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Wang YJ, Zhu YB, Wei WJ. Effect of non-selective β-receptor blockers on inflammatory factors and prognosis in advanced chronic liver disease. Shijie Huaren Xiaohua Zazhi 2021; 29:1110-1117. [DOI: 10.11569/wcjd.v29.i19.1110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Non-selective β-blockers (NSBBs) are the main treatment for portal hypertension in the context of liver cirrhosis. Studies of acute-on-chronic liver failure in patients with liver cirrhosis have shown that the application of NSBBs decreases the grades of liver failure, white blood cell count (WBC), and plasma C reactive protein (CRP) levels, suggesting that NSBBs have anti-inflammatory effects.
AIM To determine the effects of NSBBs on inflammatory factors and prognosis in advanced chronic liver disease based on a competitive risk model.
METHODS A total of 319 patients with advanced chronic liver disease treated with NSBBs at our hospital were included. The changes of hepatic venous pressure gradient (HVPG) and inflammatory factor levels before and after treatment were compared. A competitive risk model was used to analyze the effect of changes in WBC after treatment on the decompensation rate and liver-related mortality.
RESULTS HVPG, WBC, and CRP after NSBBs treatment were significantly lower than the values before treatment (P < 0.05). Taking liver transplantation and non-liver-related deaths as competitive risks, it was found that WBC response (decreased by ≥ 20%) can reduce the risk of further decompensation in patients with baseline decompensation (hazard ratio [HR] = 0.708). WBC response was identified to be an independent predictor of liver-related survival in patients without liver transplantation (HR = 0.582). WBC response increased the risk of liver-related death in liver transplant patients (HR = 1.759).
CONCLUSION NSBBs help to improve the inflammatory response in advanced chronic liver disease, which is more obvious in Child-Pugh C patients. A decrease of ≥ 20% in WBC can reduce the risk of liver-related death in patients with further decompensation and without liver transplantation.
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Affiliation(s)
- Yan-Jiao Wang
- Department of Gastroenterology, The People's Hospital of Lishui City, Lishui 323000, Zhejiang Province, China
| | - Ya-Bi Zhu
- Department of Gastroenterology, The People's Hospital of Lishui City, Lishui 323000, Zhejiang Province, China
| | - Wen-Jia Wei
- Department of Hepatology, The People's Hospital of Lishui City, Lishui 323000, Zhejiang Province, China
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Jachs M, Hartl L, Schaufler D, Desbalmes C, Simbrunner B, Eigenbauer E, Bauer DJM, Paternostro R, Schwabl P, Scheiner B, Bucsics T, Stättermayer AF, Pinter M, Trauner M, Mandorfer M, Reiberger T. Amelioration of systemic inflammation in advanced chronic liver disease upon beta-blocker therapy translates into improved clinical outcomes. Gut 2021; 70:1758-1767. [PMID: 33199442 DOI: 10.1136/gutjnl-2020-322712] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/18/2020] [Accepted: 10/19/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Systemic inflammation promotes the development of clinical events in patients with advanced chronic liver disease (ACLD). We assessed whether (1) non-selective beta blocker (NSBB) treatment initiation impacts biomarkers of systemic inflammation and (2) whether these changes in systemic inflammation predict complications and mortality. DESIGN Biomarkers of systemic inflammation, that is, white blood cell count (WBC), C reactive protein (CRP), interleukin-6 (IL-6) and procalcitonin (PCT) were determined at sequential hepatic venous pressure gradient (HVPG) measurements without NSBB and under stable NSBB intake. The influence of NSBB-related changes in systemic inflammation on the risk of decompensation and liver-related death was analysed using competing risk regression. RESULTS Our study comprised 307 stable patients with ACLD (Child-A: 77 (25.1%), Child-B: 161 (52.4%), Child-C: 69 (22.5%), median HVPG: 20 (IQR 17-24) mm Hg) including 231 (75.2%) with decompensated disease.WBC significantly decreased upon NSBB therapy initiation (median: -2 (IQR -19;+13)%, p=0.011) in the overall cohort. NSBB-related