Versorgung bei kompensierter Leberzirrhose 2018 – Evidenzbasierte prophylaktische Maßnahmen

Zusammenfassung

In Deutschland starben 2015 mehr als 13 000 Menschen an den Folgen einer Leberzirrhose. Die Diagnose einer fortgeschrittenen Leberschädigung kann häufig mit nicht-invasiven Methoden (z. B. mittels ultraschallbasierter Messung der Steifigkeit des Lebergewebes) bereits im noch kompensierten Stadium gestellt werden. Entscheidend ist bei Diagnosestellung eine umfassende Ursachenabklärung und konsequente Therapie der zugrundeliegenden chronischen Lebererkrankung, um einen weiteren Progress bis zur Dekompensation zu verhindern. Da insbesondere bei einer Dekompensation (angezeigt u. a. durch Ikterus, Aszites, hepatische Enzephalopathie, gastrointestinale Blutung) Morbidität und Mortalität deutlich ansteigen (z. B. steigt die 1-Jahres-Mortalität von 1 – 3,4 % auf 20 – 57 %), sind prophylaktische Maßnahmen zur Vermeidung einer Dekompensation indiziert. Diese Maßnahmen umfassen nach Risikostratifizierung einer portalen Hypertension den Einsatz von Propranolol oder Carvedilol sowie eine endoskopische Ligatur mit Gummibändern zur Primärprophylaxe einer Varizenblutung. Aufgrund des hohen Risikos für eine maligne Transformation (je nach Ätiologie der Leberzirrhose 2 – 8 % pro Jahr), ist auch eine sonografische Überwachung alle sechs Monate zur frühen Diagnose eines Leberzellkarzinoms entscheidend, um eine kurative Therapie zu ermöglichen. Diskutiert wird auch der Einsatz von Antibiotika zur Vermeidung von Infektionen, die in vielen Fällen eine akute Dekompensation auslösen. Hier ist die Datenlage noch nicht überzeugend und das Risiko einer Resistenzbildung ist zu beachten. Unbedingt sollte aber der Impfstatus überprüft und Impflücken geschlossen werden. Zur Versorgung bei kompensierter Leberzirrhose gehören auch eine ernährungsphysiologische Beratung und ggf. medikamentöse Therapien, um das Voranschreiten von Osteoporose und Muskelatrophie aufzuhalten. In diesem Aufsatz werden die einzelnen Maßnahmen zur prophylaktischen Versorgung bei kompensierter Leberzirrhose vorgestellt und vor dem Hintergrund der pathophysiologischen Grundlagen und wegweisender klinischer Studien diskutiert. Sollte es trotz dieser prophylaktischen Maßnahmen zu einer Dekompensation kommen (ca. 15 % der Patienten mit Leberzirrhose jährlich), ist die Indikation zur Lebertransplantation als definitive Therapie der Leberzirrhose zu prüfen (spätestens ab einem MELD-Index > 15).

Abstract

In 2015, more than 13 000 people died due to the consequences of liver cirrhosis in Germany. Frequently, relevant liver fibrosis is diagnosed by non-invasive methods (e. g., ultrasound-based measurement of liver stiffness) already in the compensated stage. Following diagnosis of liver fibrosis, a thorough investigation of the underlying chronic liver disease and effective treatment are important to prevent progression to decompensated cirrhosis. Since morbidity and mortality dramatically increase in the decompensated stage (patients may present with jaundice, ascites, hepatic encephalopathy, gastrointestinal bleeding) with an upsurge in 1-year-mortality from 1 – 3.4 % to 20 – 57 %, prophylactic measures to prevent decompensation are indicated. Based on a risk stratification, these measures include propranolol or carvedilol as non-selective betablockers, as well as endoscopic band ligations as primary prophylaxis to prevent variceal bleeding. Because of the high risk for malignant transformation (2 – 8 % per year depending on the underlying etiology), surveillance by liver ultrasound every six months is essential to detect liver cancer in an early stage and to facilitate curative therapy. Currently under debate is the administration of antibiotics to prevent bacterial infections, which commonly trigger acute decompensation. To this regard, studies are not convincing and the risk to induce drug resistance has to be observed. However, health care providers should check the vaccination status and recommend missing vaccinations. The management of compensated liver cirrhosis also includes counseling and potentially also a drug therapy to prevent osteoporosis and muscle wasting. In this review, we will discuss specific prophylactic measures in the management of compensated liver cirrhosis based on the pathophysiological background and central clinical studies. If a patient decompensates despite these prophylactic measures (approximately 15 % of patients with liver cirrhosis per year), liver transplantation has to be discussed as definitive therapy (especially in patients with MELD > 15).

Schlüsselwörter

Leberzirrhose - Portale Hypertension - Ösophagusvarizen - Sarkopenie - Surveillance HCC - Prophylaxe

Key words

Liver cirrhosis - portal hypertension - esophageal varices - sarcopenia - HCC surrveillance - prophylaxis

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