Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
What is your strategy in the management of patients with autoimmune hepatitis who failed azathioprine therapy and what parameters do you monitor with what frequency?
Great question. Around 10% of autoimmune hepatitis cases don't respond to azathioprine (AZA) and 15% may have an incomplete response to AZA. These patients require second-line therapy. Before initiating second-line therapy, it's important to exclude non-adherence. Mycophenolate Mofetil (MMF) is the ...
In what clinical scenario would you consider liver transplant evaluation for a patient with sickle cell hepatopathy?
We have evaluated and transplanted patients with sickle cell hepatopathy with severe liver dysfunction but well-controlled sickle cell. These patients will typically have jaundice, coagulopathy, and biliary strictures. They should not have significant extrahepatic complications of the hematologic di...
In what kind of patient scenario would you consider testing for inherited disorders of lipid metabolism in the evaluation of a patient with MASLD?
I usually am concerned about a monogenic cause of MASLD when the patient has steatosis without the traditional metabolic risk factors that we typically see. Additionally, if patients have other features such as severely low LDL in the setting of steatosis, rapidly progressive liver disease, early ag...
What is your approach to the management of extra-hepatic manifestations/complications of PBC?
It is very important to ask and monitor extrahepatic symptoms in PBC, as this is often underappreciated and under-treated. For pruritus, the management now also ties in closely with treatment for PBC itself. UDCA treatment does not typically improve pruritus. However, if there is an insufficient bio...
In a hospitalized patient with compensated cirrhosis or heavy alcohol use requiring analgesia, do you use acetaminophen and if so how do you approach dosing?
For compensated cirrhosis, acetaminophen could be used. It's a common practice to offer acetaminophen in these patients at max 2 g/day. Again, I would advise closely monitoring liver function. In patients with heavy alcohol use, acetaminophen could be used cautiously if the liver function is fine (w...
How do you approach the evaluation of a living donor liver transplant candidate?
In principle, anyone who is an appropriate recipient for deceased donor liver transplantation (DDLT) is also eligible for living donor liver transplantation (LDLT). Recipients in need of two organs would be an exception, as well as those needing cava interposition or in whom a complex surgical histo...
What are your diagnostic and treatment goals for a patient with cirrhotic cardiomyopathy?
Cirrhotic cardiomyopathy (CCM) affects almost a third of liver transplant candidates. In the absence of primary cardiac disease abnormalities, diagnosis is based on echocardiographic criteria that predict pre-transplant morbidity and mortality, may be reversible, but abnormalities may persist even a...
How do you approach a patient with discordant Fibroscan and serologic testing for fibrosis?
First, rule out confounding factors for discordance. Several factors can falsely elevate FibroScan readings, including active hepatic inflammation, recent alcohol use, hepatic congestion from heart failure, and recent food consumption. The FIB4 score is affected by age, platelet count, etc. When the...
How do you decide which GLP-1s to prescribe for obesity?
Unfortunately, it is the insurance companies who are making the decisions about which GLP-1 I can use, if at all. If insurance is not an issue, I will usually choose Zepbound over Wegovy due to its better efficacy (21% loss in studies vs 15%) and better tolerability. However, if patients are paying ...
When ALT is persistently normal and HBV DNA is high but noninvasive markers suggest more advanced disease, how do you triage between biopsy, immediate antiviral therapy, or close observation—and which discordance patterns most strongly suggest “silent” progression in your experience?
ALT means absolutely nothing to me. High DNA is very contagious and much more likely to cause fibrosis and liver cancer, let alone the more replication, the more integration into the hepatocyte genome, which is the main cause of liver cancer. Liver biopsy has no role here either; fibrosis is not the...