2nd Annual UC San Diego Hepatology Program

Clinical Update for the Comprehensive Management of Cirrhosis, Viral Hepatitis, Liver Cancer and End Stage Liver Disease

September 29–30, 2012UC San Diego Medical Education and Telemedicine (MET) BuildingLa Jolla, California

cme.ucsd.edu/hcc

University of California, San Diego School of Medicine

Continuing Medical Education

2251 San Diego Ave., A-160

San Diego, CA 92110

P: (619) 543-7602 / Toll-Free: (888) 229-6263

F: (619) 543-7610 / E: ocme@ucsd.edu

Visit us at:

facebook.com/ucsdcme

twitter.com/UCSanDiegoCME

SUpportErSWe would like to thank the following companies and organizations for their educational grant support. Their financial support makes this conference possible.

Merck

Salix pharmaceuticals

Bayer Healthcare

Genentech

Gilead Sciences, Inc.

Astellas

ExHIBItorSWe would also like to thank the following companies for exhibiting at this conference.

Avella Specialty pharmacy

Bayer Healthcare

Bristol Myers Squibb

Genentech

Gilead Sciences, Inc.

Merck

Nordion

otsuka America pharmaceutical, Inc.

Salix pharmaceuticals

Vertex

Wako

Course DesCription Chronic liver disease and cirrhosis account for the 11th leading cause of death in the US population and care for these patients places a tremendous burden on the healthcare system. Optimal management of patients with compensated cirrhosis may help to prolong the time that this population may maintain adequate health and functional status to remain in the workforce, improve quality of life, and minimize healthcare expenses. In order to maximize delivery of this care, tertiary care centers with transplant hepatology faculty need to recruit and educate primary care and specialty care providers to optimize management of this population. It is also vital that community providers are able to recognize signs of decompensation in patients with cirrhosis, understand how these events impact prognosis and when to refer these patients to a tertiary care enter. There remains a tremendous gap between the number of patients in need of liver transplantation and number of organs available for transplant. As a result of this, patients must be kept alive for prolonged periods of time following decompensation before they may be transplanted. Thus, in absence of exception points for hepatocellular carcinoma or other less common complications, patients awaiting organ transplant will frequently have one or more hospitalizations with acute on chronic liver failure. Morbidity and mortality are high for this patient population and without comprehensive specialized care, they may not survive for what is often a very narrow window of opportunity to reach liver transplant.

This course will provide a comprehensive update for optimal clinical care of patients with cirrhosis, viral hepatitis, liver cancer and end stage liver disease.

objeCtivesAfter completing this activity, participants should be able to:

1. Recognize the significance of Hepatocellular Carcinoma and importance of early detection

2. Implement routine surveillance for those at high risk to diagnose cirrhosis and liver cancer at an early stage in order to improve patients’ survival and outcome

3. Explore the link between viral hepatitis, cirrhosis and liver cancer, how we can impact the incidence of Hepatocellular Carcinoma by applying new treatment for HBV and HCV

4. Examine current treatment options for cirrhosis and liver cancer including surgical resection, liver transplantation, local ablation, chemoembolization, radioembolization, stereotactic radiation and new agents in clinical trials

target auDienCeThis program is designed for the primary care practitioner, gastroenterologists, oncologists and infectious disease practitioners, including MDs, PAs and NPs.

aCCreDitationThe University of California, San Diego School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

AMA: The University of California, San Diego School of Medicine designates this live activity for a maximum of 11.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Cultural CompetenCyCalifornia Assembly Bill 1195 requires continuing medical education activities with patient care components to include curriculum in the subjects of cultural and linguistic competency. It is the intent of the bill, which went into effect on July 1, 2006, to encourage physicians and surgeons, CME providers in the state of California, and the Accreditation Council for Continuing Medical Education to meet the cultural and linguistic concerns of a diverse patient population through appropriate professional development. The planners, speakers and authors of this CME activity have been encouraged to address issues relevant in their topic area. In addition, a variety of resources are available that address cultural and linguistic competency, some of which are included in your syllabus or handout materials. Additional resources and information about AB1195 can be found on our website at cme.ucsd.edu.

evaluations anD CertifiCatesTo claim your credit and obtain your certificate you will need to complete an online evaluation.

1. For complete instructions visit the evaluation website at cme.ucsd.edu/evaluation.

2. Your access code is HCC2012.

3. Complete the course evaluation.

4. Download your certificate (.pdf format).

The last day to claim credit online is Sunday, October 14, 2012.

