Non-selective β-blockers are associated with improved survival in patients with ascites listed for liver transplantation

Leithead, Joanna A.; Rajoriya, Neil; Tehami, Nadeem; Hodson, James; Gunson, Bridget K.; Tripathi, Dhiraj; Ferguson, James

doi:10.1136/gutjnl-2013-306502

Cited by 171 publications

(131 citation statements)

References 34 publications

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“…This is particularly unjustifiable in light of 2 more recent larger studies that have shown a greater survival with NSBB or no differences in survival, respectively. In the first of these studies, a propensity score-matched study in a cohort of patients with cirrhosis on the transplant wait list showed a survival advantage of patients with refractory ascites on NSBB compared to those not on NSBB and, interestingly, showed that the use of carvedilol (a NSBB with vasodilatory properties that has been shown to lead to a larger decrease in blood pressure compared to propranolol [16] ) had an intermediate survival between patients with propranolol (lowest mortality) and those not on NSBB (highest mortality) [17] . The second study, a post-hoc analysis of data from 3 RCTs about V 2 receptor antagonists in the treatment of ascites, showed no differences in mortality between those on and off NSBB, even when adjusted by MELD, mean arterial pressure, dose of beta-blockers or study group (satavaptan vs. placebo) [18] .…”

Section: Ascitesmentioning

confidence: 99%

Current Management of the Complications of Cirrhosis and Portal Hypertension: Variceal Hemorrhage, Ascites, and Spontaneous Bacterial Peritonitis

García–Tsao

2016

Dig Dis

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Cirrhosis is not a single entity but represents a disease progression across different prognostic stages, with the compensated and decompensated stages being the most important. Variceal hemorrhage (VH) and ascites are complications of cirrhosis that denote the presence of a decompensated stage. Spontaneous bacterial peritonitis (SBP) is a common bacterial infection unique to patients with cirrhosis that can precipitate the development of recurrent VH and hepatorenal syndrome (HRS), complications that denote the presence of a ‘further decompensated' stage of cirrhosis. Main current issues in the management of VH include identification of different prognostic stages that allow for individualized patient care. Management of VH cannot be performed in an isolated manner, and the presence of other complications of cirrhosis (ascites, encephalopathy) should be taken into account both in the management and in the design of clinical trials. Because management of ascites per se has not resulted in significant changes in mortality, main management issues consist of preventing further decompensating events by preventing factors that will lead to worsening vasodilatation and hemodynamic status (infections, vasodilators), preventing volume depletion (overdiuresis, GI hemorrhage) and preventing structural kidney injury (nephrotoxins). Prophylaxis of bacterial infections such as SBP currently consists of the administration of antibiotics. By preventing infections, there is evidence that recurrent VH and HRS can also be prevented. However, response to recommended empirical antibiotics in patients with suspected infection, such as SBP, is currently significantly lower than in the past because of an increase in infections secondary to multidrug resistant (MDR) organisms. One of the main predictors of the development of MDR organisms is antibiotic prophylaxis and unnecessary and prolonged use of antibiotics in hospital. Therefore, appropriate antibiotics should be used in patients with a high suspicion of infection, and antibiotic prophylaxis should be restricted to patients with the highest risk of infection.

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Section: Ascitesmentioning

confidence: 99%

Current Management of the Complications of Cirrhosis and Portal Hypertension: Variceal Hemorrhage, Ascites, and Spontaneous Bacterial Peritonitis

García–Tsao

2016

Dig Dis

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“…The authors showed that after SBP patients on NSBBs had lower blood pressure and a higher risk of hepatorenal syndrome, though it is unclear from the report whether the patients were maintained on NSBBs or not after the SBP. A very recent study assessing 322 patients with ascites (117 refractory ascites) on the waiting list for liver transplant seems to contradict these findings [22]. Indeed, patients on NSBBs had a better survival than patients not taking β-blockers, and this effect was more marked in the group of patients with refractory ascites.…”

Section: Clinical Scenarios For the Treatment Of Portal Hypertensionmentioning

confidence: 63%

Therapies: Drugs, Scopes and Transjugular Intrahepatic Portosystemic Shunt - When and How?

Abraldes

Tandon²

2015

Dig Dis

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Variceal bleeding is the most serious complication of portal hypertension. All cirrhotic patients should be screened endoscopically for varices which are present in about 30% of compensated and 60% of decompensated patients at diagnosis. In patients without varices, endoscopy surveillance should be continued every 2 years. Patients with high-risk varices (moderate or large in size, or with red color signs, or in Child-Pugh C patients) should be treated with a nonselective β-blocker to prevent bleeding (propranolol, nadolol or carvedilol). Endoscopic banding ligation is also effective for the prevention of first bleeding, and it is the first choice in patients with contraindications or intolerance to β-blockers. Acute variceal hemorrhage still has a high mortality rate (around 15%) and requires intensive care management and conservative blood transfusion policy. Treatment is based on the combined use of vasoactive drugs, endoscopic band ligation and prophylactic antibiotics. Failures are best managed by transjugular intrahepatic portosystemic shunt (TIPS). Balloon tamponade or specifically designed covered esophageal stents can be used as a bridge to definitive therapy in unstable patients. Early, preemptive TIPS might be the first choice in patients at high risk of failure (Child-Pugh B with active bleeding or Child-Pugh C up to 13 points). Patients surviving a variceal bleeding are at high risk of rebleeding. A combination of β-blockers and endoscopic band ligation is the most effective therapeutic approach. Preliminary data suggest that the addition of simvastatin increases survival in these patients.

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“…Because the debate about the use of NSBB in patients with ascites is still on-going, such data might be of major interest. Recent data showed a benefit of NSBB for patients on the transplant waiting list and for patients with ACLF [5], [6]. Propranolol effects may also be due to properties other than reducing portal pressure.…”

Section: Hvpg Hepatic Venous Pressure Gradient Nsbb Non-selective Betmentioning

confidence: 99%

Secondary prophylaxis for variceal bleeding: carvedilol vs. propranolol

Steib

Gerbes²

2017

Hepatol Int

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Non-selective β-blockers are associated with improved survival in patients with ascites listed for liver transplantation

Abstract: NSBB in patients with ascites and refractory ascites listed for liver transplantation are not detrimental, and instead are associated with reduced waitlist death. Our findings argue that NSBB are safe and may confer benefit in patients with ascites complicating end-stage liver disease.

Cited by 171 publications

References 34 publications

Current Management of the Complications of Cirrhosis and Portal Hypertension: Variceal Hemorrhage, Ascites, and Spontaneous Bacterial Peritonitis

Current Management of the Complications of Cirrhosis and Portal Hypertension: Variceal Hemorrhage, Ascites, and Spontaneous Bacterial Peritonitis

Therapies: Drugs, Scopes and Transjugular Intrahepatic Portosystemic Shunt - When and How?

Secondary prophylaxis for variceal bleeding: carvedilol vs. propranolol

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