Effect of beta-blockers on multiple haemodynamics in cirrhosis: A cross-over study by MR-imaging and hepatic vein catheterization.

BACKGROUND: Non-selective beta-blockers (NSBB) are widely used in the treatment of patients with cirrhosis. Only about 50% respond with a sufficient reduction in their hepatic venous pressure gradient (HVPG) and NSBB may induce detrimental cardiac and renal effects in the presence of severe decompensation. We aimed to assess the effects of NSBB on haemodynamics using magnetic resonance imaging (MRI) and to assess if these haemodynamic changes were related to the disease severity and HVPG response. METHOD: A prospective cross-over study of 39 patients with cirrhosis. Patients underwent hepatic vein catheterization and MRI with assessments of HVPG, cardiac function, systemic and splanchnic haemodynamics before and after propranolol infusion. RESULTS: Propranolol induced significant decreases in cardiac output (-12%) and blood flow of all vascular compartments, with the largest reductions seen in the azygos venous (-28%), portal venous (-21%), splenic (-19%) and superior mesenteric artery (-16%) blood flow. Renal artery blood flow fell by -5% in the total cohort, with a more pronounced reduction in patients without ascites than in those with ascites (-8% vs. -3%, p = .01). Twenty-four patients were NSBB responders. Their changes in HVPG after NSBB were not significantly associated with other haemodynamic changes. CONCLUSION: The changes in cardiac, systemic and splanchnic haemodynamics did not differ between NSBB responders and non-responders. The effects of acute NSBB blockade on renal flow seem to depend on the severity of the hyperdynamic state, with the largest reduction in renal blood flow in compensated patients compared to decompensated patients with cirrhosis. However, future studies are needed to assess the effects of NSBB on haemodynamics and renal blood flow in patients with diuretic-resistant ascites.

Low ascitic fluid total protein levels is not associated to the development of spontaneous bacterial peritonitis in a cohort of 274 patients with cirrhosis.

BACKGROUND: Spontaneous bacterial peritonitis (SBP) is a complication to decompensated cirrhosis. Fluoroquinolones may prevent SBP. However, predictive markers for SBP are wanted. Guidelines suggest that patients with ascitic fluid protein below 15 g/l receive fluoroquinolones to prevent SBP. This study aimed to assess the clinical utility of low ascitic fluid protein in predicting SBP in patients with cirrhosis and ascites. METHODS: A total of 274 patients with cirrhosis and ascites underwent paracentesis between January 2010 and June 2015. Patients were followed until two years, development of SBP, initiation of ciprofloxacin, death or liver transplantation. Data were compared between groups of patients with 'high' or 'low' ascitic protein. RESULTS: SBP developed in 31 patients (11.3%). No difference in mean ascitic fluid protein levels were found (SBP, mean: 8.5 g/l and no SBP 8.2 g/l, p = .825). SBP developed at equal rates in patients with 'high' or 'low' ascitic protein (10.8% (≤15 g/l) and 14.0% (>15 g/l), p = .599). The same trend was observed when adjusting the threshold below 10 g/l (11.9% (≤10 g/l) and 10.2% (>10 g/l), p = .697). CONCLUSIONS: Low ascitic fluid protein does not predict SBP in patients with cirrhosis and ascites. Better markers are needed.

Few complications after paracentesis in patients with cirrhosis and refractory ascites.

INTRODUCTION: The relevance of needle type and ultrasound guidance in connection with complications and technical problems in paracentesis in cirrhotic patients has only been sparsely described. The aim of this study was to evaluate paracentesis in cirrhotic patients with refractory ascites, focusing on technique, complications, amount of ascites drained and prognosis. MATERIAL AND METHODS: This was a retrospective study based on 51 cirrhotic patients with refractory ascites undergoing paracentesis. A total of 209 paracenteses were performed using a pigtail catheter and an intravenous catheter. Ultrasound-guided puncture or no ultrasound-guided punctured were compared with regard to amount of drained ascites, technical problems and complications both immediate and within a week of the procedure. The impact of coagulopathy was also investigated. RESULTS: 12% immediate and 5% late complications occurred, most of which were minor. No significant differences in the frequency of complications were found when comparing a pigtail to an intravenous catheter (8% versus 21%, OR = 2.81 95% CI (0.86; 9.13)), nor did the amount of drained ascites differ significantly. Ultrasound guidance did not significantly decrease the frequency of complications (7% versus 9%, OR 1.34 95% CI (0.37; 4.84)). Coagulopathy did not significantly affect the risk of complications. CONCLUSION: Paracentesis in patients with cirrhosis is associated with a low frequency of serious complications, regardless of the technique deployed. Although the material is of limited size, it appears that coagulopathy does not increase the risk of complications following this procedure.