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Gerinnungsdiagnostik und -therapie bei Leberinsuffizienz

Coagulation management in patients with liver disease

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Zusammenfassung

Hintergrund

Das Vorliegen einer fortgeschrittenen Leberfunktionseinschränkung geht mit komplexen Veränderungen der Gerinnung einher. Während in der einen Patientengruppe lebensbedrohliche Blutungskomplikationen die Prognose maßgeblich mitbestimmen, stehen insbesondere bei Patienten mit cholestatisch bedingter Lebererkrankung häufig thrombembolische Komplikationen im Vordergrund. Die Parameter der konventionellen laborchemischen Gerinnungsdiagnostik, wie Quick-Wert, aktivierte partielle Thromboplastinzeit (aPTT) und Thrombozytenzahl, können das veränderte Gleichgewicht pro- und antikoagulatorischer Faktoren nicht vollständig erfassen und sind zur Abschätzung des Blutungs- bzw. Thromboserisikos bei Patienten mit akutem Leberversagen oder dekompensierter Leberzirrhose häufig nicht ausreichend.

Diagnostik und Therapie

Durch den Einsatz einer patientennahen Gerinnungsdiagnostik unter Anwendung der Thrombelastometrie/-graphie, einer Thrombozytenfunktionstestung mittels Impedanzaggregometrie sowie gezielter Einzelfaktorenbestimmungen wird insbesondere bei Blutungskomplikationen oder im Rahmen invasiver Eingriffe eine zielgerichtete kausale Therapie der hepatischen Gerinnungsstörung ermöglicht. Dies konnte in den letzten Jahren insbesondere im Rahmen der Lebertransplantation nicht nur zu einer Reduktion der Blutungskomplikationen, sondern auch zu einer deutlichen Einsparung an nebenwirkungsbehafteten Transfusionen allogener Blutprodukte beitragen.

Diskussion

In der vorliegenden Übersichtsarbeit sollen die vielschichtigen pathophysiologischen Veränderungen der Hämostase bei fortgeschrittener Leberinsuffizienz dargestellt werden sowie Diagnosemöglichkeiten und Therapieansätze diskutiert werden.

Abstract

Background

End-stage liver disease is associated with complex alterations in hemostasis. Whereas prognosis is essentially affected by life-threatening bleeding complications in some patients, others, especially those with cholestatic liver diseases, suffer from thromboembolic complications. Standard laboratory values (SLVS; prothrombin time, activated partial thrombin time, platelet count) cannot sufficiently reflect the altered balance of pro- and anticoagulatory factors. Moreover, a couple of studies indicated that SLVS are not able to predict bleeding complications in patients with acute liver failure or decompensated liver cirrhosis.

Diagnosis and therapy

Use of bed-side coagulation diagnostics such as thrombelastometry/-graphy, detection of thrombocyte function by multiple electrode aggregometry and selective measurement of single factors allows a targeted and causal therapy of hepatic coagulopathies especially in the context of bleeding complications or surgical interventions. In recent years, coagulation management guided by these new devices has contributed to a reduction in transfusion of allogenic blood products, which may be associated with undesirable side effects.

Discussion

The current review summarizes the complex pathophysiological alterations of hemostasis associated with advanced liver insufficiency and discusses recent upcoming diagnostics and coagulation management in this patient cohort.

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  1. Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland

    A. Bienholz & F.H. Saner

  2. Klinik für Nephrologie, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Deutschland

    A. Bienholz

  3. Klinik für Gastroenterologie und Hepatologie, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland

    A. Canbay

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F.H. Saner erhielt Honorare von CLS Behring, Gilead, AstraZeneca GmbH und MSD Sharp & Dohme GmbH. A. Bienholz und A. Canbay geben an, dass kein Interessenkonflikt besteht.

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Bienholz, A., Canbay, A. & Saner, F. Gerinnungsdiagnostik und -therapie bei Leberinsuffizienz. Med Klin Intensivmed Notfmed 111, 224–234 (2016). https://doi.org/10.1007/s00063-015-0027-x

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