Dear Editor,
The liver is a vital organ that plays a crucial role in metabolism, detoxification, and immune defense. However, modern lifestyles characterized by an unhealthy diet, lack of exercise, excessive alcohol consumption, and hepatitis viral infections are significant threats to liver health of the Chinese population. In response, China initiated the National Protect Liver Day in 2001, which is observed annually on March 18. This year marks its 25th anniversary, and 24 national public welfare health education campaigns were held since its inception. Unlike the World Hepatitis Day (Table 1), which focuses on chronic viral hepatitis, China’s National Protect Liver Day addresses general liver health and aims to raise public awareness through annual campaigns under different themes. The 2025 theme, “Integrating Traditional Chinese Medicine and Western Medicine to Reverse Liver Cirrhosis”, highlights the potential of reversing liver cirrhosis through standardized treatments and awareness campaigns.
Table 1.
Differences between the National Protect Liver Day and the World Hepatitis Day.
| Aspect | National Protect Liver Day | World Hepatitis Day |
|---|---|---|
| Annual date | March 18 | July 28 |
| Launch year | 2001 | 2008 |
| Initiator | China | WHO and WHA |
| Focus and objectives | Emphasizes general liver health and educating, screening, prevention, and encouraging healthy lifestyles | Specifically targets viral hepatitis (A, B, C, D, and E) and their vaccination, testing, diagnosis, treatment, and policy |
| Target audience | General public, promote liver health and prevent liver diseases | Healthcare providers, policymakers, and general public, raise better prevention and treatment |
| Themes | Prevent and Screen Fibrosis Early to Avoid Cirrhosis (2024) Screen, Treat, and Eliminate Hepatitis B Harm (2023) |
It's Time for Action (2024) One Life, One Liver (2023) |
| Physicians engaged | Hepatologists | Infectious disease experts |
Abbreviations: WHA, World Hepatitis Alliance; WHO, World Health Organization.
The burden of chronic liver diseases, cirrhosis, and hepatocellular carcinoma (HCC) remains significantly higher in China compared to other global regions. Although the incidence of hepatitis B virus (HBV) infection has declined because of vaccination and antiviral therapies, HBV infection is still the leading cause of liver cirrhosis and HCC, accounting for 70%–80% of HCC cases. Currently, China records approximately 75 million cases of chronic HBV infections, representing approximately 30% of the global HBV burden.1 In patients with chronic hepatitis B (CHB), the overall prevalence of significant liver fibrosis and cirrhosis is substantial. Studies have indicated that approximately 20%–30% of patients with CHB infection develop significant fibrosis, and 10%–20% progress to cirrhosis over time. This highlights the relatively high prevalence of liver fibrosis among individuals with CHB, particularly those untreated with effective antiviral therapies.
In China, metabolic dysfunction-associated fatty liver disease (MAFLD) and alcohol-related liver disease (ALD) have rapidly increased over the past 20 years.2 MAFLD affects 29.6% of adults and is triggered by overnutrition, obesity, and diabetes. Overlapping etiologies, such as chronic HBV infection with MAFLD or ALD, are increasingly common, creating a unique feature of chronic liver disease in China. This dual burden accelerates liver fibrosis progression and complicates liver disease treatment and management, posing significant challenges for clinicians. In a prospective study conducted in China from 2021 to 2022, the prevalence of liver fibrosis in the general population was as follows: ≥F1, 35.45%; ≥F2, 7.53%; ≥F3, 2.55%; and F4 (cirrhosis), 1.16%.3 Among high-risk groups such as individuals with obesity, patients with diabetes, and older people, the rates of advanced liver fibrosis were 6.80%, 5.62%, and 4.08%, respectively.
Currently, cirrhosis-related mortality in China exceeds 22.4 per 100,000 people, driven by complications such as clinically significant portal hypertension, hepatic decompensation, and HCC. Concurrently, over the past decade, MAFLD-related cirrhosis has surged by 30%, exacerbated by obesity and diabetes. Therefore, China’s liver disease spectrum is marked by a dual challenge: managing HBV-related complications while addressing the rising incidence of MAFLD and ALD. Cirrhosis still accounts for a significant proportion of liver disease-related morbidity and mortality.
Hepatic fibrosis and cirrhosis involve complex pathological processes, such as hepatocyte injury and regeneration, and immune responses; thus, monotherapy is insufficient for comprehensive treatment. China’s unique integrative medicine approach, combining traditional Chinese medicine (TCM) with Western medicine, has demonstrated significant benefits in the prevention and treatment of hepatic fibrosis and cirrhosis. This integrative approach incorporates advanced Western medical treatments and integrates TCM, achieving effective complementarity between the two. In the antifibrotic treatment of patients with CHB infection and significant fibrosis, the combination of TCM and Western medicine has shown remarkable therapeutic efficacy.
