Nonselective β blockers increase risk for hepatorenal syndrome and death in patients with cirrhosis and spontaneous bacterial peritonitis

Gastroenterology. 2014 Jun;146(7):1680-90.e1. doi: 10.1053/j.gastro.2014.03.005. Epub 2014 Mar 12.


Background & aims: Nonselective β blockers (NSBBs) reduce portal pressure and the risk for variceal hemorrhage in patients with cirrhosis. However, development of spontaneous bacterial peritonitis (SBP) in these patients could preclude treatment with NSBBs because of their effects on the circulatory reserve. We investigated the effects of NSBBs in patients with cirrhosis and ascites with and without SBP.

Methods: We performed a retrospective analysis of data from 607 consecutive patients with cirrhosis who had their first paracentesis at the Medical University of Vienna from 2006 through 2011. Cox models were calculated to investigate the effect of NSBBs on transplant-free survival time and adjusted for Child-Pugh stage and presence of varices.

Results: NSBBs increased transplant-free survival in patients without SBP (hazard ratio = 0.75; 95% confidence interval: 0.581-0.968; P = .027) and reduced days of nonelective hospitalization (19.4 days/year for patients on NSBBs vs 23.9 days/year for patients not taking NSBBs). NSBBs had only moderate effects on systemic hemodynamics at patients' first paracentesis. However, at the first diagnosis of SBP, the proportion of hemodynamically compromised patients with systolic arterial pressure <100 mm Hg was higher among those who received NSBBs (38% vs 18% of those not taking NSBBs; P = .002), as was the proportion of patients with arterial pressure <82 mm Hg (64% of those taking NSBBs vs 44% of those not taking NSBBs; P = .006). Among patients with SBP, NSBBs reduced transplant-free survival (hazard ratio = 1.58; 95% confidence interval: 1.098-2.274; P = .014) and increased days of nonelective hospitalization (29.6 days/person-year in patients on NSBBs vs 23.7 days/person-year in those not taking NSBBs). A higher proportion of patients on NSBBs had hepatorenal syndrome (24% vs 11% in those not taking NSBBs; P = .027) and grade C acute kidney injury (20% vs 8% for those not taking NSBBs; P = .021).

Conclusions: Among patients with cirrhosis and SBP, NSBBs increase the proportion who are hemodynamically compromised, time of hospitalization, and risks for hepatorenal syndrome and acute kidney injury. They also reduce transplant-free survival. Patients with cirrhosis and SBP should not receive NSBBs.

Keywords: Adrenergic Receptor; Bacterial Infection; Liver Fibrosis; Mortality; β Blocker.

MeSH terms

  • Acute Kidney Injury / etiology
  • Acute Kidney Injury / mortality
  • Adrenergic beta-Antagonists / adverse effects*
  • Aged
  • Austria
  • Chi-Square Distribution
  • Disease-Free Survival
  • Female
  • Hemodynamics / drug effects
  • Hepatorenal Syndrome / diagnosis
  • Hepatorenal Syndrome / etiology*
  • Hepatorenal Syndrome / mortality
  • Hepatorenal Syndrome / physiopathology
  • Humans
  • Hypertension, Portal / diagnosis
  • Hypertension, Portal / drug therapy*
  • Hypertension, Portal / etiology
  • Hypertension, Portal / mortality
  • Hypertension, Portal / physiopathology
  • Kaplan-Meier Estimate
  • Length of Stay
  • Liver Cirrhosis / complications
  • Liver Cirrhosis / diagnosis
  • Liver Cirrhosis / drug therapy*
  • Liver Cirrhosis / mortality
  • Liver Cirrhosis / physiopathology
  • Liver Transplantation
  • Male
  • Middle Aged
  • Paracentesis
  • Peritonitis / complications*
  • Peritonitis / diagnosis
  • Peritonitis / microbiology
  • Peritonitis / mortality
  • Peritonitis / physiopathology
  • Proportional Hazards Models
  • Retrospective Studies
  • Risk Factors
  • Time Factors
  • Treatment Outcome


  • Adrenergic beta-Antagonists