Die Rolle des Anästhesisten bei Lebertransplantationen – präoperative Evaluation

Die präoperative Patientenevaluation vor einer Lebertransplantation (LTX) stellt den Anästhesisten vor eine Reihe von Herausforderungen. Unter anderem müssen aufgrund sehr unterschiedlicher Indikationen und Begleiterkrankungen Empfehlungen für die präoperative Vorbereitung der Patienten stets individuell angepasst werden. Dieser Beitrag widmet sich insbesondere der Erfassung von Komorbiditäten und der Risikoabschätzung bei Patienten zur LTX.

Abstract

Preoperative evaluation prior to listing for orthotopic liver transplantation (LT) requires a careful multidisciplinary approach with specialized teams including surgeons, hepatologists and anesthesiologists in order to improve short- and long-term clinical outcomes. Due to inadequate supply of donor organs and changing demographics, patients listed for LT have become older, sicker and share more comorbidities. As cardiovascular events are the leading cause for early mortality precise evaluation of risk factors is mandatory. This review focuses on the detection and management of coronary artery disease, cirrhotic cardiomyopathy, portopulmonary hypertension and hepatopulmonary syndrome in patients awaiting LT. Further insights are being given into scoring systems, patients with Acute-on-chronic-liver-failure (ACLF), frailty, NASH cirrhosis and into psychologic evaluation of patients with substance abuse.

Kernaussagen

• Die LTX ist die einzige wirksame Therapie bei Patienten mit ESLD.

• Der operative Eingriff stellt eine außerordentliche Belastung für die kardiovaskuläre Reserve des Patienten dar, die mit keinem anderen nicht kardiochirurgischen Eingriff vergleichbar ist.

• Das Patientenkollektiv ist sehr heterogen, da ein ESLD mit einer Vielzahl von Komorbiditäten einhergeht, die regelhaft mit extrahepatischen Organversagen vergesellschaftet sind.

• Die wichtigsten kardiovaskulären Begleiterkrankungen von Patienten mit ESLD sind die koronare Herzerkrankung, die zirrhotische Kardiomyopathie und die portopulmonale Hypertonie.

• Weitere häufige Komorbiditäten sind das hepatopulmonale und das hepatorenale Syndrom. Ebenso wie eine Fehlernährung im Sinne einer Überernährung (NASH) oder einer Malnutrition (Sarkopenie, Frailty) spielen sie eine wichtige Rolle für die Prognose von Patienten mit ESLD.

• Die Heterogenität der Patienten stellt den Anästhesisten und die weiteren Mitglieder der Transplantationskonferenz vor die anspruchsvolle Aufgabe, individuell angepasste Empfehlungen für die präoperative Vorbereitung der Patienten festzulegen. Hierzu müssen Chancen, Risiken und die Gesamtprognose gegeneinander abgewogen werden.

• Da es im Rahmen eines ESLD jederzeit zur Verschlechterung des Allgemeinzustandes oder einer Dekompensation der Leberfunktion kommen kann, sollte unmittelbar vor der Transplantation erneut eine Reevaluation stattfinden.

Schlüsselwörter

orthotope Lebertransplantation - präoperative Evaluation - Transplantationskonferenz - portopulmonale Hypertonie - hepatopulmonales Syndrom - hepatorenales Syndrom - akut-auf-chronisches Leberversagen - zirrhotische Kardiomyopathie - Frailty

Keywords

orthotopic liver transplantation - preoperative evaluation - transplantation conference - portopulmonary hypertension - hepatopulmonary syndrome - hepatorenal syndrome - acute-on-chronic liver failure - cirrhotic cardiomyopathy - frailty

Publication History

Article published online:
17 May 2024

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