国际肝病采访Shiv K Sarin 教授

Hepatology Digest: Firstly I would like to thank you Dr Sarin for joining us here today at APASL 2009. It’s a great honor to speak to you today. The APASL Consensus Draft on Acute on Chronic Liver Failure was announced in the last APASL meeting， so at this new conference will there be any supplementary information， modifications or updates to it?

国际肝病：首先感谢您接受我们的采访，Sarin教授，非常荣幸能与您交谈。在上次APASL年会上公布了“慢加急性肝衰竭APASL共识草案”，那么在这次大会上是否会有关于这个草案的补充、修订或者更新？

Dr..Sarin: Thank you for inviting me. The Consensus now has been published in Hepatology International. The abstract book and the first issue of 2009 have all the details. As you will notice acute on chronic liver failure has now been defined as a development of jaundice and coagulopathy; you do a direct hepatic insult followed within four weeks by ascites and/or encephalopathy in a patient who has a recognized or unrecognized underlying chronic liver disease. And this definition has， from the beginning， no organ failure unlike the definition from the rest. So the whole idea of the Asia-Pacific working group is that we identify patients where the acute insult causing decompensation can be allowed to take over. In a patient who already has decompensated liver disease or advanced liver disease there is nothing much you can do except a transplant， but in acute on chronic liver failure， if you identify， without organ failure， then maybe these patients can benefit. Now tomorrow， that is February 14th， again there will be a three hour session on new definitions and further progress from twelve countries on acute on chronic liver failure in 2009.

Sarin博士：感谢您的邀请。共识草案已经发表在《国际肝脏病学》上了。大会摘要汇编和09年的第一期杂志上有详细资料。就像你知道的慢加急性肝衰竭现在已经被定义为：有进展的黄疸和凝血系统疾病、有直接的肝损伤并在4周内出现腹水和/或肝性脑病的患者，不论其是否有确诊的基础慢性肝病。这个定义中不像象其他定义那样有脏器的衰竭。因此，亚太地区工作组的整体意见是，我们要在急性损伤导致的失代偿能被处理时对患者进行诊断。在患者已经有失代偿性肝病或者严重肝病的时候，除肝移植外再没有可用的治疗手段了，但如果能及时诊断出慢加急性肝衰竭，此时没有脏器衰竭，治疗可能对患者更有益处。明天是2月14号，届时还会有3个小时的会议来讨论慢加急性肝衰竭的新定义和在2009年12个国家对此疾病的诊治的进一步发展。

Hepatology Digest: And when you talk about the classification， in terms of acute on chronic liver failure which involves the pre-existence of decompensated liver cirrhosis before the liver failure develops， there can be a confusion with chronic liver failure， so how can we talk about the differences between the therapy and the prognosis and identify which situation and which classification is correct?

国际肝病：您谈到了分级的问题，慢加急性肝衰竭的定义中包括出现肝衰竭前的肝硬化失代偿期，这可能会与慢性肝衰竭混淆，那么这两者之间的治疗和预后有什么不同，怎样区分哪种情况、哪种分级才是正确的？

Dr..Sarin: The classification for liver failure is basically of acute liver failure; that is in a patient with no underlying liver disease， the patient gets jaundice and encephalopathy within a period of 4 weeks， although there are people who give it up to maybe 8 weeks or even 24 weeks. But acute on chronic liver failure is a distinct entity. There is no acute liver failure which means there is an underlying liver disease. The second entity is of a decompensated liver disease in which the patient has a known cirrhosis， he already has jaundice or ascites or encephalopathy. It is very serious. This is a different group. So acute on chronic liver failure falls in between. We have to be distinct from acute liver failure and distinct from a decompensated liver failure， and therefore now it is clear ACLF is a different and distinct entity.

Sarin博士：肝衰竭分级基本上是针对急性肝衰竭的，这种肝衰竭发生在没有基础肝病的患者身上，患者在4周内出现黄疸和肝性脑病，也有的患者会在8周甚至是24周内出现。但慢加急性肝衰竭却有本质的区别。非急性肝衰竭意味着这类患者有基础肝病。而失代偿性肝病患者有明确的肝硬化，已经出现了黄疸、腹水、肝性脑病。这类患者比较严重，是不同的组。慢加急性肝衰竭的严重程度介于这两者之间。我们要把慢加急性肝衰竭和急性肝衰竭、失代偿性肝衰竭区分开来，现在已经清楚了，慢加急性肝衰竭是有本质区别的一类疾病。

Hepatology Digest: In regards to acute liver failure， it can happen with chronic HBV carriers because of the reactivation of the virus， so for those particular patients can antiviral therapy be used and how， if so?