For assistance, please contact:

UC San Diego Continuing Medical Education Phone: (619) 543-7602 or (888) 229-6263 E-mail: ocme@ucsd.edu

uC san Diego Course DireCtors

Robert Gish, MD Medical Director, Hepatobiliary Disease and Abdominal Transplantation Chief of Hepatology Professor of Medicine

Heather Patton, MD Assistant Clinical Professor of Medicine Division of Gastroenterology

faCulty

Hamed Aryafar, MD Interventional Radiology Management Options for Portal Hypertensive Complications UC San Diego La Jolla, California

Jasmohan Bajaj, MD Associate Professor of Medicine Virginia Commonwealth University Richmond, Virginia

David Brenner, MD Vice Chancellor, UC San Diego Health Sciences Dean, UC San Diego School of Medicine La Jolla, California

Julia Cain, NP UC San Diego Perlman Oncology Center La Jolla, California

Jorge Silva Enciso, MD Assistant Clinical Professor of Medicine UC San Diego La Jolla, California

Michael Fallon, MD Professor of Medicine Director, Division of Gastroenterology, Hepatology and Nutrition The University of Texas Health Science Center at Houston Medical School Houston, Texas

Syed Abbas Fehmi, MD Assistant Clinical Professor of Medicine UC San Diego La Jolla, California

Patrick Kamath, MD Professor of Medicine Mayo Clinic Scottsdale, Arizona

Yuko Kono, MD, PhD Associate Clinical Professor of Medicine UC San Diego La Jolla, California

Alexander Kuo, MD Associate Clinical Professor of Medicine Medical Director of Liver Transplant Director of Clinical Operations for Hepatology UC San Diego La Jolla, California

Rohit Loomba, MD, MHSc Assistant Professor of Medicine Director of Hepatology Research UC San Diego La Jolla, California

Anthony Martinez, MD Assistant Clinical Professor of Medicine UC San Diego La Jolla, California

Ravindra Mehta, MD Professor of Clinical Medicine Director, CREST and MAS in Clinical Research Programs UC San Diego La Jolla, California

Sanjay Mehta, MD Assistant Clinical Professor of Medicine UC San Diego La Jolla, California

Kristin Mekeel, MD Associate Professor of Surgery UC San Diego La Jolla, California

Michel Mendler, MD Associate Clinical Professor of Medicine UC San Diego San Diego, California

Paul Pockros, MD Head, Division of Gastroenterology and Hepatology Director, Center for Liver Diseases Director, Liver Research Consortium Scripps Clinic La Jolla, California

Cynthia Santillan, MD Associate Clinical Professor of Radiology UC San Diego La Jolla, California

speaker name name of Commercial interest

nature of relevant

relationshipJasmohan Bajaj Salix

Otsuka

Merz

Advisor, Honorarium Recipient, Consultant, Research Support

Research Support

AdvisorRohit Loomba Gilead ConsultantAnthony Martinez Genentech

BMS, Gilead Sciences

Advisory Board Member, Speakers’ Bureau

Grants/Research Support Recipient

Michel Mendler Salix

Gilead

Bayer/Onyx

Speaker, Advisory Board

Speaker

SpeakerPaul Pockros Vertex, Merck, Gilead, BMS,

GenentechAdvisory Board, Research Grants, Speaker’s Bureau

DisClosure summary It is the policy of the University of California, San Diego School of Medicine to ensure balance, independence, objectivity and scientific rigor. All persons involved in the selection, development and presentation of content are required to disclose any real or apparent conflicts of interest. All conflicts of interest will be resolved prior to an educational activity being delivered to learners through one of the following mechanisms 1) altering the financial relationship with the commercial interest, 2) altering the individual’s control over CME content about the products or services of the commercial interest, and/or 3) validating the activity content through independent peer review. All persons are also required to disclose any discussions of off label/unapproved uses of drugs or devices. Participants will be asked to evaluate whether the speaker’s outside interests reflect a possible bias in the planning or presentation of the activity. This information is used to plan future activities.

The following have no relevant financial relationships to disclose:

Hamed AryafarDavid BrennerJulia CainJorge Silva EncisoMichael Fallon

Syed Abbas FehmiRobert Gish Patrick KamathYuko KonoAlexander Kuo

Ravindra MehtaSanjay MehtaKristin MekeelHeather PattonCynthia Santillan

The CME staff, meeting planners and CME committee reviewers other than listed above do not have any relevant financial relationships to disclose.

This educational activity may contain discussion of unlabeled and/or investigational uses of agents that are not approved by the FDA. Please consult the prescribing information for each product.

The views and opinions expressed in this activity are those of the faculty and do not necessarily reflect the views of the University of California, San Diego.

program

SATurdAy, SepTeMber 29, 2012

7:30 AM registration and breakfast

8:00 AM Welcome & Introductions

8:05 AM Acute on Chronic Liver Failure: defining ACLF as a unique Clinical entity, Patrick Kamath, MDThe audience will be introduced to the concept of acute chronic liver failure and, in particular, how this differs from decompensated cirrhosis. The audience will understand the rationale for establishing this entity in the vernacular of the medical community. Finally, the audience will be introduced to the potential clinical implications of this distinct disease entity.

