Gastroenterologie up2date 2016; 12(01): 75-88
DOI: 10.1055/s-0042-103062
Leber/Galle/Pankreas
© Georg Thieme Verlag KG Stuttgart · New York

Leber und Gerinnung

Omar Mohamed
,
Matthias Dollinger
,
Thomas Seufferlein
,
Martin Griesshammer
Further Information

Publication History

Publication Date:
18 March 2016 (online)

Kernaussagen

Pathophysiologie

  • Aktuelle und moderne Betrachtungen des Gerinnungssystems bieten neue Einblicke in die hämostatischen Veränderungen bei akuten und chronischen Lebererkrankungen.

  • Bei Lebererkrankungen kommt es nicht nur zu einer Reduktion prokoagulatorischer Gerinnungsfaktoren, sondern auch zu Veränderungen im antikoagulatorischen, fibrinolytischen und antifibrinolytischen System. So entsteht oft ein fragiles, aber bilanziertes Hämostasegleichgewicht.

  • Zusätzliche Ereignisse wie Infektionen, Nierenversagen, Entzündungen und Trauma können dieses System in Richtung von Blutungs- oder Thrombosekomplikationen kippen lassen.

Diagnostik und Therapie

  • Screening-Gerinnungstests wie Quick/INR sind ungenau und möglicherweise irreführend bei der fortgeschrittenen Lebererkrankung. Die prophylaktische Verwendung von Frischplasma basierend auf INR-Cut-offs wird daher nicht empfohlen.

  • Alternative In-vitro-Tests, wie das endogene Thrombinpotenzial (ETP) und die Thrombelastografie (TEG), sind nicht ausreichend validiert, um als Ersatz empfohlen zu werden.

  • Prophylaxen und Rescue-Therapie von Blutungskomplikationen bleiben momentan empirisch und sollten individualisiert werden. Der Fokus auf eine schnelle Behandlung von Infektionen, Nierenversagen und Volumenüberlastung wird durch vorhandene Studiendaten unterstützt.

  • Antifibrinolytika spielen bei Patienten mit Lebererkrankungen und Hyperfibrinolyse eine Rolle. Der „Off-Label“-Gebrauch von hämostatischen Produkten wie rFVIIa und PCC ist ungenügend validiert, kostspielig und birgt potenzielle thrombotische Risiken.

  • Patienten mit fortgeschrittener Lebererkrankung können trotz erniedrigter Gerinnungsfaktoren auch thromboembolische Komplikationen, typischerweise eine Pfortaderthrombose, entwickeln. In diesen Situationen ist das Nutzen-Risiko-Verhältnis einer Antikoagulation durch Studiendaten nicht hinreichend geklärt. Es gibt daher einen großen Bedarf an klinischer Forschung, um diese Wissenslücken zukünftig durch Studien zu schließen.

 
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