Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
How would you approach GLP-1/GIP agonist use for MASLD management in a patient who had a prior episode of pancreatitis?
If the etiology of pancreatitis has resolved (i.e., alcohol use and the patient has achieved abstinence or status post cholecystectomy for gallstone pancreatitis), then I may consider a repeat trial of GLP-1/GIP for MASH with fibrosis when there is a need to address the extrahepatic risk factors (ob...
What early response criteria and timeframe do you use to declare corticosteroid non-response and move to expedited transplant listing in patient with acute severe AIH without encephalopathy?
Remove the possibility of absorption issues. However, I would wait for a total of 5-7 days before moving on to expedited transplant listing, provided there is no worsening of the liver failure in the interim.
What are some practical tips for when a patient's consistently stated goals of care do not correlate with their actions?
First, it's important to remember that most of us have inconsistent beliefs. We both want to lose weight, and we want to eat chocolate cake; we want to get an A, and we want to go to the party. So when we see inconsistencies in others' beliefs, rather than being judgmental, we should get curious. Ou...
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 factors do you consider when deciding to treat IgA nephropathy with immunosuppression in a patient with cirrhosis, given the possibility that IgA nephropathy could be secondary to cirrhosis?
Proteinuria is the most important factor here. If there is significant proteinuria (>1 g/d) and no other clear reason for it, I would treat the IgA nephropathy with immunosuppression. Secondary IgA due to cirrhosis is usually not associated with significant proteinuria.
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.
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...
How would you manage a patient with well-controlled HIV on Biktarvy, who is interested in switching to injectable HAART but also has a history of a prior Hepatitis B Infection?
HBV is a common co-infection in people with HIV (PWH), due to shared transmission routes. Two large meta-analyses of studies published found a global a pooled prevalence of HBV infection among PWH to be between 7.6 and 8.4%, with a higher prevalence in less developed countries (10.4%) compared to mo...
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 do you use IVC caliber and collapsibility to guide decisions about diuresis?
I use IVC caliber in conjunction with my lung exam to assist with the assessment of right and left atrial pressures respectively. The IVC assessment has many caveats in different patient populations, and evaluation with POCUS can be done in two planes to better understand IVC shape.Caveats - IVC siz...