reductions of WBC (Child-C: -16 (-30;+3)% vs Child-B: -2 (-16;+16)% vs Child-A: +3 (-7;+13)%, p<0.001) and of CRP (Child-C: -26 (-56,+8)% vs Child-B: -16 (-46;+13)% vs Child-A: ±0 (-33;+33)%, p<0.001) were more pronounced in advanced stages of cirrhosis. The NSBB-associated changes in WBC correlated with changes in CRP (Spearman's ρ=0.228, p<0.001), PCT (ρ=0.470, p=0.002) and IL-6 (ρ=0.501, p=0.001), but not with changes in HVPG (ρ=0.097, p=0.088).An NSBB-related decrease in systemic inflammation (ie, WBC reduction ≥15%) was achieved by n=91 (29.6%) patients and was found to be an independent protective factor of further decompensation (subdistribution HR, sHR: 0.694 (0.49-0.98), p=0.038) in decompensated patients and of liver-related mortality in the overall patient cohort (sHR: 0.561 (0.356-0.883), p=0.013). CONCLUSION NSBB therapy seems to exert systemic anti-inflammatory activity as evidenced by reductions of WBC and CRP levels. Interestingly, this effect was most pronounced in Child-C and independent of HVPG response. An NSBB-related WBC reduction by ≥15% was associated with a decreased risk of further decompensation and death.
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Affiliation(s)
- Mathias Jachs
- Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Lukas Hartl
- Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Dunja Schaufler
- Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Christopher Desbalmes
- Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Benedikt Simbrunner
- Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria.,Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | | | - David Josef Maria Bauer
- Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Rafael Paternostro
- Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Philipp Schwabl
- Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria.,Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Bernhard Scheiner
- Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Theresa Bucsics
- Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | | | - Matthias Pinter
- Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria .,Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria.,Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
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4
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Mendoza YP, Rodrigues SG, Bosch J, Berzigotti A. Effect of poorly absorbable antibiotics on hepatic venous pressure gradient in cirrhosis: A systematic review and meta-analysis. Dig Liver Dis 2020; 52:958-965. [PMID: 32736898 DOI: 10.1016/j.dld.2020.06.048] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 06/24/2020] [Accepted: 06/29/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND The effects of poorly/non-absorbable antibiotics on hepatic venous pressure gradient (HVPG) are debated. AIM To analyze the effects of rifaximin or norfloxacin on HVPG and on markers of bacterial translocation and proinflammatory cytokines. METHODS We performed a systematic search of randomized clinical trials (RCTs) involving patients with cirrhosis and portal hypertension, assessing the effect of rifaximin or norfloxacin vs control on HVPG. Pooled analyses were based on random-effects models, heterogeneity was assessed by Cochran's Q, I2 statistic and subgroup analyses. RESULTS Five studies (215 patients) were included. Risk of bias was high in three. We found no significant differences using antibiotics versus control. The summary mean difference in HVPG was of -0.55 mmHg (95%CI:-1.52, 0.42; P = 0.27), with moderate heterogeneity (P = 0.15; I2 = 40%). RCTs with longer therapy (60-90 days) used non-selective-beta-blockers (NSBB) in both antibiotics and control arms. Subgroup analysis showed a significantly greater reduction in HVPG in the combination arm over controls (mean difference -1.46 mmHg [95%CI: -2.63, -0.28; P = 0.01]) with no heterogeneity (P = 0.46; I2 = 0%). Serum lipopolysaccharide-binding protein (LBP) significantly decreased with antibiotics, but with high heterogeneity (P < 0.001; I2 = 92%). CONCLUSIONS Rifaximin or norfloxacin did not significantly reduce HVPG in patients with cirrhosis and portal hypertension. Studies using antibiotic for longer periods on top of NSBB showed a significant decrease in HVPG.
