Who should see these patients? Endocrinology? Cardiology?
Who is left to see liver failure, decomp cirrhosis?

People quote guidelines like they are gospel. In the end guidelibes are just opinions from those who have reviewed literature. There is no guarantee that the authors have actual clinical experience.

Paid services like UpToDate are guilty of this as well.

I was taught to swim away from a sinking ship as you might get sucked down along with the ship. Trick for us is not to get sucked down.

Saturday’s Toronto Star (Canada)

Do the Americans still have a constitution in anything but name? I thought the Supreme Court gave that away.

It is still too high. Please adjust Y axis to zero

Cirrhosis is not a one way street of progression.
Many may have not seen this because it was not published in a clinical journal but this work from Ian Wanless has profound implications for Hepatology.
meridian.allenpress.com/aplm/article...

The registry needs to have a purpose. However, it can be used to push boundaries.
Examples:
1. Refractory ascites. Max age?
2. PreOp registry
3. Variceal bleed. When is too sick just too sick?
I know we have pushed well past the age criteria of 65 and so far so good.

This is code for
1. Give fluids
2. Give enough
3. Don't give too much
4. Reassess frequently, more frequently the sicker they are

Something to bear in mind, that the successful studies we see published reflect not just the science but also the skill to do the non-science dance, whether that be writing grants or writing papers or networking to publicize the work. Those with good ideas but who are not as skilled are silenced.

The key may be in the selection. There are so many variables (types of surgery, types of decompensation) that it is impossible to address from a prospective study at this point in time. It may be worthwhile to have a registry to help glean what is futile versus what is possible.

Without recurrent or refractory ascites.

Thank you for that caveat!!

Due to referral bias I am seeing a lot of worsening ascites on carvedilol.

You mean vaccine discovery for Covid
And HBV!

But the current lesson is:
Vaccines only work if you use them. Measles comes to mind.

There is an emerging contrast between Asia and Africa for chronic HBV in young people

That part is true. I have seen guys in their 20s start crying when told they needed long term treatment with Tenofovir when I worked in Ethiopia.
Need more effort with birth vaccination for Africa as it seems to be working in Asia.

In the early 2000s Jenny Heathcote did a quality of life study comparing 3 groups. Turns out Hep C was least happy, followed by liver clinic staff. Hep B was the happiest.
Hep B does not have to be catastrophic and full of stigma. People can and do live with hep B.