Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
How does HBV/HDV coinfection after liver transplant change your functional cure targets (HBsAg loss/anti-HBs) and your tolerance for residual HBV activity markers (e.g., HBcrAg or pgRNA) compared with HBV monoinfection?
HBV/HDV infection after transplant is no different from pre-transplant. Functional cure is still the goal for HBV, although HBsAg clearance may not clear the Delta virus. There is, however, a treatment for Delta now approved in the US. Core antigen and pgRNA are not available commercially and do not...
In compensated MASH cirrhosis with frailty/sarcopenia, how do you use GLP-1 receptor agonists safely—what lean-mass or functional monitoring strategy (and stopping/adjustment thresholds) do you use to prevent harmful weight-loss–associated muscle loss while pursuing cardiometabolic benefit?
In compensated MASH cirrhosis with frailty or sarcopenia, I use GLP-1 receptor agonists cautiously (and for non-MASH indications) and pair them with structured resistance exercise 2 days a week, adequate protein intake (1.2-1.5 g/kg/day), and baseline functional assessment rather than focusing on we...
How do you counsel and manage patients with ‘lean MASLD’ (normal/near-normal BMI with visceral adiposity and T2D) when using carbohydrate restriction?
Some weight loss (especially if visceral adipose or insulin resistance) and a focus on both cardiovascular and resistance exercises can help defat. Make sure there are no LAL, adrenal, or other lipid metabolism issues that require different treatment.
How does transplant listing status and anticipated time-to-transplant influence your sequencing of TIPS versus elective hernia repair in candidates with refractory ascites and a symptomatic umbilical hernia?
The question is a bit unclear - what do you mean by TIPS versus elective hernia repair?A TIPS may hasten incarceration of an umbilical hernia, so TIPS should really only be considered in the context of planned elective hernia repair.Modeling data from Mahmud et al., PMID 36098965, suggest that when ...
In a patient with Zieve's Syndrome and alcohol related cirrhosis which antibiotic regimen is safe to treat H. pylori?
I am not concerned about a cirrhotic patient receiving a fluoroquinolone, macrolide, metronidazole, or doxycycline. The drug insert labels do not raise any particular concerns for these drugs’ use, even in Child Pugh class C cirrhosis. Yes, there is a theoretical potential for overdosing patients on...
How do you consider sending fungal studies in a patient with pneumonia?
This is a very good question. One that I’ve meant to look up for a while, so thank you for prompting me to do so. I agree with Dr. @Dr. First Last's answer (he is also my division chief!), but wanted to expand further. The articles I found most helpful are cited below.When to suspect a fungal pneumo...
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