Nancy Reau, MD, is Professor of Internal Medicine, Richard B. Capps Chair of Hepatology, Associate Director of Solid Organ Transplantation, and Section Chief of Hepatology at Rush University Medical Center.

Nancy Reau, MD

Liver Lineup: Navigating Hepatitis B Prevention After ACIP’s Birth Dose Shift

Liver Lineup: Updates & Unfiltered Insights

, hosts Nancy Reau, MD, and Kim Brown, MD, take on a recent consequential and controversial public health decision: the US Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices’ (ACIP) vote to remove the universal birth-dose hepatitis B vaccine recommendation for infants born to mothers who test negative for HBV.

The conversation centers around the December 5, 2025, ACIP recommendation, which shifts the long-standing universal birth dose to an individual-based decision when maternal testing is documented as negative. While newborns of mothers with positive or unknown HBV status should still receive the vaccine within 24 hours of birth, the committee’s vote effectively eliminates universal coverage for the broader infant population.

As transplant physicians who routinely manage the downstream consequences of chronic hepatitis B, Reau and Brown say this update is a reversal of decades of data and public health success. Reau begins by reflecting on the dramatic decline in HBV prevalence and chronic infection rates following the introduction of the universal birth dose in the 1990s. The vaccine, she notes, has functioned as one of the earliest and most effective “anti-cancer vaccines,” cutting the risk of hepatocellular carcinoma in populations around the world.

Brown adds a clinical lens drawn from transplantation, recounting the striking shift over her career: before widespread HBV vaccination, chronic HBV infection was a leading indication for liver transplantation. Today, thanks to vaccination and effective antiviral therapy, HBV-related transplants are rare and largely driven by hepatocellular carcinoma, not liver failure itself. For her, the new ACIP decision raises concern about reintroducing preventable infections into the population.

A key theme throughout the discussion is the danger of relying on perfect systems. While ACIP’s updated guidance assumes universal maternal screening and accurate documentation, Reau explains that real-world data do not align. In practice, HBV screening during pregnancy is inconsistently captured, results are not always transferred across systems, and as many as 1 in 5 pregnant individuals may have no documented HBV test. This creates a major vulnerability if the universal birth dose is no longer routine.

Reau and Brown also highlight the unique epidemiology of HBV: early-life exposure, not adult behavioral risk, is the primary driver of chronic infection. Household transmission, caregiver exposure, and contact with unscreened adults remain key pathways, even when maternal status is known. Delaying vaccination until 2 months of age offers no protection during this highest-risk window.

Brown underscores the lifelong consequences of early HBV acquisition. Even in the era of effective antivirals, chronic HBV infection remains a major cause of hepatocellular carcinoma and carries the risk of reactivation during immunosuppression. For these reasons, both hepatologists view prevention, not treatment, as the cornerstone of HBV control.

Despite ACIP’s intent to give parents and clinicians more individualized decision-making power, both experts worry about widening disparities in vaccine uptake, eroding decades of progress, and placing infants, especially those in under-resourced settings, at avoidable risk.

The episode closes with a call for continued education and advocacy. Reau and Brown encourage clinicians to remain clear-eyed about the evidence, discuss the implications of delayed vaccination with families, and work to uphold the public health gains that universal hepatitis B immunization has delivered for over 30 years.

Editors’ note: Relevant Disclosures for Reau include AbbVie, Gilead, Salix, Arbutus, and VIR. Relevant disclosures for Brown include Mallinckrodt Pharmaceuticals, Gilead, Salix, Intercept, Ipsen, and Madrigal.

Brooks A. CDC Changes Infant Hepatitis B Vaccine Recommendation. HCPLive. December 5, 2025. Accessed December 10, 2025. 

https://www.hcplive.com/view/cdc-changes-infant-hepatitis-b-vaccine-recommendation

CDC. Achievements in Public Health: Hepatitis B Vaccination --- United States, 1982--2002. 

https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5125a3.htm

Podcasts

Reau and Brown discuss the recent CDC APIC decision to remove the universal birth-dose hepatitis B vaccine for infants born to mothers who test negative for HBV.

Liver Lineup: Unmet Needs and Evolving Standards in Alcohol-Associated Liver Disease, With Jessica Mellinger, MD

Liver Lineup: Updates and Unfiltered Insights

, hosts Nancy Reau, MD, and Kimberly Brown, MD, are joined by guest Jessica Mellinger, MD, to discuss rising prevalence, new care models, and evolving concepts in alcohol-associated liver disease (ALD).

Mellinger begins by addressing the troubling rise in alcohol use and ALD. Despite widespread healthcare engagement, she says patients with ALD are often diagnosed late, underscoring the need for proactive screening approaches that combine assessments of both liver health and alcohol use. She also notes that defined screening models and pathways developed for MASLD could be adapted for ALD to improve early identification and intervention.