The management of HBV-related cirrhosis has significantly progressed through the advent of dual antifibrotic therapy, which combines TCM with antiviral drugs. Studies have demonstrated that integrating TCM with nucleos(t)ide analogs such as tenofovir or entecavir enhances antifibrotic effects.4, 5, 6, 7 This approach reverses cirrhosis in some cases and promotes recompensation in patients with decompensated cirrhosis. Recent studies have highlighted the efficacy of TCM formulations such as compound Biejia-Ruangan tablets, Fuzheng Huayu capsules, and Anluo Huaxian pills in treating patients with CHB, fibrosis, and cirrhosis.5, 6, 7 After 72 weeks of treatment, compound Biejia-Ruangan tablets combined with entecavir achieved a 40% fibrosis regression rate and 41.5% cirrhosis reversal rate, which was significantly higher than that of the entecavir monotherapy group.5,6 Furthermore, with a long-term follow-up of up to 7 years, combination therapy could further reduce the incidence of HCC by 51.1% and liver-related deaths by 89.9% in patients with CHB receiving entecavir treatment.5,6 Fuzheng Huayu capsules have also shown significant efficacy in improving fibrosis reversal after 48 weeks of treatment, particularly in patients with baseline Ishak fibrosis stages F3 and F4.7 Moreover, >50% of patients with HBV-related decompensated cirrhosis treated with antivirals achieve recompensation.4 These results demonstrate that the integration of TCM with conventional antiviral regimens represents a promising approach in the management of HBV-related fibrosis and cirrhosis. More studies are needed to validate these findings and explore the mechanisms underlying the antifibrotic properties of these agents.
For MAFLD and metabolic dysfunction-associated steatohepatitis (MASH), lifestyle modifications, particularly weight loss of ≥10%, have been demonstrated to reverse fibrosis in patients with fibrosis stages F2 and F3. For example, significant weight loss can lead to a reversal of fibrosis in up to 45% of patients with advanced fibrosis through lifestyle interventions.8 In addition to lifestyle changes, anti-obesity pharmacological advancements have also shown potential in treating MASH and significant fibrosis. Glucagon-like peptide-1 receptor agonists, such as semaglutide, reduce MAFLD activity scores and improve metabolic parameters, potentially slowing fibrosis progression. Farnesoid X receptor agonists, such as obeticholic acid, have demonstrated the ability to reverse fibrosis in MASH; however, adverse effects such as pruritus and lipid disorders limit their widespread use. Resmetirom, a liver-selective thyroid hormone receptor-beta agonist, has demonstrated significant efficacy in improving liver fibrosis and MASH. In clinical trials, resmetirom achieved a 24.2% improvement in fibrosis by at least one stage in the 80 mg group and 25.9% in the 100 mg group, compared with 14.2% in the placebo group. This improvement was observed without a worsening of the MAFLD activity score. These results supported the accelerated approval by the United States Food and Drug Administration of resmetirom in March 2024 for the treatment of MASH with significant fibrosis. In addition, fibroblast growth factor 21 analogs such as pegozafermin have shown significant reductions in serum triglyceride levels and improvements in metabolic profiles, which may contribute to fibrosis reversal. The pan-peroxisome proliferator-activated receptor agonists, such as lanifibranor, have also been shown to improve insulin resistance and reduce liver fat content. Similarly, alcohol cessation reverses alcohol-related liver fibrosis, emphasizing the importance of behavioral interventions in the management of chronic liver disease. These findings underscore the critical role of lifestyle modifications and pharmacological interventions in managing and reversing liver fibrosis in patients with MAFLD and ALD.
In conclusion, the integration of antiviral therapy, antifibrotic agents, and lifestyle interventions is a multifaceted approach to the management of liver fibrosis and cirrhosis. These strategies address the underlying causes and promote fibrosis reversal and disease regression, offering hope for improved outcomes in Chinese patients with chronic liver diseases.
China has recently released updated guidelines for the prevention and treatment of liver cirrhosis and MAFLD.9,10 These guidelines provide comprehensive recommendations for the screening, diagnosis, and treatment, focusing on liver fibrosis and cirrhosis. The guidelines highlight the importance of screening high-risk populations for liver fibrosis and cirrhosis. Individuals with obesity, type 2 diabetes, metabolic syndrome, persistently high liver enzymes, or a history of excessive alcohol consumption should be screened regularly for liver fibrosis and cirrhosis. Noninvasive tools such as the fibrosis-4 index and transient elastography liver stiffness measurement are recommended for initial screening. Patients with advanced fibrosis and cirrhosis should be further screened for HCC and clinically significant portal hypertension to manage comorbidities and improve patient overall outcomes of MAFLD. Regular follow-up is crucial for monitoring disease progression and managing complications; the guidelines advocate for a multidisciplinary approach involving hepatologists, endocrinologists, nutritionists, and other specialists. Patients should be screened periodically for metabolic syndrome, diabetes, chronic kidney disease, and cardiovascular disease risk. Continuous monitoring of metabolic parameters (e.g., blood glucose and serum lipid levels) and lifestyle interventions are essential to prevent further liver damage.
