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Möglichkeiten und Zukunftsperspektiven der Leberersatztherapie

Leberunterstützungstherapien – Wo stehen wir heute?

Liver support systems

Where are we today?

  • Innovationen in der Intensivmedizin
  • Published:
Intensivmedizin und Notfallmedizin

Zusammenfassung

Obgleich beispielsweise zum Lungen- oder Nierenersatz Verfahren im klinischen Alltag etabliert werden konnten, fehlt für die Leber eine entsprechend geeignete Technik, um Patienten mit Leberausfall entweder bis zur Regeneration des eigenen Organs oder bis zur Transplantation überbrückend behandeln zu können. Weder erscheinen, basierend auf der derzeitigen Literaturlage, die Patientenkollektive ausreichend charakterisiert, noch ist klar definiert, welche grundsätzlichen, quantitativen Funktionen Leberunterstützungssysteme erfüllen müssen. Eine Validierung der wichtigsten Systemparameter wie Blutfluss, Antikoagulation und die Auswirkungen auf die Biokompatibilität fehlt. Bei den derzeit in Erprobung befindlichen oder kommerziell erhältlichen Systemen können 3 Arten unterschieden werden: 1. die Plasmapherese (z. B. SEPET® System der Firma Arbios), 2. Entgiftungsverfahren wie die Albumindialyse [z. B. MARS® (Gambro oder SPAD)] oder das Prometheus® System (Fresenius) und 3. zellbasierte, meist mit einer zusätzlichen Entgiftungseinheit versehene Bioreaktoren (z. B. ELAD® System der Firma Vital therapy). Anhand der derzeitigen Literatur erscheinen die gängigen Verfahren insbesondere im Hinblick auf Detoxifikation mit klinischer Verbesserung von Patienten mit hepatischer Enzephalopathie geeignet. Aussagen zur Effektivität des Leberersatzes bezüglich der Reduktion der Mortalität fehlen bislang, dennoch dürften die Daten von 2 großen, derzeit noch laufenden multizentrischen Studien, die die Veränderungen der Mortalität als Endpunkt haben (Relief II, MARS-System, und Helios, Prometheus-System) darüber Auskunft geben.

Abstract

Despite existing procedures to replace lung or renal function in everyday clinical routine, an equivalent method to replace liver function is still missing to bridge patients to regenerate liver function or until transplantation. At the moment, neither the patient groups who would profit from such therapies nor the characteristics of the liver replacement therapy itself seem to be clear. Evaluation of the most important systemic parameters like blood flow, anticoagulation, and influence on biocompatibility are missing. Currently there are three main types of liver support systems: (1) plasmapheresis, e.g., SEPET® (Arbios); (2) artificial detoxification systems, e.g., albumin dialysis (MARS® (Gambro) or SPAD), and Prometheus® (Fresenius); (3) bioartificial detoxification systems where hepatocytes are used in bioreactors to compensate for liver function. Based on the current literature, the commonly used systems, especially with regard to detoxification, seem to be useful in the treatment of patients with hepatic encephalopathy. At present, there is no evidence that treatment with the commercially available liver support systems can improve survival in patients with liver failure. Two large multi-center studies are being performed for MARS (Relief II) and Prometheus (Helios), which will hopefully answer these questions.

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Authors and Affiliations

  1. Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, Ismaningerstr. 22, 81675, München, Deutschland

    A. Al-Chalabi & B. Kreymann

  2. Hepa Wash GmbH, Garching, Deutschland

    B. Kreymann

  3. Klinik und Poliklinik für Innere Medizin I, Universität Regensburg, Regensburg, Deutschland

    J. Langgartner & T. Brünnler

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  1. A. Al-Chalabi
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  2. B. Kreymann
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  3. J. Langgartner
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  4. T. Brünnler
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Serie:

Neue Technologien in der Intensivmedizin

Herausgegeben von J. Langgartner (Regensburg) und R.M. Schmid (München)

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Al-Chalabi, A., Kreymann, B., Langgartner, J. et al. Möglichkeiten und Zukunftsperspektiven der Leberersatztherapie. Intensivmed 46, 347–354 (2009). https://doi.org/10.1007/s00390-009-0039-y

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  • DOI: https://doi.org/10.1007/s00390-009-0039-y

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