Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
In suspected portopulmonary hypertension with high cardiac output where mPAP is elevated but PVR is acceptable, do you base liver transplant candidacy primarily on PVR (and RV function) rather than mPAP, and how do you operationalize that in your listing decisions?
The short answer is yes. The key parameters of PVR and right heart function by transthoracic echo (mainly RV free wall strain, Fractional area change, and TAPSE in combination) are discussed by pulmonary and anesthesia colleagues at our selection conference. Specifically, we follow the current Inter...
How has the move away from a strict 6 month period of sobriety impacted your patient selection criteria for transplant of patients with alcohol associated liver disease?
The "sixth-month rule" was applied by many transplant programs years ago as a method of minimizing recidivism post-liver transplant. The evidence that this approach improves outcomes is sparse, and most programs have moved toward applying other criteria toward transplant decisions for these patients...
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...
For how long would you treat a patient with latent TB before allowing them to proceed with a liver transplant?
There are a few ways to look at the answer to this question. If the individual is stable enough to complete the Latent TB Infection (LTBI) therapy without need for a liver transplant, then treat the LTBI to completion. If the individual may need the transplant during the treatment course, then start...
How do you use objective sarcopenia/frailty measures during liver transplant evaluation to decide between expedited listing versus a defined period of prehabilitation before listing?
At our center, we screen everyone with the liver frailty index (LFI). In those found to have frailty, we refer them to a prehabilitation clinic where, apart from providing physical literacy, personalized exercise and dietary prescriptions, we monitor LFI, 6MWT, and phase angle at every visit. This a...
What is your approach to the use of GLP-1 agonists in older adults with diabetes with or at risk of sarcopenia?
This is an important question to keep an eye on, given the broadening use and effectiveness of GLP-1 agonists for various conditions, especially diabetes, and for weight loss. Unfortunately, as is so often the case, major clinical trials in this area do not reflect the heterogeneity of older adults ...
How do you approach HCC screening in patients with advanced fibrosis e.g., F3 on FibroScan?
We should first understand the underlying principles that defined the various cut-offs that resulted in this recommendation (eg, cost-effectiveness threshold for HCC screening, cut-offs for advanced fibrosis) and then go from there. Among patients with cirrhosis, the cost-effectiveness threshold wa...
How would you treat a patient with alcoholic cirrhosis and IgA nephropathy with high risk features including nephrotic range proteinuria, microscopic hematuria, and declining eGFR?
Cirrhosis is a well-known cause of secondary IgA nephropathy. Impaired removal of IgA-containing complexes by the Kupffer cells in the liver is thought to predispose to IgA deposition in the kidney (Amore et al., PMID 8302021). As in primary IgAN, polymeric IgA1 appears to be the dominant IgA isofor...
Do you avoid peritoneal dialysis in cirrhotic patients with ascites?
There are two major concerns regarding the performance of PD in patients with ascites: the potential for fluid leakage at the site of the newly placed catheter and the perceived increased potential for peritonitis. In my experience, neither of these is a compelling reason to shy away from PD in a pa...
In current practice after DCD transplantation, what early clinical or laboratory signals push you to escalate beyond MRCP-first toward earlier ERCP or targeted hepatic arterial assessment for suspected ischemic cholangiopathy?
Persistently unexplained cholestasis.