第58届欧洲肝脏研究学会年会（EASL2023）暨2023年EASL大会（EASL Congress 2023）上，EASL前秘书长（2010-2017）、挪威奥斯陆大学医院外科、炎症医学和移植部研究主任Tom Hemming Karlsen教授应邀于“State-of-the-Art: Improving liver health in Europe: the EASL-Lancet Liver Commission initiative”专题介绍EASL-《柳叶刀》肝病委员会关于改善欧洲肝脏健康的倡议。《国际肝病》有幸邀请到Karlsen教授介绍倡议提出始末及最新进展，以期为我国肝脏健康提供更为广阔的管理视角。

 

《国际肝病》

EASL-《柳叶刀》欧洲肝病委员会于2021年12月发布报告，阐述肝病如何成为整个欧洲的主要健康威胁并提出十项可采取行动的建议。能否请您谈谈欧洲肝病的现状？提出十项建议的背景？

 

Tom Hemming Karlsen教授：全球范围内都存在肝病问题，但欧洲的情况比较特殊，源于两个方面。首先，欧洲是全球酒精摄入量最高的地区，这是一个最显著的特点。其次，欧洲与其他地区一样肥胖症发病率高。我们知道肥胖症高发与脂肪肝和2型糖尿病相关肝病进展风险之间存在联系。

 

欧洲在这两个问题上面临挑战，导致欧洲肝病发生、进展以及肝病并发症（包括肝癌）呈现上升趋势，可以说，未来相当不容乐观，需要对其进行干预，这也是委员会工作的主要重点，同时委员会也致力于解决其他肝病领域的问题。

 

Liver disease is a problem everywhere in the world, but we have a special situation in Europe coming from two directions. There are the aspects which are specific to Europe, and the most pronounced feature is actually that Europe has the highest alcohol intake in the world. And besides that, as everywhere, we are also in Europe being hit by the obesity epidemic. And we know the link between the obesity epidemic and fatty liver disease and the risk of progressive liver disease associated with type two diabetes, et cetera.

 

And in many ways, there is this dual hit of problems in Europe coming from this high alcohol consumption, which is a unique feature for Europe, and the obesity epidemic which is happening everywhere. And this is creating an upward trajectory of liver disease and progressive liver disease and liver disease complications, including liver cancer in Europe, which are, I would say, providing a quite dismal outlook unless it's being handled in some way or the other. And this is really the main emphasis of the commission also working, however, into other areas of liver disease.

 

《国际肝病》

EASL-《柳叶刀》欧洲肝病委员会提出了十项可采取行动的建议，其中一半针对医务工作者。请您介绍下针对健康提供者的建议？

 

Tom Hemming Karlsen教授：我们在这个问题上并没有将视野局限在与酒精相关的肝病和肥胖症之上。我们首先制定了一项与病毒性肝炎消除有关的规划。目前欧洲各国在这个方面的法规存在较大差异，因此我认为有必要推动丙型肝炎检测以及相应药物获取的便捷度，并在全欧洲推广疫苗接种计划，特别是乙肝疫苗接种。

 

我们还努力推动肝病进入世界卫生组织非传染性疾病议程，这意味着用多学科角度看待慢性疾病。也就是说，肝病不仅需要肝脏病学家关注，同样值得其他医务工作者的关注，例如内分泌学家、基层医生等，因为他们会接触到有患肝病风险的人群。

 

我们试图为从事其他专科工作的同行提供指导，告诉他们如何进行肝病风险筛查和检测。同时，我们还提出了简化检测的建议，并将关注点从传统的肝转氨酶检测转向更强调肝脏相关死亡的决定性因素——纤维化进展。因此，在指导肝脏病学以外的同行方面，我们还有很多工作要做。这也是与《柳叶刀》合作的基础，该杂志影响广泛。因此，我们有必要将我们在肝病检测方面的知识和观念传达给从事其他专业工作的人群。

 

此外，我们的委员会还关注社会歧视相关影响，我们试图通过术语上的变化来强调这一点，因为即使在世界卫生组织的体系内，我们也有一些与肝病相关的术语，例如“酗酒”等存在一定歧视或偏见。我们正在努力鼓励使用更为中立的语言来描述患有肝病的人群，以避免吓跑那些原本可以接受肝病筛查和检测、适当照护和后续疾病监测的潜在人群。

 

We are going a little bit broader from this problem of alcohol related liver disease and obesity. We start out with a roadmap related to viral hepatitis elimination. This is still a problem in Europe. Regulations are quite heterogeneous, and I think there is a call for implementation of testing access to hepatitis C drugs and also harmonization of vaccination programs for hepatitis B throughout Europe.

