Lebertransplantation – Immunsuppression, Kurz- und Langzeitverlauf

Die Überlebensraten von Patienten nach orthotoper Lebertransplantation (LTX) haben sich in den letzten Jahrzehnten deutlich verbessert. Damit rückten neben dem Management von peri- und postoperativen Komplikationen die medikamentöse Immunsuppression, aber auch die Langzeitkomplikationen nach LTX zunehmend in den Vordergrund. Diesen Themen widmet sich der zweite Teil dieser Übersichtsarbeit zur Lebertransplantation.

Kernaussagen

• Das Management von Infektionen mit multiresistenten Erregern stellt eine große therapeutische Herausforderung in der Transplantationsmedizin dar.

• Bei transplantierten, immunsupprimierten Patienten ist ein höheres Risiko für die Entstehung maligner Erkrankungen beschrieben.

• Wegen des hohen Osteoporoserisikos sind eine medikamentöse Prophylaxe und ggf. entsprechende Lifestyle-Veränderungen bei LTX-Patienten zu empfehlen.

• Aufgrund einer etablierten HBV-Reinfektionsprophylaxe und der Verwendung neuerer potenter Virostatika sind die Überlebensraten der transplantierten Hepatitis-B-Patienten erheblich gestiegen und inzwischen vergleichbar mit denen anderer LTX-Indikationen.

• Die Verfügbarkeit neuer direkt antiviral agierender Substanzen (DAA) bedeutet aufgrund hoher Ansprechraten und einer verbesserten Verträglichkeit einen wesentlichen Fortschritt in der HCV-Therapie.

• Die Angaben über die Häufigkeit des Rezidivs von autoimmunen Lebererkrankungen variieren. Die meisten Studien zeigen trotz des Rekurrenzrisikos einen sehr guten Langzeitverlauf. Die Diagnose eines Rezidivs der Autoimmunerkrankung in der Transplantatleber ist schwieriger als bei nicht transplantierten Patienten.

• Bei den alkoholtoxischen Lebererkrankungen ist das Patienten- und Transplantatüberleben bei Einhaltung einer Alkoholabstinenz sehr gut.

• Bei Patienten mit HCC ist die LTX bei Einhaltung der Mailand-Kriterien mit einem sehr guten Langzeitüberleben und geringen Tumorrekurrenzraten assoziiert.

• Die Calcineurin-Inhibitor-induzierte Nephrotoxizität stellt die häufigste Langzeitkomplikation nach LTX dar.

• Zur Minimierung der Nebenwirkungen ist eine individualisierte medikamentöse Immunsuppression mit kombinierter Verwendung verschiedener jeweils gering dosierter Substanzen empfehlenswert.

Schlüsselwörter

Transplantatabstoßung - Immunsuppressiva - Infektionen - Hepatitis-Reinfektionen - De-novo-Malignome

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