Advances in the practice of hepatology continue to be extraordinary. Therefore, it is very fitting to provide an update to our readers about many of these advances in this edition of Current Opinion in Gastroenterology.
The advances in hepatitis C virus (HCV) therapy have been nothing short of astonishing. Multiple new combinations of direct acting antivirals have been approved, and have been proven to be well tolerated and highly effective. Therapy is now expected to not only eradicate HCV, but to eradicate the virus in a shorter time period, and in patients with cirrhosis, and even comorbid diseases. In fact, therapy has been straightforward that one of the controversies in the field is whether general practioners (and not subspecialists) can prescribe therapy. Dr Nancy Reau and Rama krishna Behara (pp. 115–119) provide a state of the art review of current therapies.
An area that continues to evolve in HCV therapy is management of the HIV–HCV coinfected patient. These patients appear to develop more rapid fibrosis progression than patients without coinfection, and are often complicated because of the use of highly active antiretroviral therapy (HAART), which has become standard of care. Fortunately, the new anti-HCV direct acting antiviral agents appear to be effective in coinfected patients. Thus, it is particularly timely that Dr Eric Meissner (pp. 120–127) reviews the state of this rapidly evolving field.
Although some of the most remarkable changes in hepatology have been in the field of HCV therapy, perhaps the most rapidly growing area in hepatology has become in the area of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH). Indeed for this last year, NASH cirrhosis was reported to be the most common indication for orthotopic liver transplantation. However, many questions surrounding NASH remain. First, the pathophysiology of NAFLD, NASH, and cirrhosis remains controversial. One of the hottest areas in the field is the role of the microbiome. This has been driven by data in experimental models suggesting that modification of the microbiome has important effects on the liver. Therefore, the review by Dr Nancy Reau, Rama Behara and Bernd Schnabl on the latest science in the blossoming field of the microbiome and NASH is fitting.
As it is clear that NASH is becoming common and important in modern hepatology, effective therapies are essential. Although it is reasonably well established that lifestyle modification (diet, exercise) are effective treatments for NASH, this is rarely successful because weight loss is often difficult to achieve and/or maintain. Thus, a pharmacologic approach would be ideal; currently, it remains controversial as to whether there is (or are) effective treatment(s). Therefore, Dr Nancy Reau, Rama Behara and Arun Sanyal provide a state of the art synopsis of the state of pharmacologic treatment of NASH, including NASH cirrhosis.
Alcoholic liver disease remains one of the more common liver diseases in the world. Unfortunately, although steroids have become standard treatment for severe alcoholic hepatitis, few, if any, other treatments appear to be effective. This is unfortunate as this disease has a poor prognosis in many patients – and new and effective treatment is required. Although many recent studies examining novel agents for treatment of alcoholic hepatitis have failed, there remains hope. Nancy Reau, Rama Behara and Dr Mack Mitchell provide and authoritative review of the latest advances in alcoholic hepatitis.
One of the most difficult to manage liver diseases is primary sclerosing cholangitis. This disease is often progressive, and moreover, beyond cirrhosis, may lead to one of the most devastating complications of primary liver disease – cholangiocarcinoma. To address this problem, a number of pharmacologic therapies have been attempted. In general, treatment remains difficult. Nonetheless, there has been substantial progress in this field, and it is therefore apropos that Nancy Reau, Rama Behara and Dr Gregory Gores provide an up to date and state of the art review of the current status of treatment for primary sclerosing cholangitis.
An extremely common problem in hospitalized patients is the development of an abrupt increase in aminotransferases. The differential diagnosis of this clinical presentation is often fairly narrow, and most commonly includes ischemic hepatitis. Unfortunately, this disorder can be confused with a variety of other diseases. Moreover, it has become apparent that the most common setting for the development of ischemic hepatitis is with preexisting cardiac disease. Drs Joe Lightsey and Don Rockey (pp. 158–163) review this field, focusing on differential diagnosis, expected outcomes, and potential therapies.
Another common problem in hospitalized patients is the development of jaundice. Further, in hospitalized patients, jaundice is often a marker for severe underlying disease. When caused by drug injury, the development of jaundice is referred to as ‘Hy's law’, and has been associated with a mortality rate of as high as 10%. Perhaps the most important aspect of jaundice in hospitalized patients is making an accurate diagnosis. Thus, Jeremy Sullivan and Dr Don Rockey (pp. 164–170) review this important subject.
Financial support and sponsorship
Gilead Pharmaceuticals, Actelion Pharmaceuticals, Connatus, Galectin, Shire, and Hyperion Therapeutics.
Conflicts of interest
There are no conflicts of interest.