From the Guidelines
Beta blockers should be used with caution in patients with decompensated cirrhosis and hepatorenal syndrome (HRS), and their use should be individualized based on the patient's hemodynamic status and risk of complications. In patients with decompensated cirrhosis, the use of non-selective beta blockers (NSBBs) like propranolol, nadolol, and carvedilol can be beneficial in reducing the risk of variceal bleeding, but may worsen outcomes in patients with refractory ascites or HRS by reducing cardiac output and exacerbating the already compromised renal perfusion 1. The recent study by the American Association for the Study of Liver Diseases (2017) suggests that the dose of NSBBs should be carefully titrated, and high doses should be avoided in patients with refractory ascites or HRS 1. Another study published in the Journal of Hepatology (2018) recommends that the use of NSBBs should be based on a critical risk/benefit evaluation in patients with refractory ascites and signs of systemic circulatory dysfunction, and that parameters such as severe hyponatraemia, low mean arterial pressure or cardiac output, and increasing SCr should be used to identify more vulnerable patients 1. A more recent study (2021) suggests that carvedilol may be safe at low doses (6.25–12.5 mg) in patients with refractory ascites, provided that patients maintain systolic pressures >90 mmHg, and that it may have a role in reducing inflammation and mitochondrial dysfunction 1. Key considerations for the use of beta blockers in patients with decompensated cirrhosis and HRS include:
- Careful titration of the dose to avoid high doses that may worsen outcomes
- Monitoring of hemodynamic status and risk of complications
- Individualization of treatment based on the patient's specific condition and risk factors
- Consideration of alternative treatments, such as vasoconstrictors and albumin, for patients with HRS
- Cautious reintroduction of beta blockers after recovery from the acute episode of decompensation and HRS, if indicated.
From the Research
Role of Beta Blockers in Decompensated Cirrhosis and Hepatorenal Syndrome
- The use of nonselective beta-blockers (NSBBs) in patients with decompensated cirrhosis and hepatorenal syndrome (HRS) is a topic of ongoing research and debate 2.
- A study found that the use of NSBBs at home was not significantly associated with the development of HRS in patients with decompensated cirrhosis 2.
- The pathophysiology of HRS involves a decrease in effective circulating arterial volume, leading to a functional form of acute kidney injury (AKI) 3.
- The definitive treatment of HRS is liver transplantation, while vasoconstrictor agents and intravenous albumin are used as a bridge therapy 4, 3.
- Beta-blockers, such as propranolol and carvedilol, are used to prevent bleeding from oesophageal varices in patients with cirrhosis, but their use in decompensated cirrhosis is controversial 5.
- Carvedilol may be superior to propranolol and should be the first-line treatment until the decompensated stage 5.
- The therapeutic window of NSBBs in cirrhosis appears to deteriorate in advanced decompensated stages, and the risk of harm is high in patients with refractory ascites, low blood pressure, and renal impairment 5.
Treatment Options for Hepatorenal Syndrome
- Vasoconstrictors, such as terlipressin and norepinephrine, are used to improve hemodynamics in patients with HRS 4.
- Albumin is used for its volume-expanding and anti-inflammatory properties to confirm the diagnosis of HRS-AKI 4.
- Midodrine, octreotide, and albumin are used in combination to improve renal function in patients with type 1 HRS 6.
- Transjugular intrahepatic portosystemic stent shunt (TIPS) is an effective treatment for type 1 HRS in suitable patients with cirrhosis and ascites, following improvement of renal function with combination therapy 6.