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Nonselective β blockers increase risk for hepatorenal syndrome and death in patients with cirrhosis and spontaneous bacterial peritonitis.
Gastroenterology 2014; 146(7):1680-90.e1G

Abstract

BACKGROUND & AIMS

Nonselective β blockers (NSBBs) reduce portal pressure and the risk for variceal hemorrhage in patients with cirrhosis. However, development of spontaneous bacterial peritonitis (SBP) in these patients could preclude treatment with NSBBs because of their effects on the circulatory reserve. We investigated the effects of NSBBs in patients with cirrhosis and ascites with and without SBP.

METHODS

We performed a retrospective analysis of data from 607 consecutive patients with cirrhosis who had their first paracentesis at the Medical University of Vienna from 2006 through 2011. Cox models were calculated to investigate the effect of NSBBs on transplant-free survival time and adjusted for Child-Pugh stage and presence of varices.

RESULTS

NSBBs increased transplant-free survival in patients without SBP (hazard ratio = 0.75; 95% confidence interval: 0.581-0.968; P = .027) and reduced days of nonelective hospitalization (19.4 days/year for patients on NSBBs vs 23.9 days/year for patients not taking NSBBs). NSBBs had only moderate effects on systemic hemodynamics at patients' first paracentesis. However, at the first diagnosis of SBP, the proportion of hemodynamically compromised patients with systolic arterial pressure <100 mm Hg was higher among those who received NSBBs (38% vs 18% of those not taking NSBBs; P = .002), as was the proportion of patients with arterial pressure <82 mm Hg (64% of those taking NSBBs vs 44% of those not taking NSBBs; P = .006). Among patients with SBP, NSBBs reduced transplant-free survival (hazard ratio = 1.58; 95% confidence interval: 1.098-2.274; P = .014) and increased days of nonelective hospitalization (29.6 days/person-year in patients on NSBBs vs 23.7 days/person-year in those not taking NSBBs). A higher proportion of patients on NSBBs had hepatorenal syndrome (24% vs 11% in those not taking NSBBs; P = .027) and grade C acute kidney injury (20% vs 8% for those not taking NSBBs; P = .021).

CONCLUSIONS

Among patients with cirrhosis and SBP, NSBBs increase the proportion who are hemodynamically compromised, time of hospitalization, and risks for hepatorenal syndrome and acute kidney injury. They also reduce transplant-free survival. Patients with cirrhosis and SBP should not receive NSBBs.

Authors+Show Affiliations

Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Vienna, Austria.Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Vienna, Austria.Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Vienna, Austria.Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Vienna, Austria.Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Vienna, Austria.Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Vienna, Austria.Section for Medical Statistics, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria.Clinical Institute of Hospital Hygiene, Vienna General Hospital, Vienna, Austria.Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Vienna, Austria.Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Vienna, Austria.Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Vienna, Austria.Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Vienna, Austria.Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Vienna, Austria. Electronic address: thomas.reiberger@meduniwien.ac.at.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

