Prävention der Dekompensation bei einer fortgeschrittenen Lebererkrankung

Die Prävention der ersten Dekompensation bei fortgeschrittener chronischer Lebererkrankung ist entscheidend zur Verbesserung der Prognose der betroffenen Patient*innen. Dies setzt die frühzeitige Diagnose einer maßgeblich zur Entstehung von Dekompensationsereignissen beitragenden klinisch signifikanten portalen Hypertonie voraus. In diesem Artikel werden die pathophysiologischen Grundlagen der Dekompensation sowie therapeutische Optionen in der Primär- und Sekundärprävention zusammengefasst.

Abstract

The transition from compensated to decompensated advanced chronic liver disease (ACLD) is associated with increased mortality. Clinically significant portal hypertension (CSPH), defined by a hepatic venous pressure gradient (HVPG) ≥10 mmHg, is the main precondition of decompensation. Non-invasive tools like transient elastography help identifying patients at risk. Preventing the first decompensation, especially ascites, is a key therapeutic goal. Non-selective beta-blockers (NSBBs), particularly carvedilol, reduce portal pressure and have shown efficacy in preventing decompensation, independent of variceal status. Lifestyle modification and treating underlying liver disease (e.g., alcohol abstinence, viral eradication) remain essential. Early identification and initiation of therapy in CSPH can change the natural history of cirrhosis and improve patient outcomes.

Schlüsselwörter

Leberzirrhose - portale Hypertension - Aszites - Varizenblutung

Keywords

cirrhosis - portal hypertension - ascites - variceal bleeding

• Literatur

• 1 D’Amico G, Zipprich A, Villanueva C. et al. Further decompensation in cirrhosis: Results of a large multicenter cohort study supporting Baveno VII statements. Hepatology 2024; 79 (04) 869-881
• 2 Balcar L, Tonon M, Semmler G. et al. Risk of further decompensation/mortality in patients with cirrhosis and ascites as the first single decompensation event. JHEP Rep 2022; 4 (08) 100513
• 3 Trebicka J, Fernandez J, Papp M. et al. The PREDICT study uncovers three clinical courses of acutely decompensated cirrhosis that have distinct pathophysiology. J Hepatol 2020; 73 (04) 842-854
• 4 Iwakiri Y, Shah V, Rockey DC. Vascular pathobiology in chronic liver disease and cirrhosis – Current status and future directions. J Hepatol 2014; 61 (04) 912-924
• 5 Clària J, Stauber RE, Coenraad MJ. et al. Systemic inflammation in decompensated cirrhosis: Characterization and role in acute-on-chronic liver failure. Hepatology 2016; 64 (04) 1249-1264
• 6 Tonon M, Balcar L, Semmler G. et al. Etiological cure prevents further decompensation and mortality in patients with cirrhosis with ascites as the single first decompensating event. Hepatology 2023; 78 (04) 1149-1158
• 7 Bettinger D, Berzigotti A, Mandorfer M. et al. Transjugular diagnostic procedures in hepatology: indications, techniques and interpretation. JHEP Rep 2025; 101437
• 8 De Franchis R, Bosch J, Garcia-Tsao G. et al. Baveno VII – Renewing consensus in portal hypertension. J Hepatol 2022; 76 (04) 959-974
• 9 Di Marco V, Calvaruso V, Ferraro D. et al. Effects of Eradicating Hepatitis C Virus Infection in Patients With Cirrhosis Differ With Stage of Portal Hypertension. Gastroenterology 2016; 151 (01) 130-139.e2
• 10 Hofer BS, Simbrunner B, Hartl L. et al. Alcohol Abstinence Improves Prognosis Across All Stages of Portal Hypertension in Alcohol-Related Cirrhosis. Clin Gastroenterol Hepatol 2023; 21 (09) 2308-2317.e7
• 11 Villanueva C, Albillos A, Genescà J. et al. β blockers to prevent decompensation of cirrhosis in patients with clinically significant portal hypertension (PREDESCI): a randomised, double-blind, placebo-controlled, multicentre trial. Lancet 2019; 393: 1597-1608
• 12 Fortea JI, Alvarado-Tapias E, Simbrunner B. et al. Carvedilol vs. propranolol for the prevention of decompensation and mortality in patients with compensated and decompensated cirrhosis. J Hepatol 2025;
• 13 Jachs M, Hartl L, Schaufler D. et al. Amelioration of systemic inflammation in advanced chronic liver disease upon beta-blocker therapy translates into improved clinical outcomes. Gut 2021; 70 (09) 1758-1767
• 14 Tevethia HV, Pande A, Vijayaraghavan R. et al. Combination of carvedilol with variceal band ligation in prevention of first variceal bleed in Child-Turcotte-Pugh B and C cirrhosis with high-risk oesophageal varices: the ‘CAVARLY TRIAL’. Gut 2024; 73 (11) 1844-1853
• 15 Abraldes JG, Albillos A, Bañares R. et al. Simvastatin Lowers Portal Pressure in Patients With Cirrhosis and Portal Hypertension: A Randomized Controlled Trial. Gastroenterol 2009; 136 (05) 1651-1658
• 16 Villa E, Cammà C, Marietta M. et al. Enoxaparin Prevents Portal Vein Thrombosis and Liver Decompensation in Patients With Advanced Cirrhosis. Gastroenterol 2012; 143 (05) 1253-1260.e4
• 17 Guerrero A, Campo LD, Piscaglia F. et al. Anticoagulation improves survival in patients with cirrhosis and portal vein thrombosis: The IMPORTAL competing-risk meta-analysis. J Hepatol 2023; 79 (01) 69-78
• 18 Moreau R, Jalan R, Gines P. et al. Acute-on-Chronic Liver Failure Is a Distinct Syndrome That Develops in Patients With Acute Decompensation of Cirrhosis. Gastroenterol 2013; 144 (07) 1426-1437.e9
• 19 Tergast TL, Kimmann M, Laser H. et al. Systemic arterial blood pressure determines the therapeutic window of non-selective beta blockers in decompensated cirrhosis. Aliment Pharmacol Ther 2019; 50 (06) 696-706
• 20 Balcar L, Mandorfer M, Hernández-Gea V. et al. Predicting survival in patients with ‘non-high-risk’ acute variceal bleeding receiving β-blockers+ligation to prevent re-bleeding. J Hepatol 2024; 80 (01) 73-81
• 21 Piecha F, Radunski UK, Ozga AK. et al. Ascites control by TIPS is more successful in patients with a lower paracentesis frequency and is associated with improved survival. JHEP Rep 2019; 1 (02) 90-98
• 22 Tiede A, Stockhoff L, Liu Z. et al. Insertion of a transjugular intrahepatic portosystemic shunt leads to sustained reversal of systemic inflammation in patients with decompensated liver cirrhosis. Clin Mol Hepatol 2025; 31 (01) 240-255
• 23 Larrue H, D’Amico G, Olivas P. et al. TIPS prevents further decompensation and improves survival in patients with cirrhosis and portal hypertension in an individual patient data meta-analysis. J Hepatol 2023; 79 (03) 692-703
• 24 Sturm L, Schultheiss M, Stöhr F. et al. Freiburg index of post-TIPS survival (FIPS) identifies patients at risk of further decompensation and ACLF after TIPS. J Hepatol 2025;