A key part of the discussion centers on Mellinger’s pioneering integrated clinic model, which brings hepatology and addiction psychiatry together in a single, co-located setting. She explains that addressing liver health and alcohol use disorder alongside underlying drivers such as anxiety, depression, insomnia, and chronic pain is critical—and that siloed systems of care have historically failed these patients.

The conversation also explores the emergence of MetALD and the overlap between metabolic and alcohol-associated liver disease. Mellinger notes that while definitions continue to evolve, understanding the interplay between metabolic dysfunction and alcohol use will be essential for tailoring therapies. GLP-1 receptor agonists, already transforming the metabolic liver disease landscape with the recent FDA approval of semaglutide for MASH, are showing early promise for ALD as well, with some patients reporting reduced alcohol cravings and improved liver parameters.

Turning to transplantation, Mellinger reflects on the progress since the Dallas Criteria were introduced, highlighting shifting attitudes toward early liver transplant in carefully selected patients. She stresses the importance of moving beyond rigid sobriety thresholds toward a more patient-centered approach focused on post-transplant support and relapse management.

The trio emphasizes that progress in alcohol-associated liver disease depends on bridging the long-standing divide between hepatology and addiction medicine. With integrated care models gaining traction, evolving definitions like MetALD reshaping clinical thinking, and novel therapeutics such as GLP-1 receptor agonists offering new hope, the field may be entering a pivotal era.

Editors’ Note: Editors’ note: Relevant disclosures for 

 include AbbVie, Gilead, Salix, Arbutus, and VIR. Relevant disclosures for 

 include Mallinckrodt Pharmaceuticals, Gilead, Salix, Intercept, Ipsen, and Madrigal. Relevant disclosures for 

Brooks A. FDA Approves Semaglutide (Wegovy) Injection 2.4 mg for Noncirrhotic MASH. HCPLive. August 15, 2025. Accessed October 14, 2025. 

https://www.hcplive.com/view/fda-approves-semaglutide-wegovy-injection-2-4-mg-for-noncirrhotic-mash

Asrani SK, Trotter J, Lake J, et al. Meeting Report: The Dallas Consensus Conference on Liver Transplantation for Alcohol Associated Hepatitis. Liver Transpl. 2020;26(1):127-140. 

Mellinger joins Liver Lineup to discuss current shortcomings in ALD diagnosis and care, the importance of addressing underlying alcohol use disorder, and more.

Liver Lineup: Innovations in Cholestatic Disease Management, With Kris Kowdley, MD

, Nancy Reau, MD, sits down with Kris Kowdley, MD, to discuss evolving approaches in cholestatic liver disease, with a particular focus on 

The conversation begins with how treatment goals have shifted from partial biochemical response to striving for full normalization of alkaline phosphatase and bilirubin, changes supported by recent global data showing improved long-term outcomes when patients achieve complete biochemical remission.

Kowdley highlights how these evolving targets are shaping clinical practice and guideline development, including the growing push to evaluate UDCA response at 6 months rather than 1 year, potentially expediting decisions about second-line therapy. The discussion also underscores the importance of incorporating staging tools such as transient elastography, which has shown promise as a biomarker and surrogate endpoint for predicting clinical outcomes in PBC.

The duo highlights the recent voluntary withdrawal of obeticholic acid from the US market as another major inflection point for clinicians, raising questions about how to manage patients who had been stable on the therapy. Kowdley reviews available alternatives, including fibrates and recently approved peroxisome proliferator-activated receptor (PPAR) agonists elafibranor and seladelpar, and addresses practical considerations when transitioning patients to new regimens. Importantly, he notes the potential of combination or even triple therapy strategies to help more patients achieve complete biochemical response.

Beyond laboratory targets, the conversation emphasizes patient-centered outcomes such as fatigue and pruritus, symptoms that often have a profound impact on quality of life but have historically lacked effective treatment. The emerging role of ileal bile acid transporter (IBAT) inhibitors represents an encouraging step forward, offering rapid relief of pruritus in PBC and other cholestatic diseases, with clinical trials underway to expand their use.

The pair also discuss diagnosis, particularly in challenging AMA-negative cases. Kowdley shares insights on when to use biopsy, how transient elastography fits into the workup, and the emerging role of genetic testing for patients with atypical presentations or suspected hereditary cholestatic syndromes.

The episode closes with reminders about comprehensive management, including monitoring bone health and tailoring therapy to the individual patient’s disease stage, biochemical profile, and quality-of-life concerns.

 has relevant disclosures with AbbVie, Gilead, Salix, Arbutus, and VIR. 

has relevant disclosures with CymaBay, Genfit, Gilead, Intercept, Ipsen, Madrigal, Mirum, Pfizer, NovoNordisk, 89Bio, AbbVie, and others.

