Abstract
Background Nonselective β-blockers (NSBB) have been associated with increased incidence of paracentesis-induced circulatory dysfunction (PICD) and reduced survival in patients with cirrhosis and refractory ascites. Aim To prospectively evaluate a hemodynamic response to NSBB in cirrhotics listed for liver transplantation with refractory ascites undergoing large volume paracentesis (LVP). Methods Patients with cirrhosis and refractory ascites, with an indication to start NSBB in primary prophylaxis for variceal bleeding, were enrolled. During two consecutive LVP, while being, respectively, off and on NSBB, cardiac output (CO), systemic vascular resistances (SVR), peripheral vascular resistances (PVR), and plasma renin activity (PRA) were noninvasively assessed. Results Seventeen patients were enrolled, and 10 completed the study. Before NSBB introduction, SVR (1896 to 1348 dyn·s·cm−5; p = 0.028) and PVR (47 to 30 mmHg·min·dl·ml−1; p = 0.04) significantly decreased after LVP, while CO showed an increasing trend (3.9 to 4.5 l/m; p = 0.06). After NSBB introduction, LVP was not associated with a significant increase in CO (3.4 to 3.8 l/m; p = 0.13) nor with a significant decrease in SVR (2002 versus 1798 dyn·s·cm−5; p = 0.1). Incidence of PICD was not increased after NSBB introduction. Conclusion The negative inotropic effect of NSBB was counterbalanced by a smaller decrease of vascular resistances after LVP, probably due to splanchnic β2-blockade. This pilot study showed that NSBB introduction may be void of detrimental hemodynamic effects after LVP in cirrhotics with refractory ascites.
Highlights
Ascites is the most frequent complication in the natural history of cirrhosis, and its development is significantly associated with impaired survival [1, 2]
Several studies demonstrated that central hemodynamics could be further worsened by large volume paracentesis (LVP) in a wide proportion of patients (15% to 85%), leading to paracentesis-induced circulatory dysfunction (PICD), which has been associated with decreased survival and shortening of paracentesis-free interval time [5]
All patients enrolled were listed for Liver Transplant (LT) and had diureticintractable refractory ascites, which was treated with suboptimal diuretic therapy, due to the following: hyperkalemia (n = 4), impaired renal function (n = 4), and refractory encephalopathy (n = 2)
Summary
Ascites is the most frequent complication in the natural history of cirrhosis, and its development is significantly associated with impaired survival [1, 2]. Development of RA determines hyperdynamic circulation, peripheral vasodilation, and an impairment of cardiac and renal function [4] In this clinical setting, several studies demonstrated that central hemodynamics could be further worsened by large volume paracentesis (LVP) in a wide proportion of patients (15% to 85%), leading to paracentesis-induced circulatory dysfunction (PICD), which has been associated with decreased survival and shortening of paracentesis-free interval time [5]. Nonselective β-blockers (NSBB) have been associated with increased incidence of paracentesis-induced circulatory dysfunction (PICD) and reduced survival in patients with cirrhosis and refractory ascites. The negative inotropic effect of NSBB was counterbalanced by a smaller decrease of vascular resistances after LVP, probably due to splanchnic β2-blockade This pilot study showed that NSBB introduction may be void of detrimental hemodynamic effects after LVP in cirrhotics with refractory ascites
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