Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
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...
In a patient with low (or normal) BMI but findings of steatosis on imaging, no cardiometabolic comorbidities, and very elevated CAP scores, what are your next diagnostic and therapeutic steps to identify the cause of their steatosis and subsequent management?
In addition to knowing the level of steatosis, liver stiffness values would be of most interest. Alcohol use should stop if there is any level of fibrosis. Lifestyle modifications (dietary/exercise) should be part of recommendations, but with a goal of around 5 % weight loss. If they have F2-3 fibro...
In hospitalized patients treated for presumed overt hepatic encephalopathy who show no meaningful improvement after 48–72 hours of adequate therapy and precipitant management, what is your highest- yield next diagnostic step and what clinical features drive that prioritization?
At this point in the clinical care pathway, I would repeat an infectious workup (blood, urine, diagnostic paracentesis; occult infections are common in our cirrhotic patients) and perform a high-quality multiphasic cross-sectional imaging test to rule out hepatocellular carcinoma (HCC), portal vein ...
With the growth of non-alcoholic beverages (e.g., NA beer, liquor, etc), how do you approach a patient's consumption of these products in the setting of alcohol related liver disease?
This is definitely a challenging conundrum to deal with. Historically, even the NA beverages would have 0.5% alcohol, so they weren't truly NA. With time, that has seemingly changed. Regardless, my approach is the same. I strongly advise against the idea that NA beverages are allowed. Mostly because...
How do you decide which patients should pursue add-on bepirovirsen rather than continue indefinite nucleos(t)ide analogue monotherapy for noncirrhotic chronic HBV?
HBsAg quantitation to determine if they meet criteria Frank discussion that only 1 in 5 patients succeed and that the 6-month weekly injections do have a relatively high rate of significant adverse hematological and renal complications requiring close laboratory monitoring. So far, most patients h...