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Affiliation(s)
- Yuly P Mendoza
- UVCM, Inselspital, Bern University Hospital, Department of Biomedical Research, University of Bern, Switzerland
| | - Susana G Rodrigues
- UVCM, Inselspital, Bern University Hospital, Department of Biomedical Research, University of Bern, Switzerland
| | - Jaime Bosch
- UVCM, Inselspital, Bern University Hospital, Department of Biomedical Research, University of Bern, Switzerland
| | - Annalisa Berzigotti
- UVCM, Inselspital, Bern University Hospital, Department of Biomedical Research, University of Bern, Switzerland.
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Propranolol Is Associated with Lower Risk of Incidence of Hepatocellular Carcinoma in Patients with Alcoholic Cirrhosis: A Tertiary-Center Study and Indirect Comparison with Meta-Analysis. Gastroenterol Res Pract 2020; 2020:1892584. [PMID: 32454812 PMCID: PMC7238337 DOI: 10.1155/2020/1892584] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 03/20/2020] [Indexed: 02/06/2023] Open
Abstract
Alcoholic cirrhosis (AC) leads to enormous disease burden and occupies a substantial proportion in the etiology of hepatocellular carcinoma (HCC), but scarce attention has been paid to this topic. Besides, propranolol has been reported to decrease the rate of HCC in viral hepatitis. We conducted a retrospective tertiary-center cohort study to identify the HCC incidence in AC patients with or without propranolol. A total of 1,046 AC patients with hospitalization had been screened, and those with regular follow-up for three years or otherwise until the date of malignancy diagnosis without meeting exclusion criteria were enrolled; finally, 23 AC patients with propranolol and 46 AC patients without propranolol were analyzed after twofold propensity-score matching. The cumulative incidence of HCC was lower in the propranolol group (log-rank test, P = 0.046). Furthermore, we undertook the meta-analysis of annual incidence of HCC in AC patients, and 1,949 publications were screened, within which eight studies were analyzed; the pooled annual incidence was 2.41%, which was higher than the calculated annual incidence of HCC in our AC cohort with propranolol (1.45%). In conclusion, propranolol is associated with decreased risk of HCC incidence in patients with AC.
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Chae M, Son ED, Bae IH, Cho EG, Kim HJ, Jung JY. UVB-dependent inhibition of lipin-1 protects against proinflammatory responses in human keratinocytes. Exp Mol Med 2020; 52:293-307. [PMID: 32080341 PMCID: PMC7062881 DOI: 10.1038/s12276-020-0388-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 01/16/2020] [Accepted: 01/29/2020] [Indexed: 01/22/2023] Open
Abstract
Lipin-1 is an Mg2+-dependent phosphatidate phosphatase (PAP1) that catalyzes a critical step in the synthesis of glycerophospholipids and is also a cotranscriptional regulator. The role of lipin-1 in the regulation of inflammatory responses has been extensively studied in various cell types but not in skin cells. In the present study, the function of lipin-1 in UVB-induced proinflammatory responses was assessed in normal human epidermal keratinocytes (NHEKs). UVB radiation downregulated lipin-1 expression. Lipin-1 inhibition was mediated by UVB-dependent sterol-response element binding protein-1 (SREBP-1) inhibition. The UVB-dependent inhibition of lipin-1 and SREBP-1 was mediated by AMPK activation. UVB-induced activation of JNK was dependent on AMPK activation and mediated lipin-1 inhibition. Prevention of UVB-mediated lipin-1 repression by introducing a lipin-1 expression vector stimulated IL-6 and IL-8 production, suggesting that lipin-1 inhibition attenuates UVB-induced IL-6 and IL-8 production. The downregulation of lipin-1 ameliorated UVB-induced NF-ĸB phosphorylation, which might be attributed to the suppression of UVB-induced accumulation of free fatty acids (FFAs). Pharmacological inhibition of PAP1 with propranolol suppressed UVB-induced production of IL-6 and IL-8 in NHEKs and reconstituted human skin models. Taken together, lipin-1 is downregulated by exposure to UVB radiation, which confers protection against UVB-induced proinflammatory responses; therefore, the inhibition of lipin-1 is a potential strategy for photoaging. Reduced production and activity of an enzyme in skin cells helps protect them from damage caused by exposure to ultra-violet light. Minjung Chae and colleagues at the Amorepacific Corporation in Yongin, South Korea, identified an anti-inflammatory effect caused by the reduction in expression of the enzyme lipin-1 when skin cells are exposed to UVB radiation. These ultra-violet rays are associated with aging and increased risk of skin cancer. Lipin-1 is involved in making glycerophospholipid molecules, which are key components of the membranes surrounding and inside cells. Identifying the enzyme’s significance for inflammation in skin cells extends previous similar findings with other cell types. The research also uncovered aspects of the molecular mechanisms mediating the skin cell response. Inhibiting lipin-1 activity might reduce the damage sunlight causes to skin.
