《国际肝病》：目前，丙型肝炎治疗取得了非常大的进展，几乎可以治愈所有患者。我们能够在全世界范围内清除HCV吗？

　　Rockey教授: 我认为答案是肯定的。目前药物治疗效果非常好，即使对于进展期肝纤维化、肝硬化、合并并发症以及特殊患者人群都非常高效。当前，我们面临的挑战是新药的可及性问题，我认为一切都要取决于新药对市场的渗透。如果这些新药在全世界范围内都可以获得，那么我们最终可以将HCV清除。我相信这些新药不久将遍及很多国家。此外，另一个问题是，在美国，这些新药的价格非常昂贵，药企可能并不情愿降低药物的价格来使之广泛普及。

　　I think the answer to that question is: yes. The treatments right now that are available are highly effective, even in patients with advanced cirrhosis, advanced fibrosis, patients with complications of liver disease, and even in special groups. The problem is availability of the new medications, so I think that it’s all going to depend on penetration of the new medications. If they’re available then I think Hepatitis C will ultimately be eradicated. I don’t suspect, however, that they’re going to be available real soon—in many places. I mean, right now, in the United States, they are extremely expensive and I think the companies right now are reluctant to make them widely available for reduced cost.

　　《国际肝病》：如何定义丙型肝炎的“治愈”？

　　Rockey教授:这是非常好的问题。多数人会将持续病毒学应答（SVR）定义为治疗结束后6个月，PCR检测病毒阴性，我认为这是一个很明确的标准。根据我的临床经验，可以将评估的时间提前至更早，因为如果患者一旦发生突破，多数是在治疗结束后的1~2个月内，更晚发生突破的情况并不多见。但是，我们通常习惯的定义是治疗结束后6个月检测。当然，多数获得SVR的患者体内的HCV被清除。重要的问题是远期的效果如何，那些已有肝纤维化或者是临床肝病进展的患者，他们的治疗效果如何。我的答案是可以期待上述病情得到逆转。正如我在报告中提到的，许多研究数据表明，多数丙型肝炎患者用新药治疗后可获得肝纤维化的逆转，发生并发症的风险降低。

　　That’s a very good question. Most people would define a sustained virological response as the absence of virus measured by PCR six months after the end of treatment. So I consider that to be a definitive cure. In my clinical experience, you probably can assess cure earlier than that. There are not many patients who break through later; most patients will break through—if they’re going to—within one or two months. But the formal definition, I think, would be six months.

　　I think most patients who have an SVR will have eradicated the virus. I think that an important question here is what happens after that. So what can we expect after an SVR in terms of progression of fibrosis, or in terms of progression of clinical liver disease? I think the answer to that is that you can expect some reversion in many patients.  The talk that I just presented showed the data in a number of studies that demonstrated that most patients will have a reversion in fibrosis—so they have less fibrosis—and many patients will have a reduction in the likelihood of complications. So this is similar to the Hepatitis B story—as you’re well familiar with—in which complications get much better after successful therapy. With Hepatitis C, maybe there is not as profound an effect, but certainly an effect.

　　《国际肝病》：获得SVR的患者还有必要接受额外的随访吗？

　　Rockey教授: 我们已经解决了大部分问题，对患者进行连续监测是非常重要的问题。对于肝硬化患者必须进行随访，包括胆红素、白蛋白的肝功能检测以及国际标准化比值（INR）和肌酐等检查，以及静脉曲张以及肝细胞肝癌（HCC）的早期筛查。此外，肝纤维化的患者也有必要进行连续性的肝纤维化的评估，我个人倾向于血液学分子标志物的检测，Fibroscan也是可以接受的一种方法。我不知道在中国是否可用Fibroscan，这取决于该方法在当地的可用性以及当地医务人员的专业技能，在不同的地方，很可能会存在差异。

　　Yes, I think we’ve addressed most of those. I think it’s important that patients have serial monitoring. In my own view, anybody who has cirrhosis must be followed up. I think that they should be followed up with serial liver tests, so bilirubin, albumin, INR, creatinine. Patients should also have screening for varices, and they should have screening for HCC. What we don’t know is how aggressive the screening program should be. It’s probably different so the guidelines have all been written based on the current understanding of Hepatitis C. This is a paradigm that’s going to shift the whole understanding and so I think the guidelines are going to change, but for right now, I would continue to follow the AASLD guidelines for screening, for varices, and HCC.

　　专家简介：Don C. Rockey, MD  美国南卡罗来纳医科大学医疗系主任，其研究领域包常见的胃肠病学和肝病学问题，负责NIH多个研究项目，担任Hepatology、Liver International杂志副主编，发表文章200余篇。