Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
In patients with MASLD, would you consider management with off-label metformin, pioglitazone (despite weight gain risk), GLP-1 RA, or simply intensify lifestyle and monitor?
In 2025, we should be assessing if patients are developing F2-F3 fibrosis especially with the use of non-invasive assessments (FIB-4 score, transient elastography, or MRI elastography), and then offering either Semaglutide or Resmetirom for these individuals w/ F2-F3, which are the only FDA approved...
How do you determine whether to limit volume removal during therapeutic paracentesis in a patient without acute or chronic kidney disease?
Large volume paracentesis (LVP) can lead to complications such as post paracentesis circulatory dysfunction. In patients who have ongoing acute renal failure, patients with borderline low blood pressure, or in patients who have a history of hyponatremia, LVP should be limited to 5L.
How do you manage PBC patients who achieve a biochemical response on second-line therapy but show worsening noninvasive markers of portal hypertension or fibrosis over the following year (e.g., rising liver stiffness and falling platelets)?
If a patient is getting worse on second line therapy, I would confirm worsening fibrosis with 2 modalities and then probably stop the second liver therapy.
Given the equivocal findings of NRG GI003, in which patients would you select for liver-directed proton therapy in the management of HCC?
Based on the results presented, there is not an indication to routinely recommend proton-based radiation for HCC. There are ongoing efforts to see if there is a subgroup that benefits from protons.
How do you sequence TIPS and elective umbilical hernia repair in cirrhotic patients with refractory ascites and a reducible hernia to mitigate the early post-TIPS incarceration risk?
Refractory ascites by itself is an indication for TIPS, and even more so if in need of umbilical hernia repair. Resolution of ascites can take 3-4 weeks; however, this is around the time when incarceration can occur due to entrapment of the bowel. Ge et al. looked at the prevalence of this, with abo...
For patients with obesity and high cardiometabolic risk whose VCTE liver stiffness is borderline (about 8–10 kPa), what is your preferred tie-breaker to justify initiating MASH-directed pharmacotherapy: ELF, a second serum fibrosis panel, repeat VCTE after weight stability, or MR-based fibrosis assessment when available?
A GLP1a would offer benefits to this patient, who is obese, at high risk for cardiometabolic diseases (particularly if the risk is cardiovascular or insulin resistance), and has early possible fibrosis caused by MASH, as evidenced by mildly abnormal VCTE measurements. The indication would not be bas...
What factors can lead to falsely elevated fibrosis readings on FibroScan (e.g., consuming sugar before the scan)?
I recommend 3 hours of fasting before performing a FibroScan. Liver stiffness may not be equivalent to fibrosis stages in the following conditions: liver congestion (right-sided heart failure, Fontan-associated liver disease), active liver inflammation (alcohol, active viral or autoimmune hepatitis)...
What minimum baseline assessment do you consider necessary to make fatigue patient-reported outcomes interpretable in PBC studies, given confounding from depression, sleep disorders, thyroid disease, and autonomic dysfunction?
Interesting and challenging question. Normally, I would check TSH annually, do a sleep study, and then use my judgement to see if fatigue was related to PBC. I must admit I do not do the Fatigue Assessment Scale (FAS) test, which gives an assessment of the severity of fatigue but does not link to a ...
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...
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 ...