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Affiliation(s)
- Minjung Chae
- Basic Research and Innovation Division, Bioscience Laboratory, AmorePacific Corporation R&D Center, Yongin-si, Gyeonggi-do, South Korea.
| | - Eui Dong Son
- Basic Research and Innovation Division, Bioscience Laboratory, AmorePacific Corporation R&D Center, Yongin-si, Gyeonggi-do, South Korea
| | - Il-Hong Bae
- Basic Research and Innovation Division, Bioscience Laboratory, AmorePacific Corporation R&D Center, Yongin-si, Gyeonggi-do, South Korea
| | - Eun-Gyung Cho
- Basic Research and Innovation Division, Bioscience Laboratory, AmorePacific Corporation R&D Center, Yongin-si, Gyeonggi-do, South Korea
| | - Hyoung-June Kim
- Basic Research and Innovation Division, Bioscience Laboratory, AmorePacific Corporation R&D Center, Yongin-si, Gyeonggi-do, South Korea
| | - Ji-Yong Jung
- Basic Research and Innovation Division, Bioscience Laboratory, AmorePacific Corporation R&D Center, Yongin-si, Gyeonggi-do, South Korea
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The Role of Non-Selective β-Blockers in Compensated Cirrhotic Patients without Major Complications. ACTA ACUST UNITED AC 2019; 56:medicina56010014. [PMID: 31905956 PMCID: PMC7022668 DOI: 10.3390/medicina56010014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 12/22/2019] [Accepted: 12/22/2019] [Indexed: 12/17/2022]
Abstract
Background and Objectives: Non-selective β-blockers (NSBB) could prevent decompensation and hepatocellular carcinoma (HCC) in cirrhotic patients with clinically significant portal hypertension (CSPH), but remained uncertain for compensated cirrhotic patients without major complications. We aimed to compare the clinical outcomes between propranolol users and non-users of a CC group without major complications. Material and Methods: We conducted this population-based cohort study by using the Taiwanese Longitudinal Health Insurance Database 2000. Propranolol users (classified as cumulative defined daily dose (cDDD)) and non-PPL users were matched with a 1:1 propensity score in both cohorts. Results: This study comprised 6896 propranolol users and 6896 non-propranolol users. There was no significant impact on the development of spontaneous bacterial peritonitis between the two groups (aHR: 1.24, 95% confidence interval (CI): 0.88~1.75; p = 0.2111). Male gender, aged condition, and non-liver related diseases (peripheral vascular disease, cerebrovascular disease, dementia, pulmonary disease, and renal disease) were the independent risk factors of mortality. PPL users had significantly lower incidence of HCC development than non-users (aHR: 0.81, p = 0.0580; aHR: 0.80, p = 0.1588; and aHR: 0.49, p < 0.0001 in the groups of 1–28, 29–90, and >90 cDDD, respectively). Conclusion: The current study suggested that high cumulative doses of propranolol could decrease the risk of hepatocellular carcinoma among compensated cirrhotic patients without major complications. Further large-scale prospective studies are still required to confirm the findings in this study. Results: It remained uncertain whether non-selective β-blockers (NSBB) could prevent decompensation and hepatocellular carcinoma (HCC) in compensatory cirrhotic patients without major complications. This study aimed to compare the clinical outcomes between propranolol users and non-users of the CC group without major complications.
