No abstract

Summary Background The safety of non‐selective β‐blockers in patients with advanced cirrhosis has been questioned in recent years. It was hypothesised that there is a particular therapeutic window. However, the specific limits still need to be determined. Aim To evaluate potential limits of the therapeutic window of non‐selective β‐blocker therapy in patients with cirrhosis and ascites Methods The impact of non‐selective β‐blockers on 28‐day transplant‐free survival was analysed in a cohort of 624 consecutive patients with decompensated cirrhosis and ascites. Three potential limits were investigated: spontaneous bacterial peritonitis, acute‐on‐chronic liver failure, mean arterial blood pressure ≤ 82 and < 65 mm Hg. Results Treatment with non‐selective β‐blockers was associated with a higher 28‐day transplant‐free survival in the overall cohort (hazard ratio: 0.621; P = .035) as well as in patients with acute‐on‐chronic liver failure (hazard ratio: 0.578; P = .031) and those with spontaneous bacterial peritonitis (hazard ratio: 0.594; P = .073). In contrast, survival benefits were markedly attenuated in patients with a mean arterial blood pressure ≤ 82 mm Hg and completely lost in those with mean arterial blood pressure < 65 mm Hg (P = .536). In spontaneous bacterial peritonitis patients with a mean arterial blood pressure < 65 mm Hg non‐selective β‐blocker treatment was associated with renal impairment. Of note, among those with a mean arterial blood pressure ≥ 65 mm Hg non‐selective β‐blocker intake was consistently associated with superior transplant‐free survival (hazard ratio: 0.582; P = .029) irrespective of the presence of spontaneous bacterial peritonitis (hazard ratio: 0.435; P = .028) or acute‐on‐chronic liver failure (hazard ratio: 0.480 P = .034). Conclusions Ascites, acute‐on‐chronic liver failure and spontaneous bacterial peritonitis do not limit the safe use of non‐selective β‐blockers in patients with cirrhosis. Mean arterial blood pressure might represent a better indicator to determine the therapeutic window of non‐selective β‐blocker treatment.

No abstract

High dosages of proton pump inhibitors are associated with an adverse outcome in patients with spontaneous bacterial peritonitis. Thus, indication for high-dosage proton pump inhibitors therapy should be evaluated carefully in these patients.

IntroductionType 2 diabetes mellitus (DM) is a frequent comorbidity among patients with liver cirrhosis. However, data regarding the impact of DM on spontaneous bacterial peritonitis (SBP) are quite limited. Our aim was to analyze the impact of DM and HbA1c values on the incidence of SBP and mortality in patients with liver cirrhosis and ascites.MethodsA number of 475 consecutive patients with liver cirrhosis and ascites were analyzed. Presence of DM as well as HbA1c was assessed at the time of the first paracentesis. Patients were followed up for a mean of 266 days. Primary endpoints were SBP development and mortality.ResultsOverall, 118 (25%) patients were diagnosed with DM. DM patients had an increased risk for developing a SBP during follow-up (HR: 1.51; p = 0.03). SBP incidence was particularly high in DM patients with HbA1c values ≥6.4%, significantly higher than in DM patients with HbA1c values <6.4% (HR: 4.21; p = 0.0002). Of note, DM patients with HbA1c <6.4% at baseline had a similar risk for SBP as those without DM (HR: 0.93; p = 0.78, respectively). After excluding all patients who were eligible for secondary antibiotic prophylaxis, HbA1c ≥6.4% but neither bilirubin nor ascites protein level were associated with primary SBP development in the multivariate analysis (p = 0.003).ConclusionsIndividuals with liver cirrhosis and concomitant DM have a higher risk for developing a SBP. HbA1c values may be useful to further stratify the risk for SBP among DM patients, which may help to identify those who benefit from antibiotic prophylaxis.