Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
In transplant candidates with MASLD and/or ALD, what changes—if any—do you make to listing readiness criteria and pre-transplant cardiometabolic optimization to improve outcomes?
We treat these patients as any others who are heading into transplant. Much depends on how ill they are; thus, we recommend optimized nutrition and PT or exercise programs in order to avoid sarcopenia and frailty. We spend a lot of time educating patients and their caregivers regarding potential war...
For refractory HE attributed to a large SPSS (≥8 mm) in a patient with MELD 12–16 and prior variceal bleeding, what is your standard peri-procedural and post-embolization plan (portal HTN prophylaxis and surveillance) to minimize worsening ascites or rebleeding while maximizing cognitive benefit?
Closing a clinically significant portosystemic shunt may worsen portal HTN, so it’s reasonable to update an EGD in 1-2 months post intervention to ensure there are no high-risk esophageal varices that would require banding. A non-selective beta blocker can also be considered to mitigate this risk of...
What is your clinical pathway when a transplant candidate reports abstinence but has a positive phosphatidylethanol (PeTH), including how you confirm results and decide on addiction-medicine involvement and listing implications?
We address the discrepancy directly with the patient. If the liver disease is moderate, we decline the patient as a candidate and require enrollment in an AUD treatment plan along with monthly Peth testing in order to eventually list. Medicines to prevent cravings are offered at hospital discharge. ...
If there is limited access to VCTE(FibroScan) and MRI elastography, which is your preferred test for fibrosis assessment?
ELF test
Should a patient who requires definitive treatment for prostate cancer as a pre-transplant requirement be strictly required to complete their course prior to transplant/initiation of immunosuppression?
To help address this complex question, I would like to call your attention to a review of the topic by Al-Adra et al., PMID 32969590. It covers several types of malignancies, including prostate cancer (Table 4). Treating this patient will require close collaboration with the transplant surgeon, urol...
How do you decide when to check a PEth level in patients hospitalized with alcohol-associated disease?
In my practice as a hospitalist and addiction medicine specialist, I use PEth (phosphatidylethanol) as an adjunctive tool to assess alcohol exposure over the preceding 2 to 4 weeks. I most commonly order it when the alcohol use history is unclear, when a patient's clinical presentation is highly sug...
What toxicity threshold would make you stop bepirovirsen while pursuing functional cure in a noncirrhotic patient with chronic HBV on suppressive nucleos(t)ide analogue therapy?
From the paper: "On the basis of a phase 2a randomized controlled trial assessing safety, tolerability, and antiviral activity of bepirovirsen, in which ALT elevations associated with HBsAg reductions were reported for NA-naïve patients, ALT increases were considered AEs of special interest. Class e...
What is your threshold for offering nucleos(t)ide analogue cessation in an HBeAg-negative, non- cirrhotic patient with low EOT qHBsAg (e.g., ~80 IU/mL), and which clinical factors would make you advise against stopping even with reliable follow-up?
I am not a big advocate of stopping nucs under most circumstances except for sAg loss. However, if the patient is really insistent and the sAg level is that low it might be OK, although many experts think <10 would be better. You have to inform the patient of a risk of a flare when stopping, to be s...
If you do not have easy access to shear wave elastography (aka Fibroscan), what do you recommend for non-invasive tests to determine if a MASLD patient has clinically significant portal hypertension and risk-stratify them?
Great question. I do magnetic resonance elastography (MRE), and if not possible, shear wave elastography (SWE). If I have access to only blood-based non-invasive liver disease assessment (NILDA), will then order enhanced liver fibrosis (ELF). However, for clinically significant portal hypertension (...
In routine cirrhosis practice, what are the main practical barriers to embedding evidence-based alcohol use disorder treatment within hepatology care?
The biggest barrier to providing care can be seen when we define the scope of practice and the training of hepatologists.Just like how some of us prescribe GLP1a to F2-F3 patients with MASH or provide lifestyle counseling to people with MASLD, but ultimately we do not provide as comprehensive care a...