The golden age of hepatology

This year marks the 30th anniversary of the identification of the hepatitis C virus (HCV; 1). Back then, in the late 1980s, hepatology was a highly specialized niche for geeky individuals who assembled once a year in Chicago for the American Association for the Study of Liver Diseases meeting.

How impressive have the developments in our speciality been over these past three decades! After the discovery of HCV, came the demonstration that we could use targeted therapy to treat hepatitis B infection (2); this had a major impact on the success of liver transplantation that was previously undermined by aggressive recurrence of this infection after transplant. In 1993, three independent groups found that the ATP7B gene was causative for Wilson disease (3–5); this was soon followed, in 1996, by the identification of the hemochromatosis HFE gene by a private research group (6). More recently, we have witnessed the revolution caused by the combination of specific direct-acting antiviral therapies against HCV. We are now entering an era in which we have new systemic therapies to treat hepatocellular carcinoma, and we are also well engaged in the fight against non-alcoholic steatohepatitis (NASH).

In parallel with these landmark discoveries and achievements, we are facing a significant increase in the demography of individuals affected by chronic liver diseases. Although hepatology is no longer restricted to the treatment of complications of alcoholic cirrhosis, we must not forget that the consumption of alcoholic beverages remains a major cause of chronic liver damage. The reasons for the increase in the number of individuals afflicted by liver disease are numerous. The recognition that epidemics of chronic liver disease differ across the world (viral hepatitis in some countries versus NASH in others) is a reminder that liver disease can affect every human being, and the task of decreasing the prevalence and the impact of these conditions is daunting. This demography has translated in increased liver transplant activity not only in countries with established transplant activities but also in countries that have had to develop such activity to respond to the needs of their population.

Not only do we know more about liver diseases and not only are we more successful in treating these conditions, but we are also much better at predicting the evolution of liver conditions. The 1964 proposal by Child and Turcotte that patients with liver cirrhosis could be classified according to their surgical risk (7) was widely adopted by the hepatology community. We are now living in an era in which the Model for End-Stage Liver Disease has replaced the Child–Turcotte classification. If we use the capacity of artificial intelligence wisely, we will soon be able to add to our knowledge and our decision tools for the benefit of our patients.

In accordance with all this evidence, hepatology has evolved as a discipline. In many countries, it is now separated into general hepatology and transplant hepatology. The need for hepatologists is increasing at a pace that is not being met by the number of new hepatologists being trained.

In Canada, we must recognize that our speciality has grown and developed at many different levels. We now have an Area of Focused Competency in Adult Hepatology recognized by the Royal College of Physicians and Surgeons of Canada. Accordingly, many centres across the country have built training programs in hepatology, transplant hepatology, or both. Our association, the Canadian Association for the Study of the Liver (CASL), has increased the number of its members to close to 500, and CASL has developed strong affiliations with other organizations, such as the Canadian Association of Hepatology Nurses and the Canadian Network of Hepatitis C.

Last year, CASL had its first stand-alone meeting in Toronto. It was highly successful, with strong attendance, a scientific program of high-level quality, a record number of abstracts, and strong support from all partners in our discipline.

As Rick Schreiber, CASL former president, said, our goal is to work together with all those interested in understanding, diagnosing, treating, and supporting individuals affected by liver diseases across Canada. We need to work together as a multidisciplinary team if we want to reach the goals of decreasing the number of patients affected by liver conditions in our country and across the world. The Canadian Liver Journal, which is only 1 year old, is the latest of our tools to transmit the knowledge and the good word of what is being achieved in Canada in the field of hepatology.

I feel privileged to have lived these last 30 years of what I consider the golden age of hepatology, and I feel confident that the best years are yet to come.