Faculty Opinions recommendation of Deleterious effects of beta-blockers on survival in patients with cirrhosis and refractory ascites.

This article provides information about the pharmacotherapy of liver cirrhosis (LC) and its complications, such as variceal hemorrhage, ascites, increased risk of bacterial infection, spontaneous bacterial peritonitis, hepatic encephalopathy, hepatorenal syndrome LC is a major healthcare problem and is associated with an increased mortality due to the development of complications. LC is currently the 11th most common cause of death globally. Prognosis of LC is highly variable and influenced by several variables, such as etiology, severity of liver disease, presence of complications and comorbidities. In advanced cirrhosis, survival decreases to one or two years. Pharmacotherapy for LC should be implemented in accordance with up-to-date guidelines and in conjunction with aetiology management, nutritional optimisation and patient education. The main treatment of uncomplicated ascites is diuretics such as spironolactone in combination with a loop diuretic. For treatment refractory ascites vasoconstrictors and albumin are recommended. Antibiotics play a well-established role in the treatment and prevention of spontaneous bacterial peritonitis. For hepatorenal syndrome, the administration of vasopressor terlipressin and albumin is recommended. Endoscopic treatment is used for variceal bleeding (for example, ligation for esophageal varices and tissue glue for gastric varices). A shunt (TIPS) is used to treat severe or repeat variceal hemorrhage or refractory ascites. Non-selective beta-blockers effectively reduce variceal re-bleeding risk in LC patients with moderate/large varices. Thus, the treatment of LC as one of the most formidable multiorgan pathologies involves a comprehensive approach aimed at the correction of the main pathology and the treatment and prevention of its complications.

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Novel Approaches to Reducing the Risk of Variceal Hemorrhage

Digestive Diseases ◽

10.1159/000456594 ◽

2017 ◽

Vol 35 (4) ◽

pp. 397-401 ◽

Cited By ~ 2

Author(s):

Frederik Nevens

Keyword(s):

Variceal Bleeding ◽

Beta Blockers ◽

Liver Stiffness ◽

Metallic Stents ◽

New Drugs ◽

Refractory Ascites ◽

Variceal Hemorrhage ◽

Endoscopic Screening ◽

Balloon Tamponade ◽

The Moment

Background: Complications of advanced liver disease occur at the moment of clinical significant portal hypertension. Nitric oxide (NO) dysfunction and fibrosis play an important role in the pathophysiology of PH, but other mechanisms are also involved. Non-selective beta blockers (NSBB) stay the cornerstone in the primary and secondary prevention of variceal bleeding, but their safety in advanced cirrhosis has been recently debated and new drugs are under investigation. Transjugular intrahepatic portosystemic shunt and balloon tamponade are the standard therapy in case of refractory variceal bleeding, but both interventions have drawbacks. Key Message: Transelastography under certain conditions and the presence of collateral circulation on imaging allow to rule-in CSPH, which makes patients open at risk for variceal hemorrhage. FXR agonists are intrahepatic NO donors; they reduce fibrosis and prevent bacterial translocation, which make them promising drugs for the treatment of PH. NSBB should be used with caution in patients with refractory ascites and certainly in those with hepatorenal syndrome. Preliminary clinical data suggest that simvastatin and enoxaparin improve the prognosis of patients with cirrhosis. Finally, covered esophageal metallic stents are safer and more effective than balloon tamponade in the case of refactory variceal bleeding. Conclusions: Liver stiffness measurements enable the selection of patients for endoscopic screening for esophageal varices. In the case of tense ascites, the dose of NSBB should be adapted to the hemodynamic condition of the patient. Self-expanding, covered esophageal metallic stents replace balloon tamponade in the treatment of massive variceal hemorrhage.

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Non-selective beta blocker use is associated with improved short-term survival in patients with cirrhosis referred for liver transplantation

BMC Gastroenterology ◽

10.1186/s12876-019-1155-1 ◽

2020 ◽

Vol 20 (1) ◽

Cited By ~ 2

Author(s):

Taiwo Ngwa ◽

Eric Orman ◽

Eduardo Vilar Gomez ◽

Raj Vuppalanchi ◽

Chandrashekhar Kubal ◽

...

Keyword(s):

Liver Transplantation ◽

Beta Blockers ◽

Kidney Injury ◽

Refractory Ascites ◽

Short Term ◽

Term Survival ◽

Bacterial Peritonitis ◽

Stage 1 ◽

Short Term Survival

Abstract Background Recent evidence cautions against the use of non-selective beta-blockers (NSBB) in patients with refractory ascites or spontaneous bacterial peritonitis while other data suggests a survival benefit in patients with advanced liver disease. The aim of this study was to describe the use and impact of NSBB in patients with cirrhosis referred for liver transplantation. Methods A single-center cohort of patients with cirrhosis, who were referred and evaluated for liver transplantation between January and June 2012 were studied for baseline characteristics and clinical outcomes. Patients were grouped according to the use of NSBB at initial evaluation, with the endpoint of 90-day mortality. Results Sixty-five (38%) of 170 consecutive patients evaluated for liver transplantation were taking NSBB. Patients taking NSBB had higher MELD and Child Pugh score. NSBB use was associated with lower 90-day mortality (6% vs. 15%) with a risk adjusted hazard ratio of 0.27 (95%CI .09–0.88, p = .03). Patients taking NSBB developed acute kidney injury (AKI) within 90 days more frequently than patients not taking NSBB (22% vs 11%), p = 0.048). However, this was related to increased stage 1 AKI episodes, all of which resolved. Twelve (27%) of 45 patients with > 90 day follow up discontinued NSBB, most commonly for hypotension and AKI, had increased subsequent MELD and mortality. Conclusions NSBB use in patients with cirrhosis undergoing liver transplant evaluation is associated with better short-term survival. Nevertheless, ongoing tolerance of NSBB in this population is dynamic and may select a subset of patients with better hemodynamic reserve.

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