Thomas Boyer教授，目前担任美国亚利桑那大学医学院肝脏研究所的主任。他的主要临床研究兴趣为肝硬化并发症的治疗。9月13日，中华医学会肝病学分会与国际肝脏研究学会（IASL）共同举办的继续教育中，他受邀做了关于肝硬化并发症管理（门静脉高压、腹水）的报告。会议间隙，他对《国际肝病》记者提出的几个相关问题进行了解答。

　　: What is the latest progress in the management of portal hypertension? What is the role of statin therapy in this setting?

　　《国际肝病》：在门静脉高压症的管理方面有什么最新进展？他汀类药物治疗对此有什么作用？
 

　　Prof Boyer: The main progress in the management of portal hypertension has been the prevention of bleeding using pharmacologic therapy and endoscopic therapy in people who are at risk for bleeding. The other major advance has been the use of TIPS to manage people who have bled, so we don’t do surgery anymore. The third major advance has been that as we treat liver disease like hepatitis C and B, the blood pressure falls as the liver gets better and therefore portal hypertension improves to the point of not being a problem. I don’t think there is a role right now for statins based on current data.

　　Boyer教授：门静脉高压症管理方面的最主要的进展为开始将药物及内镜用于有出血风险的患者的出血预防。第二方面的进展为应用经颈静脉肝内门体静脉分流术（TIPS）管理已经发生出血的患者，由此我们不再需要外科手术治疗门静脉高压症患者的出血。第三方面进展为随着我们对诸如丙型肝炎和乙型肝炎等肝病的治疗，肝脏得到好转，血压也随之降低，因此门静脉高压症会得到改善。基于当前的研究数据，我认为他汀类药物在门静脉高压症管理方面还无确定作用。
 

　　: How can we improve patients’ compliance with dietary sodium restriction and oral diuretics? Is education through regular face-to-face sessions or electronically delivered programs helpful?

　　《国际肝病》：我们如何提高患者对限钠饮食和口服利尿剂的依从性？通过诸如定期当面会谈或者电子方式传递计划等教育会有所帮助吗？
 

　　Prof Boyer: Getting people to stay on a sodium-restricted diet is difficult. It is very difficult in the US and I think it is also probably difficult in China because salt is added to all of our foods. The only thing you can do is educate your patients about what they should and should not eat and how to read food labels with respect to how much salt is in the food they are eating. Also there needs to be an emphasis on the importance of why they should not eat salt. They can overcome any diuretic regimen you choose to give them if they consume too much salt. So patient education is an important thing to do. It is the same with the taking of medications. If they don’t want to be swollen, then they need to take their medication. They need to understand the relationship between taking their pills and feeling better. As far as electronically delivered programs are concerned, it would be a good idea if you had a dietician do a recording of a low-sodium diet and then the patient could watch the recording. That would be a good idea.

　　Boyer教授：让患者坚持限钠饮食有难度。在美国，这一方法的开展非常困难，我想在中国也面临相同的问题，这是因为我们所有的食物中都加有盐。你唯一能做的事情就是教育你的患者，他们应该吃什么，不应该吃什么，以及如何通过阅读食物标签来了解食物中钠的含量。另外，医护人员还有必要向患者强调他们限盐的重要性，如果他们吃太多盐，任何利尿剂方案都将失去效力。因此，患者教育是医护人员需要去做的一件重要的工作，这与药物治疗同样重要。如果患者不想身体浮肿，他们就需要服用药物，他们要明白服用药物和感觉更好之间的关系，（这对提高口服利尿剂依从性非常有帮助）。至于谈到通过电子方式传递计划，如果由一位营养师做低钠饮食的记录，然后患者可以查看该记录，我想这会是一个好的方法。
 

　　　:: How do we weigh the risks versus the benefits of beta-blockers in cirrhotic patients? Which patients with ascites should discontinue such drugs?

　　《国际肝病》：我们如何权衡肝硬化患者应用β-受体阻滞剂的利和弊？哪些腹水患者应该停用这类药物？
 

　　Prof Boyer: The use of beta-blockers in people without ascites doesn’t have a great risk. They usually tolerate the medicine quite well. It lowers the pressure and reduces their risk of bleeding. It is very controversial as to whether beta-blockers have an adverse effect on people with ascites. There is the group in France who believe that is true; there are other people who believe it is not true. So right now I don’t think we know. But the people that they worry about are the ones with advanced disease and refractory ascites who may have a problem with beta-blockers but this is not based on randomized controlled trials but retrospective analyses of patients, and that is always hazardous.

　　Boyer教授：没有腹水的患者应用β-受体阻滞剂没有多大风险，他们通常对该药有相当好的耐受性。β-受体阻滞剂可以降低（门静脉）压力，减少出血风险。关于β-受体阻滞剂是否对腹水患者有不良反应，存在很大争议。法国的研究团队认为确实如此，而也有其他人则认为这并非是事实，所以我认为目前这个问题还没有明确的答案。对于认为晚期疾病和难治性腹水患者应用β-受体阻滞剂有风险的观点是基于回顾性分析结果，并非基于随机对照试验，但是在这两类患者应用β-受体阻滞剂的确冒有风险。
 

　　　: What is the role of vaptansin the treatment of patients with cirrhosis, ascites and hyponatremia? Are there any other potential therapies in this setting?

　　《国际肝病》：血管加压素受体拮抗剂对肝硬化腹水并低钠血症患者的治疗作用如何？对于这种情况，还有其他哪些潜在的治疗方法？
 

　　Prof Boyer: The vaptans are very effective at elevating the serum sodium in patients with hyponatremia. The problem is that all of the studies have been very short-term and when the vaptans were used long-term they actually caused liver injury. It wasn’t used in people with cirrhosis but it did cause liver injury, so in the US there is a warning about long-term use of tolvaptan in people with liver disease. The other problem is there is very little data on the combination of vaptans and diuretics. We really don’t know how to use the drugs. So I don’t think they play much of a role right now. They may help you in the hospital, short-term, but in the outpatient setting, I don’t think they play a role. Right now, to the best of my knowledge, there is nothing else that is going to change our situation as far as hyponatremia is concerned.

　　Boyer教授：血管加压素受体拮抗剂对于升高低钠血症患者的血清钠非常有效。问题是所有研究的时间都非常短，当长期应用血管加压素受体拮抗剂时，它们确实可导致肝损伤。所以，美国（FDA）对于肝病患者长期应用血管加压素受体拮抗剂给予了警告。尽管发现血管加压素受体拮抗剂肝损伤的病例并非为肝硬化患者，但是确实证明了有肝损伤风险。另一个问题是联合应用血管加压素受体拮抗剂和利尿剂的数据还非常少，我们的确不知道如何应用该药。因此，我认为它们现在的作用不大。在入院患者的短期应用，它们可有帮助，但是在门诊条件下，我认为它们没有作用。据我所知，就低钠血症而言，目前还没有其他的治疗手段。