Prädiktoren für erfolgreiche Lebertransplantationen und Risikofaktoren

Zusammenfassung

Die Lebertransplantation ist die einzige kurative Therapieoption einer chronischen Leberinsuffizienz im Endstadium. Daneben stellen onkologische Lebererkrankungen wie das HCC eine weitere Indikation für die Lebertransplantation dar, ebenso wie das akute Leberversagen.

Seit der ersten erfolgreichen Lebertransplantation durch Professor Thomas E. Starzl im Jahr 1967 haben sich nicht nur die chirurgischen, immunologischen und anästhesiologischen Techniken und Möglichkeiten geändert, sondern auch die Indikationen und das Patientengut. Hinzu kommt, dass die Empfänger ein zunehmendes Lebensalter und damit einhergehend mehr Begleiterkrankungen aufweisen.

Die Zahl an Lebertransplantationen ist weltweit weiter ansteigend. Es benötigen aber mehr Menschen eine Lebertransplantation, als Organe zur Verfügung stehen. Dies liegt am zunehmenden Bedarf an Spenderorganen bei gleichzeitig weiter rückläufiger Zahl postmortaler Organspenden.

Diese Diskrepanz zwischen Spenderorganen und Empfängern kann nur zu einem kleinen Teil durch Split-Lebertransplantationen oder die Leberlebendspende kompensiert werden.

Um den Spenderpool zu erweitern, werden zunehmend auch marginale Organe, die nur die erweiterten Spenderkriterien („extended donor criteria [EDC]“) erfüllen, allokiert. In manchen Ländern zählen hierzu auch die sogenannten DCD-Organe (DCD: „donation after cardiac death“), d. h. Organe, die erst nach dem kardiozirkulatorischen Tod des Spenders entnommen werden.

Es ist bekannt, dass marginale Spenderorgane mit einem erhöhten Risiko für ein schlechteres Transplantat- und Patientenüberleben nach Lebertransplantation einhergehen.

Um die Qualität marginaler Spenderorgane zu verbessern, hat sich eine rasante Entwicklung der Techniken der Organkonservierung über die letzten Jahre gezeigt. Mit der maschinellen Organperfusion besteht beispielsweise die Möglichkeit, die Organqualität deutlich zu verbessern. Insgesamt haben sich die Risikokonstellationen von Spenderorgan und Transplantatempfänger deutlich geändert.

Aus diesem Grunde ist es von großer Bedeutung, spezifische Prädiktoren für eine erfolgreiche Lebertransplantation sowie die entsprechenden Risikofaktoren für einen schlechten postoperativen Verlauf zu kennen, um das bestmögliche Transplantat- und Patientenüberleben nach Lebertransplantation zu ermöglichen.

Diese Einflussfaktoren, inklusive möglicher Risiko-Scores, sollen hier ebenso wie die neuen technischen Möglichkeiten in der Lebertransplantation beleuchtet werden.

Abstract

Liver transplantation is the only curative treatment option for end stage liver disease. Moreover, oncological liver disease (hepatocellular carcinoma) is an important relevant indication for liver transplantation, together with acute liver failure.

Since the first successful liver transplantation by Professor Thomas Starzl in 1967, liver transplantation has changed in many aspects. This concerns not only surgical, anaesthesiological and immunological improvements and further technical developments, but also altered patient characteristics. Patients undergoing liver transplantation are nowadays often more challenging, due to their age and relevant comorbidities.

The number of liver transplantations is constantly rising. However, there are more patients in need of liver transplantation than donor grafts are available. Discrepancies between liver transplant candidates and organ supply can only partially be compensated by split liver transplantation and liver transplantation from living donors.

To boost the pool of donor grafts, even marginal organs within the extended donor criteria (EDC) are being increasingly allocated. In some countries, even “donation after cardiac death (DCD) organs” are allocated as well.

Marginal donor grafts are often associated with reduced graft and patient survival after liver transplantation. To improve the quality of poor liver grafts, innovations in organ conservation with development of new techniques as the machine perfusion techniques have been established in recent years.

In summary, the constellation of risk factors of donor grafts as well as transplant recipients has become more challenging in recent decades. It is important to know the specific risk factors and predictors for liver transplantation, in order to obtain the best possible graft and patient survival after liver transplantation.

This review gives an overview of predictors for liver transplantation, specific risk scores and indices for donor/recipient match as well as new technical devices in liver transplantation.

Schlüsselwörter

Leberchirurgie - Leberversagen - Risikofaktor - Transplantation

Keywords

liver failure - liver surgery - risk factor - transplantation surgery

Publication History

Received: 23 March 2022

Accepted after revision: 26 May 2022

Article published online:
21 July 2022

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