Die Therapie des akuten Leberversagens – alte Mythen und neue Trends

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

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