Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
How do you approach restarting immunotherapy in a patient with metastatic melanoma who previously developed immune-mediated hepatitis (Grade 3), with liver enzymes now back to baseline levels?
I prefer to rechallenge when the irAE is back to grade 0. It depends on how long the hepatitis took to revert to a normal level. If it goes back to normal quickly (within 4 weeks), I keep patients on 8 mg methylprednisolone when rechallenging patients. If they do well, I wean them off at the second ...
How do you decide whether or not to pursue inpatient workup of an incidental liver mass?
When deciding whether to pursue inpatient evaluation of an incidentally discovered liver lesion, I ask two key questions:Is the lesion plausibly related to the clinical syndrome I’m treating now?Are there patient- or system-level barriers that would make outpatient follow-up unreliable or unsafe?Cli...
Can tacrolimus in a transplant patient be used during radiation and concurrent chemoradiation?
Patients with solid organ transplants present unique challenges in management and risk of infectious complications, among others. The short answer is that tacrolimus can be used in the lowest dose possible, along with concurrent chemoradiation and close coordination with the transplant team. If the ...
Do you recommend the use of SGLT2 inhibitors to reduce the risk of liver cirrhosis in patients with Type 2 diabetes mellitus?
Metabolic dysfunction-associated steatotic liver disease (MASLD) can be found in about 30% of adults in the U.S. Diabetes is a significant co-morbidity and increases the risk of progression to metabolic dysfunction-associated steatohepatitis (MASH). I calculate a FIB-4 index in these patients to see...
Would you recommend radiation or chemoradiation in a patient with cholangiocarcinoma s/p surgery and adjuvant treatment with single hepatic metastasis 3 years later?
Challenging case and worthy of tumor board discussion. I would likely start systemic therapy, and if response, consider regional therapy with resection or SBRT, assuming the hepatic function is adequate (keep in mind, TARE can cause liver disease). I have one patient in a similar situation, now > 5 ...
Would you ever consider using durvalumab/tremelimumab in second line after progression on atezolizumab and bevacizumab in advanced HCC?
This is a really interesting question as primary prospective trials in this setting are limited. Following progression of atezolizumab/bevacizumab, there was a recent abstract of a phase 2 trial using the combination regorafenib + pembrolizumab (N=95 patients, cohort 1 of 68 patients having received...
Would you consider long term avatrombopag use in patients with cirrhosis requiring higher platelet counts for medical therapy?
In general, no, I would not use long-term avatrombopag in patients with cirrhosis requiring higher platelet counts for medical therapy due to the perceived thrombotic risk and hemostatic abnormalities of patients with liver disease.One thing to note in assessing the risk of long-term TPO mimetic the...
How do you manage fatty liver disease in patients on olanzapine who are reluctant to change meds?
I wonder if there are hepatologists available to consult with?There is a new drug with a novel mechanism of action Rezdiffra (resmetirom) that is specifically studied/designed for MASH (NASH). I haven't seen it used yet in my patients, but I am fascinated by the mechanism of action. Will it have psy...
What is your approach to managing concurrent severe SIADH and large-volume malignant ascites when aggressive volume removal appears to exacerbate both symptoms and hyponatremia?
A challenging situation. I would approach it in a few steps: Ensure adequate solute intake since solute load determines free water clearance in SIADH. Loss of solute from repeated large-volume paracenteses can add a component of hypovolemic hyponatremia, and people with cancer and large ascites tend...
What is your standard diagnostic workup to confirm GVHD in a patient post-BMT with skin rash and jaundice?
I assume there is no diarrhea, so sigmoidoscopy would not be helpful. Gut and liver pathology are useful. Skin biopsy is less helpful. It can be fairly nonspecific, but we do it to rule out other diagnoses that have more definitive pathology. Ultimately, it is a clinical diagnosis. Liver biopsy woul...