 

Another key aspect which we are trying to push is really to have liver come on board the WHO non-communicable disease agenda, which is a way of perceiving chronic diseases in a multidisciplinary context. Meaning that liver disease should be on the radar not only of hepatologists, but also of other health care providers who are seeing people at risk for liver disease, for instance, endocrinologists, primary care physicians.

 

And we're trying to pave out a way for these colleagues working in other specialties on how they should be doing liver disease risk screening and testing. Also, we have, in conjunction with that, proposals on simplifying testing and a shift going away from the traditional focus on liver transaminases versus actually an emphasis on progressive fibrosis as really the key determinant for liver related mortality. So, we have a great job to do in terms of teaching our colleagues outside of hepatology. And that was also the basis for the work being anchored with the Lancet, which has a very broad outreach. So, there is a need for us to communicate the knowledge and the awareness that we have regarding liver disease testing within hepatology to people working in other specialty groups.

 

There is also an interesting aspect in the commission related to stigma, which we have tried to highlight in terms of nomenclature, because we have terminology in liver related nomenclature, even within the WHO system, we have terms like alcoholic, et cetera. And we're somehow trying to encourage a more neutral language when we're talking about people with liver disease, so that we don't scare away our potential people that can be screened and tested for liver disease and be brought into appropriate care and surveillance programs.

 

《国际肝病》

这些建议实施后，给欧洲肝病健康带来了哪些影响？

 

Tom Hemming Karlsen教授：就医务工作者的建议而言，我们取得了很大的进展。我们成功地制定了一份应对社会歧视的规划。我们致力于制定更有效的肝纤维化筛查策略。我们与基层医疗和内分泌学家合作，将我们专业领域的知识传递给其他同行，使其能够在日常实践中应用。目前我们已经启动了多个项目，并正在评估肝纤维化筛查的成效。

 

在其他方面，情况则较为复杂，我们仍在努力。政策层面上，比如与酒相关、与食品相关的政策，我们的工作变得更加具有挑战性且目前进展缓慢。我们已经与世界卫生组织的姐妹协会建立了合作并尝试着开个好头。总的来说，与同行的合作略有成效。然而，政策方面还有很多工作需要完成。

 

I think when it comes to the recommendations targeting the health care providers, this has gone a long way. We have successfully been trying to put out a roadmap on how to deal with stigma. We are working towards more effective strategies for liver fibrosis screening. We are having collaborations with primary care, with Endocrinologists in really bringing the knowledge out of our specialty into other colleagues’ everyday practice. There has been a number of projects initiated and there are a number of projects running on assessing the efficacy of liver fibrosis screening.

 

So, I think with regards to the recommendations versus the healthcare providers, we have been fairly successful where it's been, I would say, much more difficult and where we are still struggling. It's really on the policy level, how to have a response on alcohol policy, for instance, which is of crucial importance in dealing with the situation in Norway and in Europe and also on food related policies. I think the work is much more challenging, much slower. We have set up some collaborations with sister societies WHO so there is some movement in trying to generate momentum.

 

But in general, I think that the brief message is that working with our colleagues, we are making some progress. Working with the policy aspects, it's much more difficult and there is much work remaining.

 

《国际肝病》

未来是否需要进行修订？请您谈谈进一步的计划或建议？

 

Tom Hemming Karlsen教授：实际上我们已经启动了第二个委员会，即将组建第二期EASL-《柳叶刀》欧洲肝病委员会。第二期委员会将包括一些参与过第一期委员会的人员或委员，同时还将有新的委员加入。该委员会的目标是推动建议的实施，并评估和制定衡量实施效果的措施，正如我们之前所讨论的。

 

在第二期委员会中，我们还将努力解决一些第一期委员会未完全解决的问题。这些问题涉及欧洲人口老龄化、移民问题、全球可持续性和新的经济形势等。所有这些问题都与第一期委员会的核心信息息息相关，即强调早期检测肝病、实施早期干预和预防措施的重要性，这比终末期肝病及并发症的管理更经济且更有效。我们将继续进行后续工作，努力取得更多成果。

 

We have actually now initiated a second commission, so there will be a second Lancet Commission. There will be some of the people who were involved or some of the commissioners involved in the first commission will also be involved in the second commission. But we will also have new commissioners coming on board. The aim of the commission is what we already spoke about the implementation of the recommendations and measuring and bringing about measures on how to assess the efficacy of this implementation.

 

And I think we would also, in this second iteration of the Commission, try to address some of the topics which we didn't fully address in in the first Commission. We have problems related to the aging European population, we have problems related to migration, we have problems related to sustainability and the new economic situation globally. And all of this somehow comes together in a way towards the messages of the first Commission, which is really all about trying to detect liver disease early, trying to put in place early intervention prevention, which in the end is cheaper and more effective than end stage approaches towards complications of liver disease. Definitely be a follow up. We are working on that and there will be more to come in terms of output from the group.

 

 

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