Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
How do you decide which patient and with which device to pursue machine perfusion for the organ of a liver transplant recipient?
Choosing the machine perfusion type depends on multiple factors: patient factors - anticipating a very complex surgery (certain redo, very complex anatomy, etc.) organ factors - Marginal organs (older DCD, Fatty livers, now in general most of the DCD). The type of perfusion is typically dependent ...
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?
Evaluate ascites with triglyceride level to see if chylous - management of this is fat-restricted diet. This is common in the immediate post-transplant setting (1-3 months). If ascites is high SAAG and low total protein, then a direct hepatic venogram with pressure measurements along the hepatic vei...
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...