Non‐selective beta‐blockers in patients with ascites: The complex interplay among the liver, kidney and heart

Abstract

Non‐selective beta‐blockers (NSBBs) are the cornerstone of the primary and secondary prophylaxis of variceal bleeding in cirrhotic patients. They additionally prevent ascites development and death in compensated patients with clinically significant portal hypertension. After ascites onset, NSBBs remain beneficial for preventing further decompensations. However, as the cirrhosis progresses, the inflammation increases, systemic vasodilatation worsens, ascites turns refractory and cardiodynamic equilibrium becomes extremely fragile. In this scenario, NSBBs can critically impair the cardiac reserve and facilitate a haemodynamic breakdown, imperilling renal perfusion. Consequently, NSBB treatment should be carefully monitored or even avoided in such patients, and other options for portal hypertension management should be considered. In the present review, we explore the effects of NSBBs in patients with ascites and discuss the complex interplay among their hepatic, systemic and renal haemodynamic effects in this scenario.

Carvedilol Achieves Higher Hemodynamic Response and Lower Rebleeding Rates Than Propranolol in Secondary Prophylaxis

“…However, it induces more pronounced decreases in blood pressure, which may be detrimental in patients with (refractory) ascites. 15 Importantly Q22 , the efficacy and safety of carvedilol have never been compared systematically with propranolol in the setting of secondary prophylaxis of variceal bleeding. In fact, no RCT has compared the efficacy and safety of carvedilol plus EBL against conventional NSBBs, that is, propranolol or nadolol, plus EBL.…”

“…Although their efficacy in reducing the portal pressure has been firmly established, concerns have been raised about the safety of NSBBs in patients with ascites 15 because an increase in cardiac output is necessary to compensate for decreases in systemic vascular resistance. In particular, the use of carvedilol is controversial in this context because it not only is associated with stronger decreases of HVPG, but also mean arterial pressure (MAP).…”

“…In particular, the use of carvedilol is controversial in this context because it not only is associated with stronger decreases of HVPG, but also mean arterial pressure (MAP). Thus, its use therefore may promote renal dysfunction in patients who are compromised hemodynamically, such as patients with recurrent/refractory ascites, 15,16 who commonly may require secondary prophylaxis.…”

Risk of further decompensation/mortality in patients with cirrhosis and ascites as the first single decompensation event

“…TIPS placement has been demonstrated to improve the outcomes of patients with recurrent ascites 29 but is commonly used (too) late, although data on improved control of ascites after (pre-emptive) TIPS implantation is promising. 16,28 Future prospective studies should investigate earlier TIPS implantation in patients with grade 3 ascites at index decompensation and in patients with grade 2 ascites and high MELD (i.e., > − 15 points).…”

Management of Liver Decompensation in Advanced Liver Disease (Renal Impairment, Liver Failure, Adrenal Insufficiency, Cardiopulmonary Complications)

“…1 ) [ 15 ]. Of note, non-selective β-blockers have also been associated with HRS and should be discontinued [ 9 , 16 ]. Renal replacement therapy should be considered in the management of HRS patients who do not respond to vasoconstrictors or in those with end-stage kidney disease.…”