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近日，2024年新加坡GIHep与肝病联合大会（Combined GlHep & SHC 2024）在新加坡举办。本次会议汇聚了全球肝病领域的精英学者，共同探讨肝病的最新进展、挑战与机遇。《国际肝病》特邀新加坡国立大学医院Mark Muthiah博士围绕肝纤维化、患者临床管理等相关问题进行了深入探讨。以下为采访实录。
《国际肝病》
在您的研究中，您认为目前逆转肝纤维化领域面临的最大挑战是什么？您认为，该如何有效地促进肝纤维化的逆转？
Dr. Mark Muthiah: 感谢您的邀请。对于肝硬化和失代偿期肝硬化患者来说，最大的挑战是肝脏的恶劣环境，这使得逆转纤维化变得非常困难。事实上，无论是乙型肝炎、丙型肝炎还是脂肪性肝病，治疗这些潜在疾病是非常有益的。对于乙型肝炎和丙型肝炎，抗病毒治疗至关重要。而对于脂肪性肝病，减肥和控制代谢风险因素是必不可少的措施。目前我们尚未发现针对脂肪性肝病相关肝硬化的特殊治疗方法，但我们希望即将问世的新药物能为这一难题提供解决之道。
Hepatology Digest: In your research, what do you consider to be the biggest challenge currently facing the field of reversing liver fibrosis? How do you think can we effectively promote the reversal of liver fibrosis?
Dr. Mark Muthiah: Thank you for having me. The biggest challenge in patients with liver cirrhosis and decompensated liver cirrhosis is the harsh environment of the liver, making it very difficult to reverse the fibrosis. What has shown benefit is actually treating the underlying disease—whether it’s hepatitis B, hepatitis C, or fatty liver disease. For hepatitis B and C, treating the virus is crucial, and for fatty liver disease, weight loss and controlling metabolic risk factors are essential. Currently, there are no specific treatments for fatty liver disease-related liver cirrhosis, but we hope that upcoming drugs will provide some solutions.
《国际肝病》
目前在新加坡，代谢相关脂肪性肝病（MAFLD）的主要临床管理策略是什么？
Dr. Mark Muthiah: 全方位地管理患者至关重要。目前，我们的主要策略是通过饮食调整和生活方式干预来达到减重目的。在疾病的早期阶段，这些措施对阻止病情进一步恶化起到了关键作用。不幸的是，一旦患者发展成失代偿期肝硬化，唯一的选择便只有肝移植。
Hepatology Digest: What are the primary clinical management strategies for MAFLD currently practiced in Singapore?
Dr. Mark Muthiah: Our main strategy is weight loss through diet and lifestyle changes. Managing the patient holistically is very important. Currently, diet and lifestyle interventions are the only options we have, and they are crucial in the early stages of the disease to prevent progression. Unfortunately, once patients develop decompensated liver cirrhosis, the only option available is a liver transplant.
《国际肝病》
您在会上作题为“以患者为中心的风险评估观点：平衡竞争风险”的报告。您如何设想将以患者为中心的方法纳入肝病患者的风险评估中？在权衡肝病管理中的竞争风险时，从以患者为中心的角度来看，您认为最重要的关键因素是什么？
Dr. Mark Muthiah: 在平衡竞争风险时，我们面临的主要问题是患者的合并症，尤其是心血管相关合并症。脂肪肝患者往往合并糖尿病、高血压和高脂血症。此时，药物的选择显得尤为关键。例如，一个脂肪肝合并糖尿病的患者可能还存在肾脏问题。在这种情况下，我们需要仔细评估并决定哪个疾病更为紧迫，哪个疾病可能引发更多的问题。这就要求我们采用一种全面的治疗方法，不仅要关注肝脏疾病，还要兼顾其他可能受到影响的器官，为患者制定最有益的治疗方案。
Hepatology Digest: You presented a report titled "A Patient-Centric View of Risk Assessment: Balancing Competing Risks." How do you envision incorporating a patient-centric approach into the risk assessment for liver disease patients? When balancing competing risks in the management of liver disease from a patient-centric perspective, what are the key factors that you consider most important?
Dr. Mark Muthiah: When balancing competing risks, the main issue would be the comorbidities, especially cardiovascular comorbidities. Patients with fatty liver disease often have diabetes, high blood pressure, and high cholesterol. The choice of drug is critical. For instance, a patient with fatty liver disease and diabetes may have kidney problems. We need to decide which is more important and which problem will cause more issues. It requires a comprehensive approach to manage not just the liver, but also other organs at risk, and to select the most beneficial treatment for the patient.
《国际肝病》
在临床实践中，您遇到过或实施过哪些有效的策略或创新方法来管理失代偿期MASH肝硬化？这些策略是如何改善患者的结果和生活质量的？
Dr. Mark Muthiah: 对于失代偿期MASH肝硬化的患者，唯一的选择是肝移植。然而，这些患者往往伴有其他代谢和心血管疾病。在等待肝移植期间，患者面临更高的并发症风险。我们试图在患者等待移植期间优化共病管理，包括心血管问题、其他合并症以及体液平衡等，以确保患者能够安全地接受移植手术。另外，许多失代偿期MASH肝硬化患者还可能发展为肝癌，因此癌症管理也很重要。手术后，持续控制代谢问题对于确保患者的生活质量同样重要。
Hepatology Digest: What are some of the most effective strategies or innovations in the management of decompensated MASH cirrhosis that you have encountered or implemented in your clinical practice? How do these strategies aim to improve patient outcomes and quality of life?
Dr. Mark Muthiah: For patients with decompensated MASH cirrhosis, the only definitive option is a liver transplant. However, this is complicated by other metabolic and cardiovascular issues. Even while waiting for a liver transplant, there is a higher risk of complications. We try to optimize the management of comorbidities while patients are on the transplant waiting list. This includes managing cardiovascular issues, comorbidities, and fluid status to get them safely to a transplant. Many of these patients also develop liver cancer, and managing the cancer to enable a successful liver transplant is crucial. Post-transplant, controlling metabolic issues continues to play a significant role in ensuring a good quality of life.