编者按：“脂肪性肝炎（包括非酒精性和酒精性）是本届AASLD年会关注的主要领域之一，近年来越来越受到大家的关注，也越来越重要”，大会主席、美国亚利桑那州立大学Keith D. Lindor教授在11月12日接受《国际肝病》记者采访时如是说。

 

　　Lindor教授是脂肪性肝炎领域的专家，采访中，他从酒精性肝病（ALD）和非酒精性脂肪性肝病（NAFLD）的发病趋势、突破性进展、肝活检的应用、膳食疗法，以及尚存争议的话题等方面一一回答了记者的提问。

 

　　“对ALD和NAFLD研究的关注日益增加”

 

　　在普通人群中，非酒精性脂肪性肝病（NAFLD）的估计患病率比较容易回答，美国3.3亿人口中，大约1亿或以上患有NAFLD。关于NAFLD是一种状态还是一种疾病，尚存争议。如果我们用不同的目光看待该问题，在美国，大约只有2百万NAFLD患者会进展至肝硬化，因此，非酒精性脂肪性肝病作为一种常见的肝病病因，依然非常重要。有时候，当我们谈到大约30%的人群患有一种疾病时，更多的是指这些患者处于一种状态。相比之下，ALD患者的数量少得多。目前，对美国最常见肝病中的丙型肝炎，已经有了很好的治疗方法，因此，我们对ALD和NAFLD研究的关注日益增加。

 

　　Prof.  Lindor: The latter part is easier to answer. We think that in the US with a population of 330 million people, about 100 million or more have non-alcoholic fatty livers. There is debate as to whether this is a condition or a disease. If we look at it differently and ask what percentage of patients with non-alcoholic fatty liver has cirrhosis as a consequence, it is only around 2 million people. So it is not unimportant; it is a common cause of liver disease. Sometimes when we talk about 30% of the population having a disease, it is more of a condition. For alcoholic liver disease, the numbers are much lower. We know it is an important and common cause of liver disease and one we are becoming increasingly concerned about. For both of these, we are starting to pay more attention, mainly because we have been getting a better handle on how to treat hepatitis C, which up until now had been one of the most common and important liver diseases in this country.

 

　　“ALD研究有望取得加速进展”

 

　　近十多年来，尽管取得一些进展，ALD的研究进展仍然非常缓慢。我们用于治疗急性ALD的许多方法还是30～40年前研发的，近年来，没有研发出新的治疗。但是，另一方面， 我们对ALD潜在机制的了解越来越多，随着我们对ALD病因的更多了解，有希望转化为治疗疾病的更好方法，以新的更有针对性的靶向为目标。

 

　　另外一项非常有意义的进展就是为ALD的新治疗设计更好的试验，例如，已经召开一次关于ALD治疗终点的专题讨论会，并且AASLD和EASL计划明年再次召开会议，讨论如何更好地制定潜在终点的定义。设计临床试验时，需要应用公认的终点，目前正在做的工作将有助于我们朝着这个方向发展，ALD的研究有望取得加速进展。

 

　　Prof.  Lindor: For alcoholic liver disease, even though we are making progress, it has been frustratingly slow. Some of the treatments we use for acute alcoholic liver disease were developed 30-40 years ago. New therapies have yet to emerge. But on the other hand, we are learning more about the mechanisms that underlie these diseases. As we learn more about the causes, hopefully that will translate into better ways of treating the disease with new and better targeted therapies. One of the other things that has been happening has been greater interest in designing better trials for new treatments for alcoholic liver disease. For instance, there has been an endpoints conference and another one planned between the AASLD and the EASLD for next year to try and better define what potential endpoints would be. I think progress in designing clinical trials requires accepted endpoints to be used, and this work which is being done will help us move in that direction. Hopefully, there will be an acceleration in progress on alcoholic liver disease.

 

　　“尚不推荐代谢综合征患者开始少量或适量饮酒”

 

　　关于少量或适量饮酒是否可以预防NAFLD的问题，最初进行该方面研究工作的是Ayako Suzuki博士。对饮酒和NAFLD相关性的研究表明，少量或适量饮酒的个体患有NAFLD的可能性降低，后来有一些研究也支持这一相关性。

 

　　然而，从相关性到推荐的难度很大，对于我们实际推荐代谢综合征患者开始少量或适量饮酒，尚需数据加以证实。相关性并非因果关系，我们需要更好的研究，证实饮酒确实可以减轻NAFLD，这是一个非常有意义的问题，许多人都非常关注，但是，我们需要更多更好的数据，对该问题作出准确回答。

 

　　Prof.  Lindor: The issue of whether light to moderate alcohol consumption would prevent NAFLD is one that we may have contributed initially from work that was done with Dr Ayako Suzuki. In those associative studies, there is a suggestion that subjects who consumed light to moderate alcohol were less likely to have non-alcoholic fatty liver disease and there have been subsequent studies also suggesting that association. It is challenging to go from an association to a recommendation. For us to realistically recommend to patients who have metabolic syndrome to start drinking light to moderate alcohol, I don’t think we have the data yet to confirm that. Association is not causation and we need better studies to help us confirm that the consumption of alcohol actually leads to a reduction of non-alcoholic fatty liver disease. It is an interesting question and one that many people are interested in, but we simply need more and better data to accurately answer the question.

