全球的肝脏病学家们正面临着前所未有的挑战和机遇。今天我主要讲一讲乙肝病毒（HBV）和丙肝病毒（HCV）感染（尤其是在东南亚日益增多的伴有HIV阳性的合并感染）。慢性肝病晚期是艾滋病患者死亡的一个主要原因，可以通过高效抗逆转录酶疗法（HAART治疗）来缓解艾滋病症状。其发病机理和治疗中存在的病毒和药物相互作用值得关注。除已经熟知的影响HCV感染疾病进程的因素外，最近的研究发现肥胖是HCV阳性患者胰岛素抵抗和患糖尿病几率增加的重要因素。胰岛素抵抗同时也是导致非酒精性脂肪肝的主要决定因素，而后者又是随着西方乃至世界 肥胖人口不断增加而增多的不明原因的肝硬化的主要影响因素。另外一个日益受人关注的公共健康问题是酒精消费的不断增加以及消费人群的日益年轻化。我在我们医院中看到越来越多的急性酒精性肝炎（日后大都转化为肝硬化）患者，他们会导致各种疾病的发病率和死亡率的升高，同时也消耗掉了许多宝贵的健康资源。随着肝硬化发病率的增加以及相应的治疗手段的提高，西方国家原发性肝癌发生率的不断提高也并不奇怪。而其中大多数是原发性肝内胆管细胞癌，其确切的原因尚不清楚。尽管肝移植可以挽救肝癌患者的生命，但是尸体器官的供应不足意味着许多患者并不能得到及时的救治。活体肝移植虽然可以挽救受者的生命，但是也会给供者带来一定风险，不能有效解决供体短缺问题。如果能够通过公众健康教育和政府措施来减缓人们生活的各种压力，同时在疾病的诊断和治疗领域取得更大的成果，从而解决这些全世界共同面临的不可回避的挑战，将会是更为有效的途径。
Global challenges in liver disease
ROGER WILLIAMS
Institute of Hepatology, University College London, London, UK
Never have there been more challenges to Hepatologists worldwide or opportunities for them to tackle them. As befitting a Congress in this area of the world, issues of HBV and HCV infection,
particularly when co-infecting HIV positive subjects - the numbers of whom are increasing so fast in south east Asia – will figure largely in my presentation. End stage chronic liver disease is now the major cause of death in HIV disease successfully treated by HAART therapy, and there are many viral and drug interactions of interest in pathogenesis and in therapy. In addition to the well known factors affecting disease progression in HCV infection, the recent observations on the additional affects of obesity are important in linking it with insulin resistance and the increased frequency of diabetes mellitus in HCV positive subjects. Insulin resistance is also apparently a major determining factor in non-alcoholic fatty liver disease, increasingly important as a cause of cryptogenic cirrhosis in the West and indeed worldwide with the generally rising levels of obesity in the population. Also of major public health concern are the rising levels of alcohol consumption directly related to increasing affluence and increasingly affecting younger age groups. An increasing number of severely ill acute alcoholic hepatitis patients, often superimposed on cirrhosis, are being seen in our hospitals and cause much morbidity, mortality and health service costs. Not surprisingly, with increasing frequency as well as longer survival in cirrhosis, the prevalence of primary HCC is increasing throughout the West, as indeed is that of primary intrahepatic cholangiocarcinoma although the factors responsible for that are less certain. Finally, despite the successes of liver transplantation, shortage of cadaver organs means that many patients cannot be treated. Living donor liver transplantation, however successful for the recipients, does carry some danger for the donors and cannot be the sole approach in making up the shortage. How best to counteract the pressures of lifestyle by public health and government measures and at the same time making more widely available advances in the diagnostic and therapeutic armoury,
constitute challenges worldwide from which there can be no shirking.
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