Influence of Beta Blockers on Complications of Cirrhosis

Abstract

INTRODUCTION: Histologically cirrhosis, a chronic liver disease is characterized by fibrosis and the alteration of normal liver architecture into abnormal nodules. In the west, it is the leading cause of mortality, particularly affecting the productive age population. In our country, an estimated 188,575 cirrhosis related death in 2010 which is 18.3% of the universal burden of the disease. And the deaths due to cirrhosis increased globally from 2005 to 2015, whereas age-standardized cirrhosis mortality rates fell during the same period. The economic burden, the disease poses on the family of the patient and the patient’s loss of productive life has been overseen largely. The complications of cirrhosis are protean including portal hypertension, ascites, hepatorenal syndrome, hepatic encephalopathy, portal vein thrombosis, hepatocellular carcinoma and eventually death. Besides the complications that are disease driven, certain complications are worsened by the therapies instituted for the management of cirrhosis, of which beta blockers which have been used for managing portal hypertension since the 1980s when Lebrec et al. first demontsrated the usefulness of non selective beta blockers in a randomized controlled trial involving 74 patients with variceal bleeding, has recently drawn the interest of researchers and hepatologists worldwide, when concerns of its safety in advanced cirrhosis was raised by Serste. AIM OF THE STUDY: Aimed to analyze the impact of beta blockers on the following complications in cirrhosis: 1. Spontaneous bacterial peritonitis (SBP), 2. Refractory ascites, 3. Hepatorenal syndrome (HRS) and 4. Hepatic encephalopathy (HE). In patients who did or did not take non-selective beta blockers and thereby to test the null hypothesis that beta blockers cause worsening of the above mentioned complications. MATERIALS AND METHODS: Study Design: Single centre, case control retrospective study. Study centre: Department Of Digestive Health and Diseases, Kilpauk Medical College and Hospital, Kilpauk Medical College, Chennai. Period of Study: 2 years (January 2015 to January 2017). Study population: In Patients and Outpatients having cirrhosis and portal hypertension who were registered with the Department of Digestive Health and Disease between the period January 2009 to January 2016. Inclusion criteria: Patients having cirrhosis with portal hypertension. Exclusion criteria : Patients who had significant cardiovascular disease, extrahepatic malignancy, intrinsic renal disease and those not willing to provide consent were excluded from this study. METHODOLOGY Patients were identified from a prospectively collected data base. The following parameters were recorded at the time of enrollment to study: age, sex, duration of disease, number of hospital admissions for cirrhosis related illnesses, history of diabetes, history of upper gastrointestinal bleeding, presence of cirrhotic cardiomyopathy, portal vein thrombosis. Biochemical parameters such as complete blood count, renal function test, and liver function test were done. The MELD[5] and CTP[6,7] score were calculated based on the bilirubin, creatinine, PT/INR, albumin, presence of ascites and Hepatic Encephalopathy. RESULTS: A total of 82 patients were included in this study. The mean age of the entire cohort was 47.91 years. Predominantly our cohort had male patients (n=65, 79.3%). The overall mean duration of disease was 1.5 years. The common etiology for liver cirrhosis was ethanol (n = 61, 74.39%), followed by Chronic viral Hepatitis B (n = 9, 10.97%) cryptogenic, non alcoholic steatohepatitis and Hepatitis C. Four patients had both Hepatitis B and significant alcohol consumption. CONCLUSIONS: In this study , no significant statistical association was found between the NSBB group versus the non NSBB group in terms of the following 4 complications of cirrhois: 1. Spontaneous Bacterial peritonitis, 2. Refractory Ascites, 3. Hepatorenal syndrome, 4. Hepatic encephalopathy, To conclude, in this study non selective beta blockers are neither protective nor a risk factor for spontaneous bacterial peritonitis, refractory ascites, hepatorenal and hepatic encephalopathy. And therefore, we suggest that beta blockers can be continued safely in cirrhotics.