Textbooks are snapshots of a specialty at a moment in time and, fortunately, these are exhilarating times for those who are interested in the liver. In many areas of hepatology the pace of progress and understanding has been rapid with the flow of new information outstripping the capacity for the clinician and
investigator to evaluate and assimilate emerging concepts into practice. Much of the substantial base of knowledge underpinning the field of hepatology is presented in Comprehensive Clinical Hepatology in well written, well edited chapters. The volume has much to offer to a broad spectrum of readers. Established concepts are fully presented and practical advice is provided. These authoritative discourses allow the construction of reliable scaffolding upon which one can become current and be in a position to integrate further knowledge as it becomes available. Hepatology as we know it now has been built over the past
100 or so years on the platforms of major advances. The great leaps include the development of clinical chemistry, the introduction and widespread use of percutaneous liver biopsy, the emergence of ever more accurate and progressively less invasive imaging capabilities, the explosion of interest in hepatitis that
followed the discovery of hepatitis viruses, the development of effective therapies for liver disease – beginning with corticosteroid therapy of autoimmune hepatitis and continuing through
the several therapies available for chronic viral hepatitis – and the surgical revolution that culminated in liver transplantation which has become an accepted procedure. These are but a few of the pillars upon which modern hepatology is built. Already on the horizon are new important areas which promise to expand and reshape our understanding of the liver and its disorders, and will undoubtedly enhance our ability to prevent and treat liver diseases. Increasing attention is being paid to the roles and interactions of the several cells other than hepatocytes and cholangiocytes which are found within the liver. Stellate cells, endothelial cells, macrophages, and immunocytes have all become important areas for investigation. The many actions of
chemokines and cytokines and their regulation are becoming clinically relevant. The dynamic processes leading to fibrosis are increasingly understood as are the processes that lead to cell death through apoptosis. Effective therapeutic approaches to modulate hepatic fibrosis will surely soon be available and ways
to regulate apoptosis may be forthcoming. Genetic influences on the liver are coming of age. It is widely recognized that individuals are collections of genotypes with genetic control of myriads of hepatic processes that determine the ability to synthesize, transport, and defend. As is amply discussed and exemplified throughout the volume, hepatologists have benefited from the importation of scientific advances from other fields. The hepatic effects of alcohol and its multiple interactions are cases in point. Amongst the longest
standing concepts in medicine is that excessive use of alcohol is detrimental. The liver is an established target for the damaging effects of alcohol. It clearly induces hepatic changes and injuries to a large extent as a result of the toxic effects of acetaldehyde. The interactions of alcohol and acetaminophen have attracted
considerable attention as an example of an unfavorable drugdrug interaction with acetaminophen hepatotoxicity enhanced in patients who are regular (and often excessive) users of alcohol. Furthermore, in an example of alcohol-viral interaction, patients who have chronic hepatitis C and continue to use alcohol have been shown to have increased levels of HCV RNA, and are more likely to accelerate the rate of progression towards cirrhosis and to have impaired the effectiveness of interferon based therapy. Other examples of similar interactions abound and the concept of multiple hits leading to progressive liver
injuries has taken traction. The emerging role and importance of fat in the liver is fully examined in this volume. It is remarkable how in only one generation, concepts have changed rather dramatically regarding
the importance of fat in the liver. Once considered a benign hepatic bystander in patients who use moderate amounts of alcohol or who are obese, there has been an evolution in understanding with recognition that the patient with fatty liver may be at risk of developing progressive liver disease and even cirrhosis. In Comprehensive Clinical Hepatology the roles of environmental influences including obesity and alcohol, and the interactions between fatty liver and viral induced liver diseases, are fully considered.
The field of hepatology is forward directed with many moving parts. The clinician is far better armed now to precisely diagnose the presence of liver disease, assess the extent of injury, and present informed opinions as to the likely prognosis. New opportunities to apply emerging science to emerging clinical care are all around us. An advance in one area leads to reassessment in other areas. The challenges and opportunities of hepatologists in the 21st century are amply demonstrated throughout Comprehensive Clinical Hepatology and the editors and authors are to be saluted for creating such an accessible and complete guide. It is a fine time to be a hepatologist.
Willis C. Maddrey, MD
Professor of Internal Medicine
Executive Vice President for Clinical Affairs
The University of Texas Southwestern
Medical Center at Dallas
Dallas, TX, USA
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