parenchymal or biliary issue, then EUS liver biopsy can be an efficient approach in addition to ERCP (saving the need for separate biopsy in the event that ERCP is non diagnostic).
Would you refer a patient for kidney only or kidney and liver transplantation if they develop advanced chronic kidney disease secondary to primary hyperoxaluria type 2?
Now that the data suggesting a benefit for nedosiran for PH2 is very disappointing, I think we have to say simultaneous liver and kidney. I have this one experience. My PH2 patient had kidney only because I was thinking that nedosiran would be effective. Ultimately, the kidney failed after about 5 y...
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...
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 rule out spontaneous bacterial peritonitis in a patient with minimal ascites that is not amenable to paracentesis?
You can’t, unfortunately. You either need to keep looking for a good pocket (move patient to each side, etc.) or use clinical judgement and decide whether or not to treat empirically.
How do you decide when to initiate or restart diuretics in a cirrhotic patient with ascites if they are receiving a therapeutic paracentesis?
This question has two parts, one with a straightforward answer, the other with a much more nuanced answer, if I understand it correctly. Any patient receiving a therapeutic paracentesis should start/restart diuretics afterwards. Per the 2021 AASLD guidelines, one of the statements reads “LVP is the ...
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...