Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
How are you treating MSI-H CRC in a liver transplant recipient on tacrolimus & sirolimus?
This is an important question; however, our experience in the metastatic colorectal cancer (mCRC) setting remains very limited. This patient underwent liver transplantation three years ago and has since developed dMMR/MSI-H metastatic colorectal cancer. The patient is currently receiving tacrolimus ...
How does VExUS evaluation differ in a patient with a transjugular intrahepatic portosystemic shunt (TIPS)?
This is a very interesting question, and I don't think I have ever tried to look at VExUS in a patient with a TIPS before! Although, based on what I understand about this study, I would be cautious about relying on the original VExUS algorithm that incorporates hepatic vein, portal vein, and intrare...
In what clinical scenario would you consider the use of budesonide over prednisone as part of the pharmacologic management of autoimmune hepatitis?
Primarily in patients where the side effects of prednisone will or are too difficult to tolerate (diabetics, weight gain, metabolic syndrome, psychiatric disease, etc). I like to try prednisone first because of its ability to elucidate a biochemical response, fairly rapidly, so we know what we are d...
In pregnant liver transplant recipients, which transplant-specific modifiable targets do you prioritize to reduce prematurity and fetal growth restriction?
There is no data or guidance on how to reduce prematurity or fetal growth restriction in transplant recipients.However, regarding this patient population, the AASLD Practice Guidance on Reproductive Health summarizes the key points nicely of what's recommended in liver transplant recipients planning...
What factors can lead to falsely elevated fibrosis readings on FibroScan (e.g., consuming sugar before the scan)?
I recommend 3 hours of fasting before performing a FibroScan. Liver stiffness may not be equivalent to fibrosis stages in the following conditions: liver congestion (right-sided heart failure, Fontan-associated liver disease), active liver inflammation (alcohol, active viral or autoimmune hepatitis)...
How do you treat diffuse large B cell lymphoma (DLBCL) in a patient with cirrhosis complicated by thrombocytopenia?
Thank you for the question. This is a very challenging case. There are different factors to consider, such as age, PS, stage, and actual liver function. Liver function may have been affected by lymphoma.Most likely, the patient will require dose reductions of standard R-CHOP (such as mini R-CHOP). A...
What early response criteria and timeframe do you use to declare corticosteroid non-response and move to expedited transplant listing in patient with acute severe AIH without encephalopathy?
I would administer the corticosteroid as an IV to remove the possibility of absorption issues. However, I would wait for a total of 5-7 days before moving on to expedited transplant listing, provided there is no worsening of the liver failure in the interim.
Do you ever use Joyrnavx in a patient with end stage liver disease?
I have not encountered this novel oral small molecule medication Suzetrigine for the management of acute moderate to severe pain (FDA approved indication) in my patients with cirrhosis. The drug received FDA approval in Jan 2025 after two phase III trials where it was used for pain control after b...
How would you approach the evaluation of a patient with decompensated cirrhosis, suspect to be due to alcohol, who is not a liver transplant candidate with iron studies showing elevated saturation and ferritin over 1000?
The finding of elevated iron saturation (I suspect means above 55%) and high ferritin raises the diagnosis of true iron overload. Certainly, a Ferritin level above 1000, when the patient is not actively drinking, is consistent with cirrhosis. So, I would start phlebotomies if the Hgb >11-12 g/dL all...
How do you set practical referral and discharge criteria for a MASLD multidisciplinary clinic to capture high-risk phenotypes without being overwhelmed?
As former Director of the Penn State Health Fatty Liver Program, we structured our multidisciplinary MASLD clinic around risk stratification rather than diagnosis, with the explicit goal of capturing patients at genuine risk of progression while preserving clinic capacity. We relied on a two‑step tr...