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This week, Surfing the NASH Tsunami returns to a subject we have explored from time to time over the past two years: helping patients with cirrhosis. While the immediate stimulus for doing so was the semaglutide late-breaker at #ILC2022, our more general interest is that many patients with cirrhosis will start to decompensate and decline in a fairly short period of time. This conversation focuses on a specific question: where is the next breakthrough in cirrhosis patient management likely to come?

This conversation starts with Roger reflecting on a comment Lars had made during a previous appearance on the podcast, that we should spend more time focusing on what should be happening in the liver instead of what shouldn't. Lars notes one reason for this: when we look at other organ systems (heart or kidney, for example), we focus on how the organ functions. With the liver, we read static biopsies that do not measure actual function. He goes on to note that researchers are developing functional tests, many of which require labeled compounds and then record how they move through the body. 

At this point, Roger shifts the discussion by asking the panel where members anticipate the next major breakthrough in improving cirrhosis diagnosis and treatment. Louise responds first by noting the need to pick up patients earlier in the course of the disease as they move through the healthcare system. She envisions that this may come by adding. FIB-4 to every patient coming through the system or perhaps to something like the iLFT that John Dillon described at the Barcelona meeting. Even there, she notes, the system picks up only 50% of diseased patients. Jörn describes the need to improve diagnostic performance, both in terms of better tests and better ability to deliver both testing and results to patients. Lars questions whether the answer lies in providing imaging tests for every patient. Instead, he suggests, we need to link imaging results more closely to liquid biomarkers and then drive universal, early use of these less expensive liquid tests. As the conversation ends, Louise agrees with this point but notes again that we are assuming a level of patient communication and provider follow-through that does not exist today.