8:50 AM understanding root Cause: pathogenesis of Hepatic Fibrosis and portal Hypertension, David Brenner, MDThe audience will gain a basic understanding of the pathogenesis of hepatic fibrosis as it relates to various etiologies of chronic liver disease, including hepatitis C and NASH. The audience will be able to apply knowledge gained from this presentation in understanding therapeutic options for management of complications of portal hypertension discussed later in the program.

9:10 AM epidemiology of Cirrhosis in the uS, Rohit Loomba, MD, MHScThe audience will gain an understanding of the current burden of cirrhosis in the United States as well as insight into projected disease burden based on prevalence and natural history of chronic liver disease in the US. The impact of treatment rates and treatment efficacy of chronic HCV on projected incidence of cirrhosis in the US will be discussed given the emergence of new, promising antiviral therapies.

9:30 AM panel discussion

9:45 AM break

10:00 AM Viral Hepatitis, Cirrhosis and Liver Cancer: Strategies for prevention and Control, Anthony Martinez, MDThe audience will review pertinent findings from the 2010 Institute of Medicine report. In particular, the lack of awareness among health care providers, at-risk populations, and the public remain a major problem in the US. The IOM proposes that improved surveillance and better integration of viral hepatitis services are needed. The audience will leave with strategies specific to their role in patient care that may help to address this need.

10:20 AM Optimizing diagnostic yield by Informed Selection of Imaging Techniques in patients with Liver disease, Cynthia Santillan, MDThe audience will gain an understanding of the inherent strengths and weaknesses of various imaging modalities in patients with cirrhosis. They will be able to use guidelines provided to optimize diagnostic yield from radiographic studies within their practice.

management of patients with Compensated Cirrhosis

10:40 AM Hepatocellular Carcinoma Screening: Who, How, and How Often? Yuko Kono, MD, PhDThe audience will have an opportunity to review current screening guidelines and understand the context in which these guidelines were created. Relative risk for hepatocellular cancer in different disease states such as viral hepatitis and nonalcoholic fatty liver disease will be reviewed. The audience will learn how to use available data to determine a screening protocol based on the patient characteristics and liver imaging techniques specific to their institution or practice.

11:00 AM Management of Viral Hepatitis in Cirrhosis, Paul Pockros, MDThe audience will understand the rationale for viral eradication in patients with compensated cirrhosis as well as the limitations in reaching this endpoint based on currently available therapies. The audience will also have an opportunity to hear about emergent treatments for chronic hepatitis C and how these may expand the pool of patients eligible for therapy.

11:45 PM Surgery in the patient With Cirrhosis: understanding and Mitigating risk, Kristin Mekeel, MDThe audience will learn various means of estimating risks associated with undergoing surgery for patients with underlying cirrhosis. They will understand how different patient characteristics and type of surgery interact to predict outcomes. Finally, the audience will understand how optimization of patient care before, during, and after surgery may impact patient outcomes.

12:00 PM panel discussion

12:30 PM LuNCHeON ANd SpeCIAL LeCTure: Challenges in Hepatitis b Management: An Interactive Case discussion, Heather Patton, MD and Robert Gish, MD

management of patients with Decompensated Cirrhosis

1:30 PM Hepatic encephalopathy, Jasmohan Bajaj, MDThe audience will understand how both covert and overt hepatic encephalopathy may impact quality of life, healthcare expenditures, and patient outcomes. They will also leave with an understanding of the available tools for assessment of HE severity and optimal medical management.

2:10 PM endoscopic Assessment and Management of portal Hypertensive bleeding, Syed Abbas Fehmi, MDThe audience will understand the risk of portal hypertensive bleeding as it relates to the natural history of cirrhosis. Current evidenced-based guidelines for surveillance and management will be reviewed. The audience will also understand alternative options for difficult to manage cases and guidelines regarding when these cases may be appropriate for referral to a tertiary care center.

2:30 PM Ascites, Hyponatremia and Spontaneous bacterial peritonitis, Michel Mendler, MDThe audience will understand that ascites formation is one of the earliest complications of cirrhosis, how development of ascites impacts survival, and current options for medical management. The audience will gain appreciation for the significance of development of hyponatremia in patients with cirrhosis and ascites, review means of management, and understand how this variable could be incorporated into current organ allocation systems. Finally, the audience will learn the importance of prompt diagnosis and treatment of peritonitis, shifting trends in organisms causing SBP, and identification of patients eligible for prophylaxis against this complication.

2:50 PM panel discussion

3:10 PM break

3:30 PM extrahepatic Manifestation of Cirrhosis, Michael B. Fallon, MDThe audience will review the common extrahepatic manifestations of cirrhosis with special emphasis on the pulmonary complications of advanced liver disease. The audience will gain an understanding of the early indicators of these pulmonary complications specific to patients with cirrhosis and how early recognition and management may impact transplant outcomes.