Brooks A. Intercept Voluntarily Withdraws Obeticholic Acid (Ocaliva) for PBC From US Market. HCPLive. September 11, 2025. Accessed September 18, 2025. 

https://www.hcplive.com/view/intercept-voluntarily-withdrawals-obeticholic-acid-ocaliva-for-pbc-from-us-market

Brooks, A. FDA Grants Accelerated Approval to Elafibranor (Iqirvo) for PBC. HCPLive. June 10, 2024. Accessed September 18, 2025. 

https://www.hcplive.com/view/fda-grants-accelerated-approval-to-elafibranor-iqirvo-for-pbc

Brooks, A. FDA Grants Accelerated Approval to Seladelpar (Livdelzi) for Primary Biliary Cholangitis. HCPLive. August 14, 2024. Accessed September 18, 2025. 

https://www.hcplive.com/view/fda-grants-accelerated-approval-to-seladelpar-livdelzi-for-primary-biliary-cholangitis

Kowdley joins Liver Lineup to discuss evolving approaches in cholestatic liver disease and recent progress in PBC.

Liver Lineup: GLP-1 RAs and FGF21s for MASH, with Mary Rinella, MD

, hosts Nancy Reau, MD, and Kimberly Brown, MD, sit down with Mary (Maru) Rinella, MD, a professor of medicine and director of Clinical Trials and the Metabolic and Fatty Liver Program at the University of Chicago, to discuss the rapidly evolving therapeutic landscape for 

metabolic dysfunction-associated steatohepatitis (MASH)

The conversation opens with a discussion about GLP-1 receptor agonists, which Rinella notes are already ubiquitous in her practice, with nearly 60% of patients being on one by the time they see her because of the overlap of comorbidities like diabetes and obesity with MASLD. She explains that the liver benefits of these agents appear to be primarily mediated by weight loss, though findings from the ESSENCE trial of Novo Nordisk’s semaglutide have demonstrated resolution of steatohepatitis and improvements in fibrosis.

Editors’ note: This episode was recorded prior to the FDA approval of semaglutide (Wegovy) injection 2.4 mg for the treatment of noncirrhotic MASH on August 15, 2025.

The conversation then shifts to strategies for integrating GLP-1 receptor agonists with resmetirom (Rezdiffra), the first FDA-approved agent for MASH. Rinella emphasizes the importance of staggering initiation, typically waiting 3 to 6 months before layering therapies, to both monitor for side effects and determine which drug is driving clinical response. She highlights the need for individualized, patient-centered strategies based on comorbidities and disease severity.

Looking ahead, the discussion turns to next-generation incretin therapies, including dual and triple agonists such as tirzepatide, survodutide, and retatrutide. While early-phase studies suggest significant weight loss and metabolic benefits, all 3 experts note phase 3 data are needed to establish their antifibrotic efficacy. The group also notes challenges in advanced liver disease: while weight loss can improve fibrosis, it also poses important implications for sarcopenia risk and acceleration, a trade-off that is particularly concerning in the context of cirrhosis, where malnutrition already heightens risk.

The experts also delve into FGF21 analogues, a class Rinella describes as one of the most promising in development with agents such as efruxifermin and pegozafermin showing some of the largest antifibrotic signals to date. Although recent cirrhosis trials were limited by short follow-up periods, Rinella expresses confidence that longer studies will confirm meaningful fibrosis improvements, additionally pointing to emerging research suggesting possible effects on alcohol consumption, opening new avenues for treatment in patients with overlapping metabolic and alcohol-related liver disease.

Finally, the group considers where the field is headed. Within the next decade, Rinella says she anticipates a much richer therapeutic armamentarium that could allow most patients with MASH to receive targeted treatment. However, she cautions that decompensated cirrhosis remains an area of unmet need, with no therapies yet convincingly effective.

Brooks A. Semaglutide Improves Steatohepatitis, Fibrosis in Phase 3 MASH Trial. 

. April 30, 2025. Accessed August 20, 2025. 

https://www.hcplive.com/view/semaglutide-improves-steatohepatitis-fibrosis-phase-3-mash-trial

Brooks A. FDA Approves Semaglutide (Wegovy) Injection 2.4 mg for Noncirrhotic MASH. 

. August 15, 2025. Accessed August 20, 2025. 

Brooks A. Efruxifermin Shows Potential for Fibrosis Reduction in Phase 2b MASH Cirrhosis Trial. 

. May 9, 2025. Accessed August 20, 2025. 

https://www.hcplive.com/view/exfruxifermin-misses-primary-endpoint-phase-2b-compensated-mash-cirrhosis-trial

Hosts Nancy Reau and Kimberly Brown are joined by Mary Rinella to discuss the evolving MASH treatment landscape with GLP-1s and FGF21s in development.

Nancy Reau, MD

Articles