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Akutes Leberversagen

Aktuelle Aspekte zur Diagnostik und Therapie

Acute liver failure

Current aspects of diagnosis and therapy

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Zusammenfassung

Störungen der Partialfunktionen der Leber, wie Synthese, Exkretion oder Biotransformation, sind für Verlauf und Prognose des Patienten mit Multiorgandysfunktion von maßgeblicher Bedeutung und werden bei Betrachtung klassischer Parameter, wie Serumtransaminasen oder -bilirubin in ihrer Inzidenz unterschätzt. Umgekehrt bestimmen extrahepatische Komplikationen, wie hyperdynames Kreislaufversagen, hepatorenales Syndrom (HRS) oder hepatische Enzephalopathie (HE), die Prognose des akuten Leberversagens im engeren Sinne. Für die Diagnose „akutes Leberversagen“ wird neben Koagulopathie und Ikterus daher auch die HE herangezogen. Zur Verlaufsbeurteilung des Patienten mit akutem Leberversagen oder schwerer Leberdysfunktion im Rahmen des Multiorganversagens werden heute neben klassischen „statischen“ Parametern, wie Serumbilirubin „dynamische“ Tests, die den aktuellen Funktions- und Perfusionszustand der Leber anhand komplexer Leistungen, z. B. der Elimination des Farbstoffs Indozyaningrün, ermitteln, empfohlen. Neben spezifischen oder kausalen Behandlungsmöglichkeiten, wie der Gabe von N-Acetylcystein (NAC) bei der Paracetamolintoxikation oder der Beendigung der Schwangerschaft beim HELLP-Syndrom (hemolysis, elevated liver enzymes, low platelet counts), stehen mit der Gabe von Albumin und Terlipressin und der extrakorporalen Unterstützung der Entgiftungsfunktion, z. B. mit der Albumindialyse, aktuell neue Behandlungskonzepte zur Verfügung, die in aktuellen Studien eine günstige Beeinflussung der schlechten Prognose des Leberversagens nahe legen. Beim akuten Leberversagen mit erwarteter Letalität >80% bleibt dagegen die Lebertransplantation das Therapieverfahren der Wahl.

Abstract

Disturbances of some partial liver functions, such as synthesis, excretion, or biotransformation of xenobiotics, are important for prognosis and ultimate survival in patients presenting with multiple organ dysfunction on the intesive care unit (ICU). The incidence of liver dysfunction is underestimated when traditional “static” measures such as serum-transaminases or bilirubin as opposed to “dynamic” tests, such as clearance tests, are used to diagnose liver dysfunction. Similar to the central role of the failing liver in MODS, extrahepatic complications, such as hepatorenal syndrome and brain edema develop in acute or fulminant hepatic failure and determine the prognosis of the patient. This is reflected in the required presence of hepatic encephalopathy in addition to hyperbilirubinemia and coagulopathy for the diagnosis of acute liver failure. In addition to these clinical signs, dynamic tests, such as indocyanine green clearance, which is available at the bed-side, are useful for the monitoring of perfusion and global liver function. In addition to specific and causal therapeutic interventions, e.g. N-acetylcysteine for paracetamol poisoning or termination of pregnancy for the HELLP-syndrome, new therapeutic measures, e.g. terlipressin/albumin or albumin dialysis are likely to improve the poor prognosis of acute-on-chronic liver failure. Nevertheless, liver transplantation remains the treatment of choice for fulminant hepatic failure when the expected survival is <20%.

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  1. Klinik für Anaesthesiologie und Intensivmedizin, Universität des Saarlandes

    M. Bauer & A. Kortgen

  2. Klinik für Anaesthesiologie und Intensivtherapie, Friedrich-Schiller-Universität, Jena

    M. Bauer & M. Paxian

  3. Klinik für Anästhesiologie und Intensivmedizin, Universität des Saarlandes, Kirrberger Straße/Geb. 57, 66421, Homburg/Saar

    M. Bauer

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Bauer, M., Paxian, M. & Kortgen, A. Akutes Leberversagen. Anaesthesist 53, 511–530 (2004). https://doi.org/10.1007/s00101-004-0682-4

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