国际肝病：由于病毒的再激活，慢乙肝携带者会发生急性肝衰竭，那么对这类患者，抗病毒疗法是否有效，如果有效，又是如何发挥效应的？

Dr..Sarin: Yes， it’s a very important question. In the etiology of acute on chronic liver failure， in the West， it is alcohol. If a patient who is drinking alcohol and has alcoholic cirrhosis goes onto a binge or drinks more， he gets alcoholic hepatitis. Or drugs are a common cause. While in the East， like in China or in India or the sub-continent， it is reactivation of Hepatitis B. It means the patient who is having a chronic HBV infection， gets a flare， means he gets high ALT， maybe more than five to ten times， and has got jaundice， has bilirubin and may even have presence of ascites or liver failure. In such patients， whether to treat with antivirals or not is a very debatable issue. When you are given our latest studies which we have not published， the randomized controlled trial of twenty-five patients， thirteen were given antivirals， twelve were not given， there is a rapid decrease in the DNA， a rapid decrease in the ALT levels however there was no benefit in survival. So my recommendation is – patients who have a flare， they will have high DNA levels and then an antiviral like tenofovir or maybe telbivudine or entecavir should be tried.

Sarin博士：是的，这是个很重要的问题。在西方，慢加急性肝衰竭的主要病因是酗酒。如果患者酗酒并有酒精性肝硬化，但还不加以节制，则会发展为酒精性肝炎。还有，药物也是一个常见诱因。然而在东方，例如中国、印度或者次大陆，则主要是因为HBV的再激活。慢乙肝患者疾病恶化，即出现高水平的谷丙转氨酶，或许5倍、10倍于正常值；出现黄疸，胆红素升高；或许甚至出现腹水或者肝衰竭。对这类患者，是否进行抗病毒治疗还是个很有争议的话题。在我们还未发表的最新研究中，对25名患者进行了随机对照试验，13名患者给予抗病毒治疗，12名未给予抗病毒治疗。抗病毒治疗组DNA水平和谷丙转氨酶水平都有迅速下降，但患者生存期并没有提高。所以，我的建议是，如果患者病情恶化，并有高水平DNA，那么可以尝试使用抗病毒疗法——例如替诺福韦、替比夫定、恩替卡韦等。

Hepatology Digest: How can we prevent the onset of acute on chronic liver failure during treatment of chronic viral hepatitis?

国际肝病：在对慢性病毒性肝炎患者的治疗过程中，如何预防出现慢加急性肝损伤呢？

Dr..Sarin: During treatment of chronic viral hepatitis， acute on chronic liver failure may generally not develop unless the patient with chronic hepatitis B or C has a super-added viral infection， for example he gets an acute hepatitis A or an acute hepatitis E or a patient with hepatitis C， gets an acute B or a patient with hepatitis B gets acute C， so a super-added viral infection or a drug， say anti-tubercular therapy or a high dose of paracetamol or sometimes even some of these fungal， or like you have， mushrooms. So an acute insult has to be defined and these can be prevented but you can’t change the chronic liver disease.

Sarin博士：在对慢性病毒性肝炎的治疗过程中，一般来说不会出现慢加急性肝衰竭，除非患者有HBV或者HCV的混合感染。例如，患有急性甲肝或急性戊肝或丙肝，同时又有HBV急性感染；或者患有乙肝同时又感染了HCV。因此混合病毒感染、抗结核治疗药物、过量的对乙酰氨基酚、有时甚至是一些真菌感染都会造成急性损伤。因此要确定急性损伤，这些是能预防的，但患者的慢性肝病状态是无法改变的。

Hepatology Digest: Thank you for joining us today Dr.essor Sarin. It was our pleasure.

国际肝病：感谢您接受我们的采访，非常荣幸。

Dr..Sarin: Thank you.

Sarin博士：谢谢。