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Dtsch Med Wochenschr 2019; 144(15): 1034-1039
DOI: 10.1055/a-0652-8224
Klinischer Fortschritt
Intensivmedizin
© Georg Thieme Verlag KG Stuttgart · New York

Die Therapie des akuten Leberversagens – alte Mythen und neue Trends

Treatment of Fulminant Hepatic Failure – Myth and Facts
Nadja Rifaie
  Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen
,
Fuat H. Saner
  Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen
› Institutsangaben
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Publikationsverlauf

Publikationsdatum:
26. Juli 2019 (online)

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Was ist neu?

Diagnosestellung Es ist von entscheidender therapeutischer und diagnostischer Konsequenz zwischen einem echten akuten Leberversagen und einer akuten Dekompensation einer chronischen Lebererkrankung mit oder ohne Organausfall zu unterscheiden.

Therapie Ungeachtet des klinischen Eindrucks gehört ein Patient mit akutem Leberversagen zunächst auf die Intensivstation. Sofern möglich, ist eine kausale Therapie durchzuführen. Bisher existiert kein funktionierendes Leberersatzverfahren. Plasmapherese kann nützlich sein.

Gerinnungsstörung Untersuchungen der letzten Jahre zeigen, dass beim ALV eher eine Thromboseneigung als die bisher vermutete Koagulopathie besteht.

Enzephalopathie und Hirnödem Die Enzephalopathie und ein potenziell letales Hirnödem spielen eine entscheidende Rolle für die Prognose.

Transplantation Bei akutem Leberversagen wird zunehmend weniger transplantiert. Dies liegt am ehesten am Fortschritt in der intensivmedizinischen Therapie.

Abstract

Acute liver failure (ALF) refers to primary damage to a previously healthy liver. It is a rare disease with an incidence of about 200–500 cases/year in Germany. The liver can recover to restitutio ad integrum or lead to death in no time despite best medical treatment. Due to the rarity and potentially dramatic clinical course, patients with acute liver failure should be promptly referred to a special liver unit that can provide a liver transplantation as rescue treatment.

The ALF should be strictly distinguished from “acute-on-chronic” liver failure (ACLF), which may show a similar clinical course but does not qualify for a high-urgency listing and transplantation.

The reason for an ALF remains unknown in up to 20 % of cases. Hepatotropic virus (HAV, HBV and HEV) are the most common causative agents in Africa and Asia, while in North America and Northern and Central Europe, more drug-related liver failure is more frequent. Among drugs paracetamol and phenprocoumone are the leading cause for ALF. However, there are a couple of dietary supplements, herbs and mushroom poisoning that cause ALF.

Other reasons are ischemic hepatitis and autoimmune hepatitis.

Schlüsselwörter

Akutes Leberversagen - Hämodynamik - Hirnödem - Kritisch kranker Patient - Lebertransplantation

Key words

acute liver failure - hemodynamic - brain edema - critical care - liver transplantation
 