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Brito-Azevedo A. Diuretic window hypothesis in cirrhosis: Changing the point of view. World J Gastroenterol 2019; 25:3283-3290. [PMID: 31341355 PMCID: PMC6639551 DOI: 10.3748/wjg.v25.i26.3283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 05/09/2019] [Accepted: 06/01/2019] [Indexed: 02/06/2023] Open
Abstract
Since the 1970s, non-selective beta-blockers (NSBB) have been used to prevent variceal upper bleeding in advanced cirrhotic patients. However, several recent studies have raised the doubt about the benefit of NSBB in end-stage cirrhotic patients. In fact, they suggested a detrimental effect in these patients that even reduced survival. All of these studies have been assembled to compose the “window therapy hypothesis”, in which NSBB would have traditional indication to be initiated to prevent variceal upper bleeding; however, treatment should be stopped (or not be initiated) in patients with end-stage cirrhosis. NSBB would reduce the cardiac reserve of these patients, worsening systemic perfusion and prognosis. However, it should be emphasized that these studies present important bias issues, and their results also suggested that diuretic treatment may also be behind the effects observed. In this opinion review, we changed the point of view from NSBB to diuretic treatment, based on a physiopathogenic approach of circulatory parameters of cirrhotic patients studied, and based on diuretic effect in blood pressure lowering and in other hypervolemic disease, as heart failure. We suggest a “diuretic window hypothesis”, composed by an open window in hypervolemic phase, an attention window when patient present in a normal plasma volume phase, and a closed window during the plasma hypovolemic phase.
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Affiliation(s)
- Anderson Brito-Azevedo
- Liver Transplant Unit, São Lucas Hospital, Rio de Janeiro 22061-080, Brazil
- Liver Transplant Unit, São Francisco na Providência de Deus Hospital, Rio de Janeiro 20520-053, Brazil
- Liver Transplant Unit, Adventist Silvestre Hospital, Rio de Janeiro 22241-280, Brazil
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Reiberger T, Mandorfer M. Beta adrenergic blockade and decompensated cirrhosis. J Hepatol 2017; 66:849-859. [PMID: 27864004 DOI: 10.1016/j.jhep.2016.11.001] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 10/30/2016] [Accepted: 11/07/2016] [Indexed: 12/15/2022]
Abstract
Non-selective betablockers (NSBBs) remain the cornerstone of medical treatment of portal hypertension. The evidence for their efficacy to prevent variceal bleeding is derived from prospective trials, which largely excluded patients with refractory ascites and renal failure. In parallel to the increasing knowledge on portal hypertension-induced changes in systemic hemodynamics, cardiac function, and renal perfusion, emerging studies have raised concerns about harmful effects of NSBBs. Clinicians are facing an ongoing controversy on the use of NSBBs in patients with advanced cirrhosis. On the one hand, NSBBs are effective in preventing variceal bleeding and might also have beneficial non-hemodynamic effects, however, they also potentially induce hypotension and limit the cardiac reserve. An individualized NSBB regimen tailored to the specific pathophysiological stage of cirrhosis might optimize patient management at this point. This article aims to give practical recommendations on the use of NSBBs in patients with decompensated cirrhosis.
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Affiliation(s)
- Thomas Reiberger
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria.
| | - Mattias Mandorfer
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
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