Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
What are your top takeaways from AASLD 2025?
A lot of interest and research in new steatotic liver disease classifications (MASLD, Met-ALD, and ALD) with interesting abstracts about assessment of alcohol use (PETH, AUDIT-C) and the number of metabolic comorbidities that occur in these classifications. Very robust clinical research workshop, as...
Which patient characteristics increase the diagnostic yield of A1AT level testing in newly diagnosed cirrhosis, and when should phenotyping be performed in addition to measuring levels?
We have issues with getting phenotypes paid for by Medicare and Medicaid, so I often send a level first. If the level is below 80 mg/dL, then I send the phenotype. Also, concern is raised in patients with FH of cirrhosis or emphysema, or the patient does not have other obvious risk factors for cirrh...
In DCD liver offers where NRP or hypothermic oxygenated perfusion is available, what donor/recipient factors are still absolute or near-absolute reasons to decline because of ischemic cholangiopathy risk?
Since the advent and subsequent rapid development of machine perfusion techniques, liver transplant programs are ever-broadening their consideration of previously thought to be "extended" donors. Risks of ischemic cholangiopathy may be linked to the expertise of the program in using machine perfusio...
How would you approach GLP-1/GIP agonist use for MASLD management in a patient who had a prior episode of pancreatitis?
If the etiology of pancreatitis has resolved (i.e., alcohol use and the patient has achieved abstinence or status post cholecystectomy for gallstone pancreatitis), then I may consider a repeat trial of GLP-1/GIP for MASH with fibrosis when there is a need to address the extrahepatic risk factors (ob...
For remote liver transplant recipients back under the care of a community gastroenterologist (or PCP), what should be the approach to new liver enzyme elevations?
Elevated liver enzymes in post-transplant patients who live far from their transplant center are a common challenging issue. Many factors will influence your recommendation to the local physician: height of enzyme elevation, cholestatic, hepatitic, or mixed profile, and associated symptoms (pain, fe...
What factors do you consider when deciding to treat IgA nephropathy with immunosuppression in a patient with cirrhosis, given the possibility that IgA nephropathy could be secondary to cirrhosis?
Proteinuria is the most important factor here. If there is significant proteinuria (>1 g/d) and no other clear reason for it, I would treat the IgA nephropathy with immunosuppression. Secondary IgA due to cirrhosis is usually not associated with significant proteinuria.
How do you balance the need for diuretics from a volume perspective (Ex: ascites, edema) in decompensated cirrhotic patients and progressive renal dysfunction?
There is no discrete answer to this question. Much depends on the overall goal of care. For a transplant candidate, higher creatinine may be needed for transplant access and be tolerated, but risk need for post-transplant RRT. If goals are palliative, symptom control supersedes renal function.
In a patient with low (or normal) BMI but findings of steatosis on imaging, no cardiometabolic comorbidities, and very elevated CAP scores, what are your next diagnostic and therapeutic steps to identify the cause of their steatosis and subsequent management?
In addition to knowing the level of steatosis, liver stiffness values would be of most interest. Alcohol use should stop if there is any level of fibrosis. Lifestyle modifications (dietary/exercise) should be part of recommendations, but with a goal of around 5 % weight loss. If they have F2-3 fibro...
How would you manage a patient with well-controlled HIV on Biktarvy, who is interested in switching to injectable HAART but also has a history of a prior Hepatitis B Infection?
HBV is a common co-infection in people with HIV (PWH), due to shared transmission routes. Two large meta-analyses of studies published found a global a pooled prevalence of HBV infection among PWH to be between 7.6 and 8.4%, with a higher prevalence in less developed countries (10.4%) compared to mo...
What is your strategy to manage the complication of long-term immunosuppression in liver transplant recipients, specifically renal dysfunction and onset of cardiometabolic comorbidities?
Educating patients early on after their transplant is important as to the medical complications associated with CNI use. With regard to renal dysfunction, trying to minimize CNI use as judiciously and as timely as possible is paramount. Switching to an mTOR inhibitor appears best to do early on afte...