Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
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...
What specific clinical and echocardiographic thresholds lead you to taper/de-escalate pulmonary hypertension therapy before liver transplant?
The goal in pulmonary hypertension therapy pre-transplant is to fulfill the MELD exception criteria in terms of mean pulmonary artery pressure, pulmonary vascular resistance, as well as right ventricular function by echo. Once those criteria are satisfied, maintain those PH therapy doses until the t...
In severe alcohol-associated hepatitis complicated by renal dysfunction or prolonged hospitalization, do you start medications for alcohol use disorder during the admission or defer until medical stabilization?
In this scenario, the priority is to understand what the patient's future will be. It may be a transplant, discharge home from a rehab facility, possibly need for dialysis, or even palliative care. Regardless, I would defer until medical stabilization.
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...
How would you approach the management of asymptomatic ALT and GGT elevation in an older adult patient with depression with psychosis and without history of hepatitis who recently had dose of quetiapine increased and new initiation of SNRI?
The answer when you suspect drug-induced liver injury depends on the X elevation above normal of ALT and bilirubin. In addition, exclusion of other coexistent factors, i.e., alcohol use, metabolic risks, or other medications. From liver tox, quetiapine may elevate liver tests in 30% of patients. Bel...
In a PSC patient who has received liver transplant, what graft and/or patient factors predispose to a more rapid return of their disease and how do you manage these peri-operatively and post-transplant?
Unfortunately, there are not a lot of modifiable risk factors for recurrent PSC. If the patient has concomitant IBD, then good control of the disease helps to prevent risk. Other risk factors include young age, HJ anastomosis, female gender, and cold ischemia time. Not much we can do about these.
In patients with MASLD/MASH, do you perform any cardiac testing to create a patient's risk profile, given that cardiac complications are the top cause of morbidity and mortality in this patient population (especially those with advanced fibrosis)?
This is a very important question, particularly because the new ACC guidelines suggest the use of more advanced lipid markers, like Apolipoprotein B and Lipoprotein (a), in individuals who are deemed "high risk" for cardiac disease. Unfortunately, they didn't specifically mention MASLD/MASH as a ris...
If a patient has persistent ascites requiring diuretics after TIPS, at what point do you consider re-evaluation of TIPS?
Some may still require some diuretics, particularly if lower extremity edema is an issue post-TIPS. Otherwise, if paracentesis is needed ~6 weeks after TIPS and the patient is free of HE, then consider IR dilating the TIPS further. When TIPS is for ascites, IR should really start with a small calibe...
Pending final results, but in what scenario would you select bepirovirsen as opposed to established therapy for hepatitis B patients (ex: TAF or TDF)?
Bepe looks like the first drug that will be approved for the functional cure of hepatitis B. All patients with hepatitis B are potentially eligible for treatment. However, it is much more likely to be successful if the quantitative s Ag is below 3,000 or 1,000 IU. This is very good reason to start d...
How do you determine the timing and frequency of therapeutic thoracentesis in patients with symptomatic hepatic hydrothorax?
It is determined by the patient's symptoms. The patient should also get a paracentesis if there is concomitant ascites, otherwise the pleural effusion will re-accumulate as soon as it is drained unless the ascites is removed.