Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
When do you consider giving IV albumin for severe hypoalbuminemia with third-spacing of fluid outside of standard indications (i.e., large-volume paracentesis, HRS, SBP, shock, etc.)?
On the wards, I do not treat the albumin number. Severe hypoalbuminemia with third spacing, by itself, is not an indication for IV albumin. The consistent signal from the literature is that albumin should not be used simply to raise serum levels or to “pull fluid back in” as an adjunct to diuretics....
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.
In patients entering AUD treatment who also have obesity/diabetes (a MetALD phenotype), how do you modify your thresholds for fibrosis assessment and for initiating AUD pharmacotherapy and metabolic therapy (e.g., GLP-1 receptor agonists) with the explicit goal of reducing future liver and cardiovascular events?
In patients with a MetALD phenotype entering AUD treatment, I do not lower fibrosis assessment thresholds but rather focus on the higher pre-test probability that they may have significant liver fibrosis; I apply standard guideline-based NIT cutoffs while ensuring timely and complete evaluation. I u...
How are you treating MSI-H CRC in a liver transplant recipient on tacrolimus & sirolimus?
This is an important question; however, our experience in the metastatic colorectal cancer (mCRC) setting remains very limited. This patient underwent liver transplantation three years ago and has since developed dMMR/MSI-H metastatic colorectal cancer. The patient is currently receiving tacrolimus ...
How do you decide between anticoagulation or portal vein recanalization in a patient with portal vein thrombosis?
It depends on cirrhotic vs non-cirrhotic. For cirrhotic, best to reference the AASLD 2020 guidance here - Northup et al., PMID 33219529.For non-cirrhotic: important to determine the etiology as well as evaluate for a hypercoagulable state, including checking for JAK2 and CALR.If acute and non-occlus...
How do you evaluate and manage acute alcohol withdrawal when symptom-driven protocols are confounded/unreliable?
Librium 50 TID Librium 50 BID Librium 50 qam and can discharge them unless they’re getting PRN. I don’t do CIWA since it’s so subjective, but just have staff take vitals q4h and if BP systolic above 160 or heart rate above 115 then PRN. The best way to not have breakthrough seizures and avoid drug s...
How do you decide whether to initiate semaglutide for MASH when alcohol intake is near MASLD/MetALD boundary ranges or fluctuates with intermittently positive PEth—specifically, do you require a documented period of reduction/abstinence before treatment, or do you start therapy with a modified monitoring/futility framework?
Typically, my approach is to ensure that alcohol is not contributing to their liver disease before initiating anti-fibrotic therapy. I usually counsel them and monitor their PETH testing serially. Sometimes, cutting out alcohol itself will help reduce their fibrosis level over time and may obviate t...
What antibiotic prophylaxis do you recommend for a cirrhotic patient with an upper GI bleed, if any, in light of the recent meta-analysis published in JAMA Internal Medicine?
This study highlights the lack of high-quality data supporting the recommendation for antibiotic prophylaxis in cirrhosis patients with upper GI bleeding. At my institution, we usually recommend a short course of 3 to 5 days, though some clinicians extend it to 7 days. If there is ongoing bleeding, ...
How does VExUS evaluation differ in a patient with a transjugular intrahepatic portosystemic shunt (TIPS)?
This is a very interesting question, and I don't think I have ever tried to look at VExUS in a patient with a TIPS before! Although, based on what I understand about this study, I would be cautious about relying on the original VExUS algorithm that incorporates hepatic vein, portal vein, and intrare...
In what clinical scenario would you consider the use of budesonide over prednisone as part of the pharmacologic management of autoimmune hepatitis?
Primarily in patients where the side effects of prednisone will or are too difficult to tolerate (diabetics, weight gain, metabolic syndrome, psychiatric disease, etc). I like to try prednisone first because of its ability to elucidate a biochemical response, fairly rapidly, so we know what we are d...