Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
In young, non-cirrhotic HBV–HDV coinfection with minimal fibrosis on elastography, do you perform lifelong 6-month HCC surveillance based on HDV status alone, or do you modulate surveillance intensity based on fibrosis trajectory and treatment response?
There are two separate issues. The frequency of liver cancer stent with used to initiate. It is not dependent on the risk of cancer. It is related to the doubling times of cancer in the ability to detect cancer when they are small, which is why a six-month interval is always chosen. While the rest ...
How would you manage a patient with HIV, re-infection of hepatitis C that has not yet been treated, chronic hepatitis B infection on BIC/FTC/TAF with undetectable HIV viral load but HBV viral load consistently >100,000 with normal ALT?
Your concern about HBV reactivation during DAA therapy is real and well-documented, as it can occur in up to 24 of HBsAg-positive patients during or after DAA therapy when not on HBV-active therapy. However, the solution per guidelines is concurrent HBV prophylaxis/treatment, not sequential treatmen...
When patients meet criteria for more than one MASH-directed agent class, how do you sequence versus combine therapies in someone with high cardiovascular risk but borderline hepatic severity, and what surrogate-response threshold would make you comfortable escalating to dual therapy?
In a patient with high cardiovascular (CV) risk and only borderline hepatic severity, I generally prioritize a metabolically effective agent first, such as glucagon-like peptide-1 (GLP-1)-based therapy, given the dual CV and hepatic benefit, and reassess liver response before adding liver-directed t...
Do you obtain liver biopsy to confirm the diagnosis of cirrhosis if cirrhotic liver morphology is noted on imaging?
This question touches upon two interesting trends: 1) There is an increasing trend in Radiology to report "cirrhotic liver morphology" in the "Impressions" section. When you then review the Body of the report, often these cases are noted to only have a heterogeneous appearing liver with surface nodu...
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 do you consider the clinical relevance of elevated serum B12 levels as a marker of underlying hepatic disease?
Elevated B12 levels have shown significant relevance and significance to many underlying conditions, particularly a high correlation with underlying liver disease. About 1 in 5 to 1 in 4 B12 levels >1000 pg/ml had a significant correlation. It is a prognosticator, in my opinion, and the literature s...
In contemporary LT evaluation, when do you move away from functional stress testing as the default CAD screen in cirrhosis and instead choose coronary CT angiography or upfront invasive angiography, and which clinical features most reliably drive that choice (limited exercise capacity, chronotropic incompetence, CKD, severe vasodilatory physiology)?
There is no universal answer to this question. While guidelines offer framework definitions, every transplant center faces a unique set of challenges. A center's protocol is ultimately dictated by its specific patient population's risk profile, local waitlist times/transplant availability (high vs. ...
How do you decide when to initiate or restart diuretics in a cirrhotic patient with ascites if they are receiving a therapeutic paracentesis?
This question has two parts, one with a straightforward answer, the other with a much more nuanced answer, if I understand it correctly. Any patient receiving a therapeutic paracentesis should start/restart diuretics afterwards. Per the 2021 AASLD guidelines, one of the statements reads “LVP is the ...
How do you rule out spontaneous bacterial peritonitis in a patient with minimal ascites that is not amenable to paracentesis?
You can’t, unfortunately. You either need to keep looking for a good pocket (move patient to each side, etc.) or use clinical judgement and decide whether or not to treat empirically.
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.