Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
What patient factors guide your selection of maintenance therapies for a patient with autoimmune hepatitis?
I have no deep insight here. The goal is to try to get labs as normal as possible - also realizing that once achieved normal labs do not per se imply normal liver. Histological control lags biochemical control by years, hence the need for prolonged therapy and biopsies prior to withdrawal of therapi...
What is your approach to the management of anti-pruritic therapies in patients with cholestatic liver disease?
If the patient has PBC, the newer FDA PPAR drugs (elafibranor and seladelpar) for PBC have an anti-pruritic effect, though they are mainly approved to lower ALP and are thought to be disease-modifying. For PFIC and Allagille syndrome, IBAT inhibitors (odevixibat and maralixibat) are helpful and are ...
What kind of monitoring do you choose in patients at risk for reactivation of hepatitis B who are on immunosuppression?
For patients at high risk of reactivation, I initiate prophylaxis and, given high efficacy, I don’t routinely monitor (other than to schedule annual appointments to make sure patients are getting refills). Generally, these patients are getting routine labs done by their oncologist or rheumatologist....
All things being equal, what patient factors are you looking at in the selection of TAF or TDF in the management of hepatitis B?
If renal function is normal and bone density is not a concern, TDF is much less expensive and has excellent long-term safety.
In what scenarios do you defer treatment of a patient's hepatitis C if they are undergoing liver transplant evaluation?
If a patient were to improve with treatment but still need a transplant then the improvement my actually disadvantage the patient by lowering the MELD reducing priority for receiving an organ offer.
How do you explain the additional risks that a transplant recipient may carry by pursuing a hepatitis C positive organ if they are negative?
I generally counsel that the risks are there from an infection-transmission perspective but that the treatment of hepatitis C is so facile and easily done now that there are not any long term risks. As long as we can get hepatitis C treatment started with the first few months after transplant (in re...
When would you choose to measure a patient's spleen stiffness?
While there is data to support the use of spleen stiffness to assess for clinically significant portal hypertension, spleen stiffness has not yet made the leap to clinical care, at least in my practice. One population where I would consider using it would be in patients with Fontan-associated liver ...
Who would be the right candidate in which TIPS placement would reduce portal hypertension to allow for a previously unattainable procedure?
I would put a TIPS in patients whose only problem is portal hypertension and no significant liver dysfunction, such as cirrhotic patients whose HCV is cured, or abstinent alcoholics, or any other patients whose underlying etiology is controlled.
What role do you see for albumin infusions in patients with hypoalbuminemia to help assist in volume status, outside of its use in replenishment after a large volume paracentesis or renal dysfunction?
I do not give albumin infusions for hyponatremia per se. However, I do give albumin for renal dysfunction and hyponatremia.
How does the use of checkpoint inhibitors for treatment of HCC impact timing of liver transplant and subsequent immunosuppression?
This is a challenging issue with concerns for checkpoint inhibitor/immunotherapy (IO) resulting in rejection of a transplanted organ. In our practice, we have a local protocol based on our consensus that at least 6 weeks of washout for IO prior to transplantation. Post-transplantation, IO is not use...