Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
What parameters would you use to monitor and interpret iron levels in a hemochromatosis patient where ferritin is unreliable due to underlying chronic inflammation?
The biggest question in these situations is whether the patient truly has iron overload vs. just high ferritin. If iron sat is not elevated, true iron overload is very unlikely. If both ferritin and iron sat are elevated, but they don't have a homozygous C282Y genotype, I make sure that the patient ...
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...
When treating with SBRT and immunotherapy for unresectable HCC, how do you sequence the treatment?
Great question. No great data in this space regarding optimal sequencing. In general, I would sequence SBRT first, followed by initiation of immunotherapy. Some data suggest that SBRT may best prime IO if administered prior to IO. Additionally, if the IO regimen preferred is atezolizumab/bevacizumab...
Can tamoxifen be safely prescribed for breast cancer patients with cirrhosis?
Tamoxifen would definitely not be my preferred endocrine agent in a patient with cirrhosis. I have had many cases of tamoxifen-induced liver injury. The incidence of MASH due to tamoxifen is really underreported in the literature. In a case of pre-existing MASH or other liver disease, I switch to an...
What is your strategy to manage the complication of long-term immunosuppression in liver transplant recipients, specifically renal dysfunction and onset of cardiometabolic comorbidities?
Educating patients early on after their transplant is important as to the medical complications associated with CNI use. With regard to renal dysfunction, trying to minimize CNI use as judiciously and as timely as possible is paramount. Switching to an mTOR inhibitor appears best to do early on afte...
How does the presence of porto-mesenteric vein thrombosis impact a patient's transplant candidacy?
This is nuanced and depends if the portal vein thrombosis (PVT) is acute vs chronic with cavernous transformation. Main PVT is not necessarily an absolute contraindication to liver transplant. Current guidelines recommend anticoagulation for acute main PVT in patients who are (or may be) transplant ...
How do you decide which patient and with which device to pursue machine perfusion for the organ of a liver transplant recipient?
In general, these are the principles I consider to pump livers prior to transplant: Patient comorbidities: Even if the donor is ideal and the surgery is not expected to be challenging, minimizing the risk of reperfusion injury and early allograft dysfunction is important in patients with coronary a...
How will the recent withdrawal of Ocaliva for the treatment of PBC impact your therapeutic and management plan for these patients?
It was unfortunate to lose a drug that was effective for many PBC patients but the FDA approved 2 new PBC drugs last year. These are PPAR agonists (elafibranor and seladelpar) and are well-tolerated and have been effective in reducing ALP in PBC. These are second-line add-on drugs to UDCA (should be...
What is your strategy to manage peri-procedural bleeding risk in patients with cirrhosis?
We use TEG primarily here and mostly ask our colleagues to routinely check TEGs to guide transfusion strategies. It remains a challenging situation to monitor and manage because of the unique profile and difficulty in accurately assessing what is truly needed. Certainly, no empiric FFP for specific ...
How would you workup a patient who develops ascites AFTER liver transplantation?
Challenging patient population. TTE to try to exclude cardiac etiology - HFpEF is often a significant factor, particularly with cardiorenal physiology. Sometimes, a hepatic venogram is needed to confirm no outflow obstruction. Good CTA to assess for portal vein stenosis - in the post-transplant sett...