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Non-selective Beta blockers (NSBB)
The Aspirin of Hepatologist
Ahmed Abdul Ghany
Why?
• Decrease portal pressure
• Decrease risk of bleeding from hypertensive gastropathy
• Lower incidence of bacterial translocation
• Decrease development of spontaneous bacterial peritonitis
NSBBs achieve their effects through
Reducing cardiac output via Beta 1 receptor blockade
Reducing portal blood flow through splanchnic vasoconstriction via Beta 2 receptor blockade
Several studies in cirrhotic patients withoutNSBB treatment established a correlation between BP and transplantation-free survival
As cirrhosis progress, cardiovascular system looses it’s compensatory ability, thus patients with low mean arterial Bp (< 82 mmHg) had lower survival
Liach. Gastro 1988
Modified peripheral vasodilatation hypothesis
Arroyo V, et al 2009
Predictors of worse survival
• Mean arterial Bp < 80 mmHg
• Cardiac index below 1.5 l/min/m2
Krag gut 2010
How effective are NSBBs in advanced liver cirrhosis ?
Krag, et al,. 2012
Window of opportunity opened by
Presence of varices
Start NSBB
Closed by
Refractory ascitesSBPHRSLow MAP
STOP NSBB
Paracentesis induced circulatory dysfunction (PICD)
Refractory ascites is characterized by repeated paracentsis, which has been shown to trigger PICD.
PICD defined as increase in renin level at least 50% one week after paracentesis.
Lack of cardiac adaptation after paracentesisunder beta blockers may explain the increase in PICD incidence.
Patients with PICD who are on NSBB medications, have a higher incidence of acute kidney injury (AKI) reaching 71%.
Serste et al., Liver International 2015
Transplantation-free survival with SBP
Mandofer M, et al., 2014
Mandofer M, et al., gastro 2014