Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
Are there any specific guidelines for the transplantation of metastatic disease to the liver or are these institution specific?
For patients with colon cancer metastases to the liver or those having neuroendocrine (NET) metastases to the liver, there are specific UNOS criteria that govern prioritization on the waiting list through MELD exception. The transplant community is closely following graft and patient survival as wel...
Having gone through multiple iterations, what MELD updates/considerations should we anticipate in the future?
All MELD updates have related to improving the calibration of the model in predicting 90-day mortality, making adjustments to correct disparities. The most likely updates at this point will relate to the periodic need to recalibrate the coefficients of the prediction model as time passes and clinica...
What parameters would you use to monitor and interpret iron levels in a hemochromatosis patient where ferritin is unreliable due to underlying chronic inflammation?
The biggest question in these situations is whether the patient truly has iron overload vs. just high ferritin. If iron sat is not elevated, true iron overload is very unlikely. If both ferritin and iron sat are elevated, but they don't have a homozygous C282Y genotype, I make sure that the patient ...
When treating with SBRT and immunotherapy for unresectable HCC, how do you sequence the treatment?
Great question. No great data in this space regarding optimal sequencing. In general, I would sequence SBRT first, followed by initiation of immunotherapy. Some data suggest that SBRT may best prime IO if administered prior to IO. Additionally, if the IO regimen preferred is atezolizumab/bevacizumab...
Can tamoxifen be safely prescribed for breast cancer patients with cirrhosis?
Tamoxifen would definitely not be my preferred endocrine agent in a patient with cirrhosis. I have had many cases of tamoxifen-induced liver injury. The incidence of MASH due to tamoxifen is really underreported in the literature. In a case of pre-existing MASH or other liver disease, I switch to an...
How does the presence of porto-mesenteric vein thrombosis impact a patient's transplant candidacy?
This is nuanced and depends if the portal vein thrombosis (PVT) is acute vs chronic with cavernous transformation. Main PVT is not necessarily an absolute contraindication to liver transplant. Current guidelines recommend anticoagulation for acute main PVT in patients who are (or may be) transplant ...
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...