Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
In patients with Met-ALD, how do you approach their treatment plan?
This is a complicated question as Met-ALD is not a homogeneous disease state. This means that some patients will have ethanol-predominant disease, whereas others will have more metabolic issues. However, for all patients whom I suspect have significant alcohol use, I start by asking them to eliminat...
For cirrhotic patients that we take care of in the community, when should be the optimal timing of referral for liver transplantation aside from the MELD score?
This is a challenging issue for all doctors, both as the referring doctor and the transplant institution. We do not want to evaluate patients who are unlikely to be transplanted, but the MELD score is not an adequate reflection of all patients' disease severity. For our referring doctors, I never ha...
Given that cardiovascular disease is the top cause of morbidity/mortality in patients with MASLD, do you perform any additional screening and/or testing for these patients to minimize this impact?
MASLD should likely be thought of as part of a cardiometabolic disease with a wide spectrum of manifestations. I see my clinic as part of this management, but I do not do a complete cardiac assessment routinely on all my patients. I do not do this simply for the challenge of addressing all these iss...
What cardiac testing do you perform for patients undergoing liver transplant evaluation?
Each institution I am aware of has slightly different approaches to cardiac testing for transplantation candidacy. In our institution, we have patients undergo a TTE with a bubble study at a minimum. However, patients with any risk factor for coronary disease will undergo coronary angiography (CT or...
Do you have any concerns about lower extremity compression (e.g., compression stockings, intermittent pneumatic compression, etc.) worsening ascites in a patient with portal hypertension?
This is an interesting question, and I have to admit, not one I've thought about regularly. When I think of lower extremity compression and the contraindications, portal hypertension and ascites are not contraindications that immediately come to mind. I do understand the reasoning behind the questio...
How do you decide whether to use pharmacologic VTE prophylaxis in hospitalized patients with decompensated cirrhosis?
For all patients, I begin by using a standard risk prediction tool to determine if the patient is appropriate for pharmacologic VTE prophylaxis. At our institution, the Padua risk prediction tool is embedded in our electronic health record/admission set. Clinical guidelines- including those from the...
What graft and patient factors would increase the risk of early graft failure?
Patients who have had previous abdominal surgery, especially in the setting of portal hypertension, might have an increased transfusion requirement and periods of liver hypoperfusion, so may thus be at risk for early raft dysfunction. Any other recipient feature that could be expected to increase th...
Is there a serum ammonium level for which you recommend initiation of dialysis in a patient with hepatic encephalopathy?
Because there is a very poor correlation between ammonia levels and hepatic encephalopathy, I do not make recommendations based on ammonia levels. My approach is to treat each case individually in consultation with our hepatology colleagues. If a patient has encephalopathy and is not responding to m...
Are there any specific guidelines for the transplantation of metastatic disease to the liver or are these institution specific?
For patients with colon cancer metastases to the liver or those having neuroendocrine (NET) metastases to the liver, there are specific UNOS criteria that govern prioritization on the waiting list through MELD exception. The transplant community is closely following graft and patient survival as wel...
Having gone through multiple iterations, what MELD updates/considerations should we anticipate in the future?
All MELD updates have related to improving the calibration of the model in predicting 90-day mortality, making adjustments to correct disparities. The most likely updates at this point will relate to the periodic need to recalibrate the coefficients of the prediction model as time passes and clinica...