国际肝病采访Kwang Hyub Han教授

Hepatology Digest: This September, your article entitled “New Diagnostic Method for Liver Fibrosis and Cirrhosis” was published in Cancer. In this article, you pointed out that liver stiffness measured by transient elastography (FibroScan) is a non-invasive, reproducible, and reliable method to assess hepatic fibrosis as well as to diagnose liver cirrhosis. What do you think needs to be considered when we use transient elastography to diagnose cirrhosis?

Prof. Han: In HBV carriers and also HCV, sometimes it is very hard to know the real histologic background without a biopsy, but most people don’t like to have a liver biopsy. Another issue is liver biopsy sensitivity, or specificity, and even histology is not 100%. FibroScan is a very easy test and it’s a numeric score so we can predict and we can monitor them. So it is a very easy screening tool in the beginning and we can easily monitor again and again.

Hepatology Digest: The Journal of Korean Medical Science published your study about upper gastrointestinal bleeding in patients with cirrhosis entitled “Clinical Features and Treatment Outcomes of Upper Gastrointestinal Bleeding in Patients with Cirrhosis” in August of this year. Your findings showed that initial hemostasis was achieved in 86.8% of acute upper G.I bleeding in 464 patients with cirrhosis cases, but rebleeding occurred in 3.8% and 16.8% of cases within five days and six weeks of hemorrhage, respectively. For such a population, how could we optimize our therapeutic strategy to prevent rebleeding?

Prof. Han: This is an ongoing study by multi-center trial. We are monitoring two groups who had  (3:32) to prevent bleeding and the other group is prophylactic band ligation. We need to see, because one arm is very easy to follow and for the other arm we need to document and have some more evidence-based data. It is still an ongoing study.

Hepatology Digest: Can you give us some advice on how to detect early HCC for chronic hepatitis B patients?

Prof. Han: We need to define the high-risk group. In Asia, especially in China, which is an HBV endemic area, anyone older than 40 who is an HBV carrier should be monitored using ultrasonography. However, sometimes it is not easy to ask patients to visit again and again. By using our prediction model, we can classify the group that is really high-risk and the group that is low-risk. We can then separate them and focus on the high-risk group and emphasize to the patients to monitor. In the low-risk group we can check one time a year or ask them to visit again when they are over 40 and we can then check.

Hepatology Digest: Do you find that this approach is more effective in areas where cost is an issue and incomes are low?

Prof. Han: It is a quite different approach according to the economic background. In Japan, they prefer to monitor more frequently, with more surveillance tools and that is more expensive, but Japan is a rich country. Korea is in-between Japan and China. China initially focused on the high-risk group, who had cirrhosis, HBV, high ALT, and frequent drinking, but they need to move from the high-risk group to the intermediate group in the near future as conditions improve. It depends on financial support; otherwise they do not follow directions well even though the doctor asks them to visit again and again.

Hepatology Digest: This April, you published an article entitled “Persistent Hepatitis B Viral Replication Affects Recurrence of Hepatocellular Carcinoma after Curative Resection” in Liver International. In this article, you pointed out that persistent viremia increased recurrence independently after surgery and to prevent long-term recurrence, antiviral therapy should be initiated in those with detectable serum HBV DNA. So for these patients, could you give us some advice on how to select antiviral agents?

Prof. Han: That’s a very good question, but there is very limited data to support it. The patients who develop HCC have a higher chance to have recurrence. We tried to reduce the recurrence. One factor is the background of the non-tumor area. When we analyzed who did not have any recurrence after successful surgery, the most cases are those with a non-cirrhotic background and no inflammation. Therefore, we tried to reduce the inflammation. The best way to reduce inflammation is to use a potent antiviral, but we are also concerned with cost-effectiveness. Lamivudine is the cheapest drug but it might have some resistance. The other drugs, such as entecavir or other drugs are more potent, but they are more expensive, so we need to have a balance.

Hepatology Digest: You mentioned lamivudine as being cheaper, but I have heard some lectures where they have talked about long-term cost and lamivudine can be more expensive long-term. Do you find this to be the case?

Prof. Han: Partly yes, but partly no. In cases where there is a low viral load, lamivudine even though it isn’t potent, it might be ok. In cases where we have a high viral load with progressed liver disease, they might have a high risk of development of viral (09:12). In those cases we should start with a more potent drug like entecavir.

Hepatology Digest: So perhaps in certain cases lamivudine would be a good economical choice?

Prof. Han: Yes, especially in cases where they can not afford the more expensive drug lifelong. If the government supports it, like in western countries or Japan, that would be fine. However, in Asia, if a patient can not afford to maintain antiviral therapy then we should consider which one would be better practically.