Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
Would you consider making a diagnosis of hepatorenal syndrome-associated acute kidney injury with a one-day diagnostic fluid challenge instead of a two-day challenge to expedite vasoconstrictor therapy if needed?
Depending on the circumstances, of course. If the patient is already significantly fluid overloaded, even one day of fluids may not be necessary. The main issue is renal vasoconstriction, as these patients are never truly total-body fluid depleted. The key question is whether the renal vasoconstrict...
When pulmonary vasodilator therapy lowers PVR to transplant targets but causes systemic hypotension or worsening renal perfusion in decompensated cirrhosis, how do you adjust therapy (dose reduction, agent change, accepting higher PVR) while preserving both hemodynamic eligibility and overall transplant candidacy?
Fortunately, an uncommon problem, but when it does occur, careful dose reduction of the offending agent may help. Also, I would consider going from any offending oral medication to an inhaled prostacyclin to avoid/minimize systemic effects.
What is your approach to perioperative risk stratification and optimization in patients with cirrhosis?
The VOCAL-Penn score is one piece of information that I use for risk stratification in patients with cirrhosis. I usually treat symptomatic decompensated cirrhosis first (hepatic encephalopathy, ascites, hepatic hydrothorax, hepatorenal syndrome, variceal bleeding), because the risk scores usually c...
Would you consider adding a loop diuretic for patients with HRS type 1 who are on a stable dose of vasoconstrictors to enhance diuresis?
As a last resort, I would much rather do therapeutic paracentesis for fluid overload with albumin infusions.
In patients who meet Baveno VII NIT criteria for CSPH and are candidates for NSBB to prevent decompensation, when (if ever) do you still perform screening endoscopy before starting NSBB, and what specific findings would change your management?
I consider screening endoscopy along with NSBB in patients meeting criteria for CSPH who are also Childs B or C, based on favorable results from the CAVARLY TRIAL (Tevethia et al., PMID 39067870) that demonstrated reduced risk of bleeding in this patient subgroup with NSBB and band ligation of high-...
Do you avoid terlipressin for patients with hepatorenal syndrome who have an elevated bilirubin level?
The CONFIRM trial excluded patients with Grade 3 acute on chronic liver failure (due to increased risk of pulmonary complications). There have also been concerns raised that using terlipressin on liver transplant candidates might improve their MELD score enough to jeopardize their spot on the waitin...
How do you counsel patients experiencing symptoms/complications of menopause who desire use of HRT if they have a history of known hepatic adenomas?
There is a strong recommendation to avoid estrogen-containing HRT in these patients. Depending on the severity of the symptoms and if they do not currently have adenomas, we may have a risk-benefit discussion regarding estrogen-based HRT and close imaging monitoring of adenoma development. Certainly...
How do people approach non-HIV patients with hepatitis B, a negative Hepatitis B E antigen, normal LFTs and relatively low HBV DNA between 2000-20000?
Treatment of chronic Hep B is recommended to prevent maternal-fetal transmission, reactivation during chemotherapy, recurrence after liver transplantation, and in patients with decompensated cirrhosis. Treatment has been shown to reverse fibrosis and cirrhosis. Specifically referring to the above sc...
Is the Enhanced Liver Fibrosis (ELF) test superior to the FIB-4 test in the diagnosis of MASLD?
In terms of diagnostic accuracy for advanced fibrosis in MASLD, ELF is superior to FIB-4; however, here are the caveats to consider: FIB-4 is a simple and readily available test that is best used to rule out advanced fibrosis (high negative predictive value), and ELF is best used to rule in advanced...
Can fatty liver disease present with elevations in alkaline phosphatase without other liver enzyme elevations (AST and ALT)?
It is very atypical but can occur. Patients usually have elevations in aminotransferases (usually ALT higher than AST) and there can be very mild concurrent elevations in alkaline phosphatase. An isolated alkaline phosphatase elevation should however prompt a more extensive serological work up as we...