AINS Anästhesiologie · Intensivmedizin · Notfallmedizin · Schmerztherapie, Thieme Verlag Heft 5-2024, Jahrgang 59) ISSN 1439-1074 Seite(n) 296 bis 309 DOI: 10.1055/a-2168-9977 CareLit-Dokument-Nr: 318600 |
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Die theoretische Rationale für die Kombination aus Albumindialyse und einer klassischen Hämodialyse bei akutem (ALF) und akut-auf-chronischem Leberversagen (ACLF) ist gut verständlich. Dennoch konnte bisher nur für den therapeutischen Plasmaaustausch (TPE) ein Überlebensvorteil beim ALF nachgewiesen werden. Dieser Beitrag stellt das Prinzip der Albumindialyse und des TPE sowie die wichtigsten Studien zu diesen Verfahren bei ALF und ACLF dar. Abstract Combining albumin dialysis for the removal of hydrophobic substances with classical haemodialysis in the treatment of acute liver failure (ALF) and acute-on-chronic liver failure (ACLF) has a strong theoretical rational and clinical data showed a positive effect on laboratory and partly clinical characteristics of ALF and ACLF. However, neither the MARS nor the Prometheus System has so far been able to demonstrate a mortality benefit in ALF or ACLF patients. To date, only the use of therapeutic plasma exchange (TPE) has demonstrated significant removal of pathogen-associated (PAMPs), damage-associated molecular patterns (DAMPs) and pro-inflammatory cytokines. In addition, TPE also acts simultaneously by replacing protective but depleted mediators, thus improving multiple key pathophysiological principles of both ALF and ACLF. In ALF, both high-volume and standard-volume TPE showed a significant improvement in survival. The data on the use of TPE in ACLF is still sparse, with only two Chinese monocentric studies in patients with exclusively hepatitis B-associated ACLF suggesting potentially improved survival with TPE. The currently recruiting APACHE study will include patients with the modern EASL-CLIF definition of ACLF. Kernaussagen Sowohl das ALF als auch das ACLF sind durch ein hepatisches und ein extrahepatisches Multiorganversagen charakterisiert. Pathophysiologisch zentral ist hier das Zusammenspiel von unkontrollierter Inflammation, Koagulationsstörung und endothelialer Dysfunktion. Albumindialyse entfernt sowohl wasserlösliche als auch proteingebundene Toxine beim Leberversagen. Der therapeutische Plasmaaustauch entfernt zudem DAMPs, PAMPs und proinflammatorische Zytokine und führt über den Ersatz mit Plasma gesunder Spender zum Ausgleich protektiver, aber verbrauchter Faktoren. Additive Albumindialyse konnte bisher keine Verbesserung des Überlebens bei Patienten mit ALF oder ACLF zeigen. Therapeutischer Plasmaaustausch verbessert das transplantationsfreie Überleben bei Patienten mit ALF. Bei Patienten mit ACLF ist eine große klinische Studie in der Rekrutierungsphase, um den Effekt von Plasmaaustausch zu untersuchen. Schlüsselwörter akutes Leberversagen - akut-chronisches Leberversagen - extrakorporale Therapie - Albumindialyse - therapeutischer Plasmaaustausch Keywords acute liver failure - acute-on-chronic failure - extracorporeal therapy - Albumin dialysis - therapeutic plasma exchange 17 May 2024 © 2024. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany Literatur 1 Saliba F, Camus C, Durand F. et al. Albumin dialysis with a noncell artificial liver support device in patients with acute liver failure: a randomized, controlled trial. Ann Intern Med 2013; 159: 522-531 DOI: 10.7326/0003-4819-159-8-201310150-00005. (PMID: 24126646) CrossrefPubMedGoogle Scholar 2 MacDonald AJ, Subramanian RM, Olson JC. et al. Use of the molecular adsorbent recirculating system in acute liver failure: results of a multicenter propensity score-matched study. Crit Care Med 2022; 50: 286-295 DOI: 10.1097/CCM.0000000000005194. 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