4:15 PM Interventional radiology Management Options for portal Hypertensive Complications, Hamed Aryafar, MDThe audience will gain an up-to-date review of data for the role and timing of tranajugular intrahepatic portosystemic shunt (TIPS) as well as a review of long-term outcomes and patency with newer coated stents. The audience will also learn about new techniques to assist in placement of TIPS in patients with thrombus or difficult anatomy. Finally, the audience will learn about alternative techniques for management of bleeding gastric varices.

4:35 PM Coagulopathy in Cirrhosis and Associated Vascular Complications, Robert Gish, MDThe audience will gain understanding of the complexity of pro- and anti-coagulation defects that occur in cirrhosis. Based on this complexity, they will also become familiar with techniques for accurately assessing risk for bleeding and thombosis such as the thromboelastogram. Finally, audience will understand the incidence, prevalence, and significance of vascular thromboses in patients with cirrhosis.

5:00 PM panel discussion

5:30 PM Welcome reception

SuNdAy, SepTeMber 30, 2012

7:30 AM breakfast

management of patients with Decompensated Cirrhosis (Continued)

8:00 AM Acute Kidney Injury in Cirrhosis, Ravindra Mehta, MDThe audience will review the most common and serious causes of acute kidney injury in patients with decompensated cirrhosis. They will learn the most common triggers for AKI in this population and how this translates to early recognition and management of this complication. Finally, the audience will understand the current data for optimal medical management as well as the cases in which early institution of renal replacement therapy may be indicated.

8:30 AM Infectious Complications in patients with Cirrhosis, Sanjay Mehta, MDThe audience will understand to recognize the increased propensity to infectious complications in patients with cirrhosis and how infectious may trigger a cascade of events that results in multi-organ failure. The audience will learn the most common and serious infectious complications in cirrhotics and optimal means for early recognition and management.

8:50 AM Cirrhotic Cardiomyopathy, Jorge Silva Enciso, MDThe audience will become familiar with the increasingly recognized entity of cirrhotic cardiomyopathy, current hypotheses regarding its pathogenesis, means of establishing diagnosis, and impact on patient outcomes.

9:10 AM panel discussion

9:30 AM break

9:50 AM bioartificial Liver devices: Where does the Technology Stand in 2012? Heather Patton, MDThe audience will review the type of devices studied to support liver function and results of trials using these devices for specific indications. The audience will gain an understanding of the potential role such support devices may provide in clinical care in the future and latest developments in this technology.

10:10 AM estimation of prognosis and Need for Transplant evaluation, Alexander Kuo, MDThe audience will appreciate the importance of recognizing appropriate timing for transplant referral in achieving optimal patient outcomes. They will also have an understanding of the available techniques to estimate prognosis in this patient population.

acute or Chronic liver failure

10:30 AM palliative Care In Cirrhosis: When and How To Introduce palliative Care in end Stage Liver disease, Julia Cain, NPThe audience will appreciate the important but difficult balance of planning for end of life while awaiting transplant due to the significant shortage of organs available. This will include a discussion of recognizing when patients have become too sick to safely undergo transplant surgery and the difficult task of redirecting goals of care in these circumstances. Finally, the audience will appreciate the complementary roles that hepatology and palliative care specialists can play in care of patients with decompensated cirrhosis.

10:50 AM panel discussion

11:15 AM Final Adjournment

SUpportErSWe would like to thank the following companies and organizations for their educational grant support. Their financial support makes this conference possible.

Merck

Salix pharmaceuticals

Bayer Healthcare

Genentech

Gilead Sciences, Inc.

Astellas

ExHIBItorSWe would also like to thank the following companies for exhibiting at this conference.

Avella Specialty pharmacy

Bayer Healthcare

Bristol Myers Squibb

Genentech

Gilead Sciences, Inc.

Merck

Nordion

otsuka America pharmaceutical, Inc.

Salix pharmaceuticals

Vertex

Wako

2nd Annual UC San Diego Hepatology Program

Clinical Update for the Comprehensive Management of Cirrhosis, Viral Hepatitis, Liver Cancer and End Stage Liver Disease

September 29–30, 2012UC San Diego Medical Education and Telemedicine (MET) BuildingLa Jolla, California

cme.ucsd.edu/hcc

University of California, San Diego School of Medicine

Continuing Medical Education

2251 San Diego Ave., A-160

San Diego, CA 92110

P: (619) 543-7602 / Toll-Free: (888) 229-6263

F: (619) 543-7610 / E: ocme@ucsd.edu

Visit us at:

facebook.com/ucsdcme

twitter.com/UCSanDiegoCME