The fourth edition of The Liver Meeting® Academic Debates on Friday afternoon continued the spirited tradition of education, competition and entertainment between four teams of fellows.
Each team presented its side and offered a rebuttal. A panel of judges and the audience peppered the debaters with questions. At the end, the audience voted for which team in each debate presented the best argument based on argument construction, slide quality, topic mastery, presentation and skill in responding to questions.
During “Liver Transplantation for Elderly Patients,” teams from Yale University and the University of Colorado debated whether a 73-year-old woman with decompensated cirrhosis from primary biliary cholangitis complicated by non-bleeding esophageal varices on a band-ligation program, ascites on moderate diuretic doses and recurrent overt hepatic encephalopathy in remission on lactulose/rifaximin should be placed on the transplant list. She’s had type 2 diabetes for 10 years, a MELD-Na of 20, is ambulatory and has a six-minute walk of 350 meters.
The Yale team of Lamia Haque, MD, MPH, and Chiara Saroli Palumbo, MD, argued that this patient should be offered a transplant because she is an excellent candidate based on the standard thorough evaluation. The key is to rely on the physiological, not chronological, age to provide the most evidence-based care, as stated in AASLD guidelines. Frailty matters more than age, and the case patient is not frail.
“Our population with liver disease is aging, “ Dr. Palumbo said. “The only question is how will we as a transplant community respond to this changing demographic. Will we continue to strive to offer the best care for our patients and adapt to the evolving challenges they present or choose to rely on outdated historical models and deny people the care they need?”
The University of Colorado team of Avash Kalra, MD, and Prashanth Francis, MD, argued that because of the scarcity of donor organs and the fact that age is a risk factor for worse outcomes, the case patient who has so many co-morbidities is not a suitable transplant candidate. The Colorado team noted that USPSTF screening guidelines recommend that for this patient, cervical cancer screening was recommended to stop eight years earlier, with breast and colon cancer screening recommended to end within the next two years.
“So the question is how can we put a woman with this many co-morbidities through the biggest surgery of her life, then commit her to chronic, lifelong immunosuppression when we wouldn’t even offer her routine medical care?” Dr. Francis said.
By a margin of two votes, the audience voted for the Yale team’s presentation.
The opening debate featured an all-Pennsylvania affair with fellows from the University of Pittsburg Medical Center (UPMC) going against the Albert Einstein Medical Center in Philadelphia on the subject of “Biopsy vs. Noninvasive Assessment of NASH.” The debate was framed around a case of a 50-year-old diabetic, obese and hypertensive man on metformin and statin therapy who presents for evaluation of abnormal liver tests. He had no additional work-up after being told 10 years ago he had a “fatty liver.” The patients reports rare alcohol use but has been unsuccessful with weight loss.
The Einstein Medical Center team of Deepanshu Jain, MD, and Rohit Nathan, DO, supported noninvasive assessment. The team cited the significantly higher cost of the procedure when compared with MR-elastography (MRE) and other noninvasive methods. Drs. Jain and Nathan promoted the performance of serum-based testing and vibration-controlled transient elastography (VCTE) as a simple, safe and cost-effective alternative to biopsy that allows for sharing of information with the patient during the visit.
“ERCP used to be the gold standard test to diagnose biliary lesions, but our colleagues in gastroenterology have moved on to less invasive MRCP and ultrasound,” Dr. Nathan said. “We as hepatologists should move forward with the changing paradigm. Maybe liver biopsy should be called the silver standard or the bronze standard.”
The UMPC team of Matthew Klinge, MD, and Akshata Moghe, MBBS, PhD, argued in favor of biopsy. UMPC argued that based on clinical guidelines, NASH is a biopsy-proven diagnosis, so any NASH treatment requires a biopsy. Also, noninvasive procedures such as MRE are operator-dependent, giving an estimate of stiffness, not fibrosis. The team also argued against the general perception that biopsies are dangerous procedures.
“There are complications just like any invasive procedure,” Dr. Klinge said. “Severe bleeding requiring intervention occurs in one out of every 2,500 procedures. To put that in a frame of reference with a procedure we’re much more comfortable with, we recommend screening colonoscopies for every person over the age of 50, and severe bleeding there occurs in one of every 600 to 1,250 procedures.”
The audience vote gave the edge to Einstein Medical Center team.