Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
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...
How does HBV/HDV coinfection after liver transplant change your functional cure targets (HBsAg loss/anti-HBs) and your tolerance for residual HBV activity markers (e.g., HBcrAg or pgRNA) compared with HBV monoinfection?
HBV/HDV infection after transplant is no different from pre-transplant. Functional cure is still the goal for HBV, although HBsAg clearance may not clear the Delta virus. There is, however, a treatment for Delta now approved in the US. Core antigen and pgRNA are not available commercially and do not...
In compensated MASH cirrhosis with frailty/sarcopenia, how do you use GLP-1 receptor agonists safely—what lean-mass or functional monitoring strategy (and stopping/adjustment thresholds) do you use to prevent harmful weight-loss–associated muscle loss while pursuing cardiometabolic benefit?
In compensated MASH cirrhosis with frailty or sarcopenia, I use GLP-1 receptor agonists cautiously (and for non-MASH indications) and pair them with structured resistance exercise 2 days a week, adequate protein intake (1.2-1.5 g/kg/day), and baseline functional assessment rather than focusing on we...
How do you counsel and manage patients with ‘lean MASLD’ (normal/near-normal BMI with visceral adiposity and T2D) when using carbohydrate restriction?
Some weight loss (especially if visceral adipose or insulin resistance) and a focus on both cardiovascular and resistance exercises can help defat. Make sure there are no LAL, adrenal, or other lipid metabolism issues that require different treatment.
How does transplant listing status and anticipated time-to-transplant influence your sequencing of TIPS versus elective hernia repair in candidates with refractory ascites and a symptomatic umbilical hernia?
The question is a bit unclear - what do you mean by TIPS versus elective hernia repair?A TIPS may hasten incarceration of an umbilical hernia, so TIPS should really only be considered in the context of planned elective hernia repair.Modeling data from Mahmud et al., PMID 36098965, suggest that when ...
What is your approach to the use of GLP-1 agonists in older adults with diabetes with or at risk of sarcopenia?
This is an important question to keep an eye on, given the broadening use and effectiveness of GLP-1 agonists for various conditions, especially diabetes, and for weight loss. Unfortunately, as is so often the case, major clinical trials in this area do not reflect the heterogeneity of older adults ...
In a patient with Zieve's Syndrome and alcohol related cirrhosis which antibiotic regimen is safe to treat H. pylori?
I am not concerned about a cirrhotic patient receiving a fluoroquinolone, macrolide, metronidazole, or doxycycline. The drug insert labels do not raise any particular concerns for these drugs’ use, even in Child Pugh class C cirrhosis. Yes, there is a theoretical potential for overdosing patients on...
How do you consider sending fungal studies in a patient with pneumonia?
This is a very good question. One that I’ve meant to look up for a while, so thank you for prompting me to do so. I agree with Dr. @Dr. First Last's answer (he is also my division chief!), but wanted to expand further. The articles I found most helpful are cited below.When to suspect a fungal pneumo...
Do you avoid peritoneal dialysis in cirrhotic patients with ascites?
There are two major concerns regarding the performance of PD in patients with ascites: the potential for fluid leakage at the site of the newly placed catheter and the perceived increased potential for peritonitis. In my experience, neither of these is a compelling reason to shy away from PD in a pa...
In cirrhosis with suspected HRS-AKI and baseline CKD or chronically elevated creatinine, how do you define a clinically meaningful ‘improvement’ during an albumin trial (over 24–48 hours) to distinguish HRS-AKI from volume-responsive AKI?
If the acute rise in serum creatinine returns to the pre-AKI level, the patient has volume-responsive AKI.