Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
Should an individual who received the purified protein Hepatitis B vaccine in 1985 receive a booster or have antibody titers checked?
I recommend you ask yourself two questions. How likely has this individual lost humoral immunity? Did they receive B cell deplaning chemotherapy or have CLL, etc? How likely is the individual to be re-exposed? If the answer to both is low, re-vaccination probably provides no benefit.
How do you decide between anticoagulation or portal vein recanalization in a patient with portal vein thrombosis?
It depends on cirrhotic vs non-cirrhotic. For cirrhotic, best to reference the AASLD 2020 guidance here - Northup et al., PMID 33219529.For non-cirrhotic: important to determine the etiology as well as evaluate for a hypercoagulable state, including checking for JAK2 and CALR.If acute and non-occlus...
What are your top takeaways from AASLD 2025?
A lot of interest and research in new steatotic liver disease classifications (MASLD, Met-ALD, and ALD) with interesting abstracts about assessment of alcohol use (PETH, AUDIT-C) and the number of metabolic comorbidities that occur in these classifications. Very robust clinical research workshop, as...
In a patient with Zieve's Syndrome and alcohol related cirrhosis which antibiotic regimen is safe to treat H. pylori?
I am not concerned about a cirrhotic patient receiving a fluoroquinolone, macrolide, metronidazole, or doxycycline. The drug insert labels do not raise any particular concerns for these drugs’ use, even in Child Pugh class C cirrhosis. Yes, there is a theoretical potential for overdosing patients on...
At what BMI or waist-circumference threshold do you opt to move from Fibroscan to other NILDA for fibrosis assessment?
The XL-validation study found a liver stiffness measurement (LSM) failure of 1% for the XL and 16% for the M probe, in patients with a BMI of 28 or above. In people with a BMI of 40 or above, the XL-probe failure was 5%, and the best predictor of failure was a skin-to-capsule distance (SCD) ≥25 mm (...
If you do not have easy access to shear wave elastography (aka Fibroscan), what do you recommend for non-invasive tests to determine if a MASLD patient has clinically significant portal hypertension and risk-stratify them?
Great question. I do magnetic resonance elastography (MRE), and if not possible, shear wave elastography (SWE). If I have access to only blood-based non-invasive liver disease assessment (NILDA), will then order enhanced liver fibrosis (ELF). However, for clinically significant portal hypertension (...
How do you manage symptomatic ascites in a patient with SBP?
In my personal practice, the management of symptomatic ascites in the setting of concurrent SBP is a complex situation and can lead to potential complications. As SBP is a common precipitant of HRS in a cirrhotic patient with ascites, especially if hemodynamically unstable, my answer is IT DEPENDS o...
How do you utilize Cystatin-C as a marker of renal dysfunction in patients with chronic liver disease?
Liver disease is definitely one of those circumstances that results in lower creatinine production. As such, cystatin-C is likely a better marker than creatinine for renal function in those patients, even more than usual.
In patients with Met-ALD, would you still offer the same therapeutic/pharmacologic treatments (ex: GIP/GLP-1 agonists, Resmetirom, ex) for management of their disease as in a "pure" MASLD patient?
We would need to differentiate which is the bigger driver force (alcohol vs metabolic dysfunction) to determine the likelihood that MASH treatment would be effective. Alcohol use can be objectively quantified by phosphatidylethanol, which is a test commonly available in health systems with a liver t...
How do you approach cognitive impairment in the assessment of transplant candidacy?
Three main elements of cognitive impairment in organ transplantation present themselves: Impact on the candidate's ability to qualify for organ listing. Impact on the candidate's future ability to care for themself including adherence to the post-operative immunosuppressant regimen. Ability to cons...