 

　　“对肝活检的需求大大减少”

 

　　目前，关于对NAFLD等患者何时进行肝活检，已经发生了相当大的变化。过去的18个月里，瞬时弹性成像已经在美国得到广泛应用，并且世界其他地区应用该技术的时间更久，这是一种非常方便的检测手段，可以在诊所现场操作，并且几乎马上得到结果，倾向于可以避免肝活检所固有的某些样本变异性问题。

 

　　随着瞬时弹性成像的快速利用，我们对肝活检的需求减少。对于NAFLD以及几乎所有其他肝病患者，应用肝纤维化的程度可以预测转归。目前，应用瞬时弹性成像，我们可以非常准确地确定患者是否为显著性肝纤维化，有助于避免对肝活检的需求。

 

　　关于NAFLD的另外一个重要问题，就是我们应用无创性检测不能确定患者是否患有脂肪性肝炎，但是，在另一方面，目前发现，与是否存在脂肪性肝炎相比，是否存在肝纤维化是更重要的转归预测因素。因此，对肝纤维化的无创性检测，可以为我们提供非常有价值的预后信息。

 

　　Prof.  Lindor: The question about when to perform a liver biopsy has changed fairly dramatically. In the United States, transient elastography has now been widely employed over the last 18 months. Other parts of the world have had access to this technology for longer. We are finding this is a very convenient test to do. It can be done almost as point of care in the office setting and the results are available almost immediately. It tends to avoid some of the issues with sampling variability inherent in liver biopsy. With the rapid utilization of transient elastography, we are seeing less need for liver biopsy. In patients with non-alcoholic fatty liver disease (as well as almost any other liver disease), the level of fibrosis can predict a poorer outcome, but now with transient elastography, we are pretty good at determining whether a patient has a fibrotic liver. That often helps us move away from the need for a liver biopsy. One of the other important factors in non-alcoholic fatty liver disease is that we cannot determine whether a patient has steatohepatitis with a non-invasive test, but, on the other hand, what we are finding now is that the presence or absence of fibrosis is a more important predictor of outcome than the presence or absence of steatohepatitis. So non-invasive measures of fibrosis are giving us very valuable prognostic information.

 

　　“尚无膳食补充剂推荐用于ALD或NAFLD患者”

 

　　目前，尚无已知或确定的饮食变化或补充剂 可以可靠地用于NAFLD或ALD患者。Lindor教授提到，中国或许可以通过其丰富的传统治疗历史，有望回答这一问题。中国的经验非常重要，在很多时候，我们都在关注中国正在进行的研究，出现的新数据可能表明某种补充剂或草药具有价值。在美国，难以应用标准化的产品，所以进行这些研究非常困难。另外一点就是，人们往往并没有寻求治疗医生和医务人员的指导，就已经广泛应用这些产品，由于人们多数都是在试验外和标签外应用这些产品，所以组织临床试验变得非常困难。

 

　　Prof. Lindor: At this point, there aren’t any known or established dietary changes or supplements we can reliably point to for utilization in patients with either non-alcoholic or alcoholic liver disease. I suspect we will probably look to China to answer that question through its rich history of traditional therapies. The experience there is much greater. In many cases, we keep an eye on what is going on in China for emerging datasets that might suggest that a supplement or herbal preparation would be of value. These are difficult-to-do studies in the United States in terms of acquiring a standardized product to use. The other point is that there is often widespread utilization of these products by the population without seeking input from treating physicians and health providers, and it becomes difficult to organize clinical trials because the off-trial/off-label use can be so pronounced.

 

　　本届AASLD年会的亮点和热点

 

　　在采访最后，Lindor教授为我们介绍了今年AASLD年会的亮点。他认为，此次会议主要对以下下三大领域进行讨论：

 

　　①病毒性肝炎。目前，在丙型肝炎的治疗方面，已经取得巨大成功，乙型肝炎的治疗再次成为关注增加的话题；关于丙型肝炎的治疗策略和结果，仍然有待开展更多的研究，许多研讨会对该话题进行探讨。

 

　　②脂肪性肝炎。对越来越重要的脂肪性肝炎的关注，包括非酒精性和酒精性脂肪性肝炎。

 

　　③肝细胞癌。肝细胞癌的检测和治疗也是此次会议的亮点之一。

 

　　Lindor教授指出：“中国医生对这三个领域的话题都很关注。随着世界一体化，我们对特定疾病的关注，很快会引起全世界的广泛关注”

 

　　Prof. Lindor: At this meeting, I think there are three main areas being discussed. One is viral hepatitis. As we are doing a better job of treating hepatitis C, treatment for hepatitis B is again emerging as a topic of increased interest. The treatment strategies and the consequences for hepatitis C still haven’t been worked out and there are a number of sessions devoted to that topic. The second area of interest is the emerging importance of steatohepatitis, whether it is non-alcoholic or alcoholic. The third topic I see emerging is the detection and management of hepatocellular cancers. All three of these topics would be of great interest to Chinese physicians. As the world becomes smaller, the concerns that we have about specific diseases become more common across the various continents.

 

　　专家简介：

 

　　Keith D. Lindor博士，美国亚利桑那州立大学健康管理学院院长。在2012年1月加入美国亚利桑那州立大学（ASU）之前，Lindor博士为梅奥医学院院长、梅奥医疗中心胃肠肝病科顾问、梅奥医学院医学教授。其研究兴趣包括成人胆汁淤积性肝病，尤其是原发性胆汁性胆管炎和原发性硬化性胆管炎，以及非酒精性脂肪性肝炎；研究主要聚焦临床试验和优化以上疾病患者的医疗管理方法。