  • Literatur

  • 1 Canbay A, Tacke F, Hadem J. et al. Acute liver failure: a life-threatening disease. Dtsch Arztebl Int 2011; 108: 714-720 . doi:10.3238/arztebl.2011.0714
    PubMedGoogle Scholar
  • 2 Navarro VJ, Khan I, Bjornsson E. et al. Liver injury from herbal and dietary supplements. Hepatology 2017; 65: 363-373 . doi:10.1002/hep.28813
    CrossrefPubMedGoogle Scholar
  • 3 Hu J, Zhang Q, Ren X. et al. Efficacy and safety of acetylcysteine in “non-acetaminophen” acute liver failure: A meta-analysis of prospective clinical trials. Clin Res Hepatol Gastroenterol 2015; 39: 594-599 . doi:10.1016/j.clinre.2015.01.003
    CrossrefPubMedGoogle Scholar
  • 4 Ichai C, Orban JC, Fontaine E. Sodium lactate for fluid resuscitation: the preferred solution for the coming decades?. Crit Care 2014; 18: 163 . doi:10.1186/cc13973
    CrossrefPubMedGoogle Scholar
  • 5 Bernal W, Auzinger G, Dhawan A. et al. Acute liver failure. Lancet 2010; 376: 190-201 . doi:10.1016/S0140-6736(10)60274-7
    CrossrefPubMedGoogle Scholar
  • 6 Karvellas CJ, Cavazos J, Battenhouse H. et al. Effects of antimicrobial prophylaxis and blood stream infections in patients with acute liver failure: a retrospective cohort study. Clin Gastroenterol Hepatol 2014; 12: 1942-1949 e1941 . doi:10.1016/j.cgh.2014.03.011
    CrossrefPubMedGoogle Scholar
  • 7 Saliba F, Camus C, Durand F. et al. Albumin dialysis with a noncell artificial liver support device in patients with acute liver failure: a randomized, controlled trial. Ann Intern Med 2013; 159: 522-531 . doi:10.7326/0003-4819-159-8-201310150-00005
    CrossrefPubMedGoogle Scholar
  • 8 Larsen FS, Schmidt LE, Bernsmeier C. et al. High-volume plasma exchange in patients with acute liver failure: An open randomised controlled trial. J Hepatol 2016; 64: 69-78 . doi:10.1016/j.jhep.2015.08.018
    CrossrefPubMedGoogle Scholar
  • 9 Lisman T, Stravitz RT. Rebalanced Hemostasis in Patients with Acute Liver Failure. Semin Thromb Hemost 2015; 41: 468-473 . doi:10.1055/s-0035-1550430
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 10 Bernal W, Hyyrylainen A, Gera A. et al. Lessons from look-back in acute liver failure? A single centre experience of 3300 patients. J Hepatol 2013; 59: 74-80 . doi:10.1016/j.jhep.2013.02.010
    CrossrefPubMedGoogle Scholar
  • 11 Wendon J. European Association for the Study of the Liver. Electronic address eee, Clinical practice guidelines p. et al. EASL Clinical Practical Guidelines on the management of acute (fulminant) liver failure. J Hepatol 2017; 66: 1047-1081 doi:10.1016/j.jhep.2016.12.003
    CrossrefPubMedGoogle Scholar
  • 12 Acharya SK, Bhatia V, Sreenivas V. et al. Efficacy of L-ornithine L-aspartate in acute liver failure: a double-blind, randomized, placebo-controlled study. Gastroenterology 2009; 136: 2159-2168 . doi:10.1053/j.gastro.2009.02.050
    CrossrefPubMedGoogle Scholar
  • 13 Plauth M, Cabre E, Campillo B. et al. ESPEN Guidelines on Parenteral Nutrition: hepatology. Clin Nutr 2009; 28: 436-444 . doi:10.1016/j.clnu.2009.04.019
    CrossrefPubMedGoogle Scholar
  • 14 Bernal W, Murphy N, Brown S. et al. A multicentre randomized controlled trial of moderate hypothermia to prevent intracranial hypertension in acute liver failure. J Hepatol 2016; 65: 273-279 . doi:10.1016/j.jhep.2016.03.003
    CrossrefPubMedGoogle Scholar
  • 15 Germani G, Theocharidou E, Adam R. et al. Liver transplantation for acute liver failure in Europe: outcomes over 20 years from the ELTR database. J Hepatol 2012; 57: 288-296 . doi:10.1016/j.jhep.2012.03.017
    CrossrefPubMedGoogle Scholar
  • 16 [Anonym]. Richtlinien zur Organtransplantation gem. § 16 TPG. Deutsches Ärzteblatt 2016; 113 DOI: 10.3238/arztebl.2016.rili_baek_OrgaWlOvLeberTx20160226.
    PubMedGoogle Scholar
  • 17 McPhail MJ, Wendon JA, Bernal W. Meta-analysis of performance of Kings's College Hospital Criteria in prediction of outcome in non-paracetamol-induced acute liver failure. J Hepatol 2010; 53: 492-499 . doi:10.1016/j.jhep.2010.03.023
    CrossrefPubMedGoogle Scholar
  • 18 Rela M, Kaliamoorthy I, Reddy MS. Current status of auxiliary partial orthotopic liver transplantation for acute liver failure. Liver Transpl 2016; 22: 1265-1274 . doi:10.1002/lt.24509
    CrossrefPubMedGoogle Scholar
  • 19 Anderson TN, Zarrinpar A. Hepatocyte transplantation: past efforts, current technology, and future expansion of therapeutic potential. J Surg Res 2018; 226: 48-55 . doi:10.1016/j.jss.2018.01.031
    CrossrefPubMedGoogle Scholar