Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
In a patient with low (or normal) BMI but findings of steatosis on imaging, no cardiometabolic comorbidities, and very elevated CAP scores, what are your next diagnostic and therapeutic steps to identify the cause of their steatosis and subsequent management?
In addition to knowing the level of steatosis, liver stiffness values would be of most interest. Alcohol use should stop if there is any level of fibrosis. Lifestyle modifications (dietary/exercise) should be part of recommendations, but with a goal of around 5 % weight loss. If they have F2-3 fibro...
What is your preferred dosing of IV ganciclovir for CMV disease in immunocompromised patients?
For treatment, I usually start with 5 mg/kg IV q 12 hr, and the dose is adjusted for renal function with the help of ID pharmacists. I can consider going to 7.5 mg/kg if there is a concern for very severe disease or low-level resistance, but to be honest, I don't think I've ever done that, given the...
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 ...
How do you manage oxaliplatin-induced splenomegaly?
Oxaliplatin can lead to sinusoidal obstructive syndrome (SOS), which will result in portal hypertension. Splenomegaly is one of the portal hypertension signs.The SOS is correlated with cumulative oxaliplatin dose, and cumulative dose >1000 mg/m2 is considered a potential threshold (Overman et al., P...
Under which circumstances is there a role for reduction in immunosuppression post-SOT in a patient with recurrent CMV viremia and/or disease?
While the decision regarding immunosuppression is always up to the primary transplant team, as the infectious disease consultant, I always inquire about the ability to reduce immunosuppression during episodes of CMV syndrome or disease even if it is a first episode. This becomes even more important ...
How long do you treat uncomplicated gram-negative rod bacteremia in solid organ transplant recipients?
My approach to the duration of therapy for GNR bacteremia in SOT patients depends on the source of the bacteremia, the available antibiotics, the patient's net state of immunosuppression, and the organism. There are situations where 7 days of therapy are adequate (One example: E.coli urosepsis in a ...
How do you balance the need for diuretics from a volume perspective (Ex: ascites, edema) in decompensated cirrhotic patients and progressive renal dysfunction?
There is no discrete answer to this question. Much depends on the overall goal of care. For a transplant candidate, higher creatinine may be needed for transplant access and be tolerated, but risk need for post-transplant RRT. If goals are palliative, symptom control supersedes renal function.
For remote liver transplant recipients back under the care of a community gastroenterologist (or PCP), what should be the approach to new liver enzyme elevations?
Elevated liver enzymes in post-transplant patients who live far from their transplant center are a common challenging issue. Many factors will influence your recommendation to the local physician: height of enzyme elevation, cholestatic, hepatitic, or mixed profile, and associated symptoms (pain, fe...
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...
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...