These guidelines are intended to standardize the screening, diagnosis, and treatment for liver fibrosis and cirrhosis in China, ultimately enhancing patient outcomes and reducing the liver disease burden.
Given the significant research advancements and latest 2024 guidelines on MAFLD issued by the Chinese Society of Hepatology, the 2025 National Protect Liver Day will emphasize comprehensive management strategies for HBV-related and fatty liver-related fibrosis and cirrhosis. The initiative aims to standardize, promote, and disseminate evidence-based integrated traditional Chinese and Western medicine approaches, emphasizing their pivotal role in advancing the prevention and treatment of liver cirrhosis within China’s healthcare systems.
Authors’ contributions
Cuicui Shi: Writing – original draft. Jiangao Fan: Writing – review & editing, Conceptualization, Funding acquisition.
Declaration of competing interest
The authors declare that there is no conflicts of interest.
Acknowledgements
This work was supported by Noncommunicable Chronic Disease-National Science and Technology Major Project of China (No. 2023ZD0508700).
Footnotes
Peer review under the responsibility of Editorial Office of Liver Research.
References
- 1.Xiao J., Wang F., Wong N.K., et al. Global liver disease burdens and research trends: analysis from a Chinese perspective. J Hepatol. 2019;71:212–221. doi: 10.1016/j.jhep.2019.03.004. [DOI] [PubMed] [Google Scholar]
- 2.Yip T.C., Fan J.G., Wong V.W. China’s fatty liver crisis: a looming public health emergency. Gastroenterology. 2023;165:825–827. doi: 10.1053/j.gastro.2023.06.008. [DOI] [PubMed] [Google Scholar]
- 3.Liu S., Wan H., Yang L., Shen J., Qi X., LiverHome study group High prevalence of steatotic liver disease and fibrosis in the general population: a large prospective study in China. J Hepatol. 2025;82:e23–e25. doi: 10.1016/j.jhep.2024.07.026. [DOI] [PubMed] [Google Scholar]
- 4.Wang Q., Zhao H., Deng Y., et al. Validation of Baveno VII criteria for recompensation in entecavir-treated patients with hepatitis B-related decompensated cirrhosis. J Hepatol. 2022;77:1564–1572. doi: 10.1016/j.jhep.2022.07.037. [DOI] [PubMed] [Google Scholar]
- 5.Ji D., Chen Y., Bi J., et al. Entecavir plus Biejia-Ruangan compound reduces the risk of hepatocellular carcinoma in Chinese patients with chronic hepatitis B. J Hepatol. 2022;77:1515–1524. doi: 10.1016/j.jhep.2022.07.018. [DOI] [PubMed] [Google Scholar]
- 6.Luo L., Yao X., Yang W. Biejia-Ruangan compound and incidence of hepatocellular carcinoma. J Hepatol. 2023;78:e141–e142. doi: 10.1016/j.jhep.2022.11.012. [DOI] [PubMed] [Google Scholar]
- 7.Zhao Z.M., Zhu C.W., Huang J.Q., et al. Efficacy and safety of Fuzheng Huayu tablet on persistent advanced liver fibrosis following 2 years entecavir treatment: a single arm clinical objective performance criteria trial. J Ethnopharmacol. 2022;298 doi: 10.1016/j.jep.2022.115599. [DOI] [PubMed] [Google Scholar]
- 8.Zhou D., Fan J. Drug treatment for metabolic dysfunction-associated steatotic liver disease: progress and direction. Chin Med J (Engl) 2024;137:2687–2696. doi: 10.1097/CM9.0000000000003355. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Xin S.L., Xu X.Y. Research progress on liver fibrosis, cirrhosis, and portal hypertension in 2024 (in Chinese) Zhonghua Gan Zang Bing Za Zhi. 2025;33:7–9. doi: 10.3760/cma.j.cn501113-20241128-00601. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Fan J.G., Xu X.Y., Yang R.X., et al. Guideline for the prevention and treatment of metabolic dysfunction-associated fatty liver disease (version 2024) J Clin Transl Hepatol. 2024;12:955–974. doi: 10.14218/JCTH.2024.00311. [DOI] [PMC free article] [PubMed] [Google Scholar]