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Anästhesiol Intensivmed Notfallmed Schmerzther 2005; 40(4): 199-206
DOI: 10.1055/s-2004-826116
Aktuelle Medizin und Forschung
© Georg Thieme Verlag KG Stuttgart · New York

Extrakorporale Blutreinigung im schweren Leberversagen mit der Albumindialyse MARS® - Einfluss auf intensivmedizinisch relevante Parameter

Extracorporeal Blood Purification in Severe Liver Failure with the Albumin Dialysis MARS® - Impact on Relevant Intensive Care ParametersS.  Mitzner1 , S.  Klammt1 , J.  Stange1 , G.  F. E.  Nöldge-Schomburg2 , R.  Schmidt1
  • 1 Klinik und Poliklinik für Innere Medizin (Direktor: Prof. Dr. med. habil. R. Schmidt), Universität Rostock
  • 2 Klinik und Poliklinik für Anästhesiologie und Intensivmedizin (Direktorin: Prof. Dr. med. habil. G. F. E. Nöldge-Schomburg), Universität Rostock
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Publication History

Publication Date:
15 April 2005 (online)

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Zusammenfassung

Klinische Studien zum Einsatz von extrakorporalen Leberersatzverfahren werden seit über 50 Jahren durchgeführt. Dabei kamen sowohl die Standard-Blutreinigungstechniken wie die Dialyse, Adsorption, Hämo- und Plasmafiltration als auch Bioreaktor-basierte Ansätze unter Verwendung von Leberzellen oder -geweben zum Einsatz. Die klinischen Erfahrungen beschränken sich dabei allerdings meist auf die Nutzung im akuten Leberversagen. Seit 1993 steht mit dem Molecular Adsorbent Recirculating System (MARS®) ein Verfahren zur Verfügung, das die Techniken von Dialyse, Filtration und Adsorption in einem biokompatiblen Ansatz vereint. Humanes Serum Albumin (HSA) wird dabei als selektiver molekularer Adsorber eingesetzt, der gezielt eiweißgebundene Substanzen, wie etwa Gallensäuren oder Bilirubin, binden kann. Die Anhäufung von Substanzen dieser Gruppe kann wesentlich zum Unterhalt und zur Verstärkung von Organdysfunktionen im Leberversagen beitragen. Sie werden unter anderem mit der Entstehung bzw. Verschlechterung der hyperdynamen hypotonen Kreislaufdysregulation, der hepatischen Enzephalopathie, dem hepatorenalen Syndrom, eingeschränkter hepatischer Proteinsynthese und starkem Juckreiz beim Leberversagen in Zusammenhang gebracht. Das HSA übernimmt die Giftstoffe vom Patientenblut und durchläuft eine, räumlich vom Blut getrennte, Entgiftungsstrecke (eine Bicarbonatdialyse, zwei Adsorber), um dann erneut zum Patientenblut zurückzufließen. Bis heute wurden über 4000 Patienten mit Leberversagen mit mehr als 16 000 Einzelbehandlungen therapiert. Damit handelt es sich beim MARS®-Verfahren um das am häufigsten klinisch eingesetzte Leberunterstützungssystem. Neben akuten Leberversagen wurden vor allem akut dekompensierte chronische Lebererkrankungen (Acute-on-Chronic Liver Failure, ACLF) behandelt. Der Einfluss auf intensivmedizinisch relevante Parameter durch die extrakorporale Behandlung wird im Zusammenhang mit den Besonderheiten eines Patienten mit einem Leberversagen (Infektanfälligkeit, atypischer Infektverlauf, Gerinnungsstörungen mit Blutungsneigung) diskutiert.

Abstract

Extracorporeal liver support methods have been tested for over 50 years now. Standard techniques of blood purification like dialysis, adsorption, hemo- and plasmafiltration as well as bioreactor-based approaches using liver cells or tissues have been used. Most clinical experience, however, is limited to use in acute liver failure (ALF). Since 1993, the Molecular Adsorbent Recirculating System (MARS®) has been used clinically - a system that combines dialysis, filtration and adsorption in a biocompatible method. Human serum albumin (HSA) acts as a selective molecular adsorbent binding protein-bound compounds like bile acids or bilirubin. These substances can contribute to the maintenance or even further aggravation of liver failure. They are linked with the pathogenesis of hyperdynamic hypotonic circulation, hepatic encephalopathy, hepatorenal syndrome, impaired hepatic protein synthesis, and intractable pruritus seen in chronic liver failure. HSA takes over the toxic substances from a patient"s blood and passes through a remote detoxification process including bicarbonate-dialysis and a two-step adsorption. It is then recirculated in the patient's blood. Up to today, more than 4000 patients have been treated in approximately 16 000 single sessions. Thus, MARS® represents the most frequently used liver support method at the present time. In addition to ALF, mainly acute decompensations of chronic liver failures (ACLF) have been treated. The impact of the extracorporeal treatment on relevant medical parameters of intensive care medicine is discussed with regard to the specific situation of the liver-failure patient (susceptibility to infection, atypical picture and course of infection, coagulation disorders and bleeding tendencies).

Schlüsselwörter

Leberschaden · Bilirubin · Gallensäuren · Albumin · Albumindialyse · Leberersatzverfahren

Key words

Hepatic failure · bilirubin · bile acids · albumin · albumin dialysis · liver support methods

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Dr. med. Steffen Mitzner

Klinik und Poliklinik für Innere Medizin, Universität Rostock

Ernst-Heydemann-Straße 6 · 18055 Rostock

Email: steffen.mitzner@med-uni-rostock.de