24631577

Citation

Mandorfer, Mattias, et al. "Nonselective Β Blockers Increase Risk for Hepatorenal Syndrome and Death in Patients With Cirrhosis and Spontaneous Bacterial Peritonitis." Gastroenterology, vol. 146, no. 7, 2014, pp. 1680-90.e1.
Mandorfer M, Bota S, Schwabl P, et al. Nonselective β blockers increase risk for hepatorenal syndrome and death in patients with cirrhosis and spontaneous bacterial peritonitis. Gastroenterology. 2014;146(7):1680-90.e1.
Mandorfer, M., Bota, S., Schwabl, P., Bucsics, T., Pfisterer, N., Kruzik, M., ... Reiberger, T. (2014). Nonselective β blockers increase risk for hepatorenal syndrome and death in patients with cirrhosis and spontaneous bacterial peritonitis. Gastroenterology, 146(7), pp. 1680-90.e1. doi:10.1053/j.gastro.2014.03.005.
Mandorfer M, et al. Nonselective Β Blockers Increase Risk for Hepatorenal Syndrome and Death in Patients With Cirrhosis and Spontaneous Bacterial Peritonitis. Gastroenterology. 2014;146(7):1680-90.e1. PubMed PMID: 24631577.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Nonselective β blockers increase risk for hepatorenal syndrome and death in patients with cirrhosis and spontaneous bacterial peritonitis. AU - Mandorfer,Mattias, AU - Bota,Simona, AU - Schwabl,Philipp, AU - Bucsics,Theresa, AU - Pfisterer,Nikolaus, AU - Kruzik,Matthias, AU - Hagmann,Michael, AU - Blacky,Alexander, AU - Ferlitsch,Arnulf, AU - Sieghart,Wolfgang, AU - Trauner,Michael, AU - Peck-Radosavljevic,Markus, AU - Reiberger,Thomas, Y1 - 2014/03/12/ PY - 2013/12/23/received PY - 2014/03/07/revised PY - 2014/03/07/accepted PY - 2014/3/18/entrez PY - 2014/3/19/pubmed PY - 2014/7/22/medline KW - Adrenergic Receptor KW - Bacterial Infection KW - Liver Fibrosis KW - Mortality KW - β Blocker SP - 1680 EP - 90.e1 JF - Gastroenterology JO - Gastroenterology VL - 146 IS - 7 N2 - BACKGROUND & AIMS: Nonselective β blockers (NSBBs) reduce portal pressure and the risk for variceal hemorrhage in patients with cirrhosis. However, development of spontaneous bacterial peritonitis (SBP) in these patients could preclude treatment with NSBBs because of their effects on the circulatory reserve. We investigated the effects of NSBBs in patients with cirrhosis and ascites with and without SBP. METHODS: We performed a retrospective analysis of data from 607 consecutive patients with cirrhosis who had their first paracentesis at the Medical University of Vienna from 2006 through 2011. Cox models were calculated to investigate the effect of NSBBs on transplant-free survival time and adjusted for Child-Pugh stage and presence of varices. RESULTS: NSBBs increased transplant-free survival in patients without SBP (hazard ratio = 0.75; 95% confidence interval: 0.581-0.968; P = .027) and reduced days of nonelective hospitalization (19.4 days/year for patients on NSBBs vs 23.9 days/year for patients not taking NSBBs). NSBBs had only moderate effects on systemic hemodynamics at patients' first paracentesis. However, at the first diagnosis of SBP, the proportion of hemodynamically compromised patients with systolic arterial pressure <100 mm Hg was higher among those who received NSBBs (38% vs 18% of those not taking NSBBs; P = .002), as was the proportion of patients with arterial pressure <82 mm Hg (64% of those taking NSBBs vs 44% of those not taking NSBBs; P = .006). Among patients with SBP, NSBBs reduced transplant-free survival (hazard ratio = 1.58; 95% confidence interval: 1.098-2.274; P = .014) and increased days of nonelective hospitalization (29.6 days/person-year in patients on NSBBs vs 23.7 days/person-year in those not taking NSBBs). A higher proportion of patients on NSBBs had hepatorenal syndrome (24% vs 11% in those not taking NSBBs; P = .027) and grade C acute kidney injury (20% vs 8% for those not taking NSBBs; P = .021). CONCLUSIONS: Among patients with cirrhosis and SBP, NSBBs increase the proportion who are hemodynamically compromised, time of hospitalization, and risks for hepatorenal syndrome and acute kidney injury. They also reduce transplant-free survival. Patients with cirrhosis and SBP should not receive NSBBs. SN - 1528-0012 UR - https://www.unboundmedicine.com/medline/citation/24631577/Nonselective_β_blockers_increase_risk_for_hepatorenal_syndrome_and_death_in_patients_with_cirrhosis_and_spontaneous_bacterial_peritonitis_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0016-5085(14)00306-0 DB - PRIME DP - Unbound Medicine ER -