Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
How do you use objective frailty or sarcopenia measures to trigger transplant referral in patients with low MELD?
Frailty and sarcopenia in patients with end-stage liver disease increase pretransplant waitlist mortality and risks of extended stay and complications post-transplant. We all know that a low MELD may be influenced by several factors, and by including creatinine in its formula, sarcopenia may spuriou...
What factors make you recommend complete abstinence versus a harm-reduction target when counseling on alcohol use in patients with steatosis and ongoing moderate drinking?
I think a healthy adult can drink 1-2 drinks, once or twice a week at low risk. The issues of greater risk arise when even this level of consumption occurs in the setting of other factors (operating machinery), clinical states (pregnancy), or comorbidities (increased BMI, DM, concurrent chronic live...
How do you sequence TAVR versus liver transplant listing in candidates with severe aortic stenosis and decompensated cirrhosis when MELD is rising—what clinical features most strongly favor accelerating TAVR versus deferring valve intervention?
The response to this is not straightforward, as the decision depends on the severity of AS and the patient's severity of liver disease and transplant candidacy. The decision involves Cardiology and the liver team. In severe AS, TAVR may be indicated with no other viable option. Intervention risk, fr...
How do you evaluate and manage acute alcohol withdrawal when symptom-driven protocols are confounded/unreliable?
I developed a structured, objective approach centered on PAWSS risk stratification and standardized mMINDS plus RASS monitoring rather than relying solely on symptom-driven tools like CIWA. At intake, patients with suspected alcohol use disorder undergo PAWSS assessment, baseline mMINDS scoring, RAS...
What is your approach to initiating naltrexone in patients with alcohol use disorder and co-occurring liver disease?
In patients with AUD and co-occurring liver disease, I think the hepatotoxicity concerns around naltrexone have historically been overstated relative to both the actual evidence and the hepatic risk of ongoing alcohol exposure itself. The original 1980s data that triggered the FDA hepatotoxicity war...
Do you rely on HbA1c to monitor glycemic control in a patient with diabetes and compensated cirrhosis, given that advanced liver disease can systematically lower HbA1c independent of actual glucose control?
A1C is a great test, but it has many limitations. One major one is that it depends on red cell circulation time being normal for interpretation using common standards for average glucose values. Cirrhosis will potentially shorten red cell lifespan depending on associated complications and severity. ...
In patients with MASLD and F2–F3 fibrosis, would you initiate Resmetirom even if they are not making active lifestyle changes?
Yes, many patients had an underlying metabolic disorder that is difficult/impossible to address with lifestyle interventions alone and will go on to progress in their liver disease if left alone. Now with the approval of Semaglutide in August 2025 by the FDA and the approval of Resmetirom, we have t...
In patients who develop severe precapillary PH within 6–12 weeks after LT, which potentially reversible post-transplant contributors do you prioritize ruling out before escalating PAH therapy because they are most actionable and most plausibly causal in your experience?
The development of pre-capillary pulmonary artery hypertension post-liver transplant in the timeframe mentioned can be extremely serious. Obviously, the most life-threatening concern to rule out is acute pulmonary embolism, which could cause fairly dramatic hemodynamic changes and right heart dysfun...
How do you manage anticoagulation/antiplatelet therapies with strong indications for uninterrupted therapy in the setting of urgent procedures?
If anticoagulation is absolutely contraindicated because of the bleeding risk of the procedure, then "bridging" will usually make the most sense, most of the time, with low molecular weight heparin such as enoxaparin. If dual antiplatelet agents are contraindicated, particularly in the first month a...
In settings where alcohol use is commonly underreported, what is your preferred practical approach to reduce MASLD vs ALD misclassification in routine hepatology or primary care (structured AUD screening, targeted alcohol biomarkers such as PEth/EtG, or a combined attribution algorithm), and how do you operationalize it without undermining patient engagement?
My practical approach is a combined strategy: routine use of a structured alcohol assessment (AUDIT-C) alongside metabolic risk profiling, with targeted use of objective biomarkers such as PEth when the reported alcohol history is uncertain or discordant with the clinical picture. I frame these asse...