Recently, several studies have suggested that non selective beta-blockers (NSBB) may have beneficial effects in patients with acute on chronic liver failure (ACLF) through reducing the severity of inflammatory response. On the other hand, the use of beta blockers remains controversial in non-cirrhotic patients with septic shock. The aim of this study was to explore the impact of NSBB in patients with ACLF and distributive shock requiring vasopressors (norepinephrine).
Patients and methods: Eighty consecutive patients with ACLF admitted from June 2010 to Sept 2015 in a specialized ICU were retrospectively studied. All patients had distributive circulatory failure defined by the need for norepinephrine to achieve a target mean arterial pressure of 65mmHg after adequate fluid resuscitation. The study subjects were classified into NSBB+ (receiving NSSB) and NSBB- (not receiving NSBB) groups. Patients were followed up from admission in the ICU to death, transplantation or last follow up visit for patients alive without transplant at the end of the study.
Results: The study population included 58 males and 22 females. The mean age of the study participants was 54 ± 9 years. Causes of cirrhosis were alcohol in 62%, HCV in 19%, HBV in 6% and others in 16%. Mechanical ventilation (MV) and renal replacement therapy (RRT) were used in 72% and 49% patients, respectively (including 40% with both MV and RRT in addition to vasopressors). Forty patients out of eighty (50%) were receiving NSBB at admission (NSBB+). The mean of the MELD score at admission was not significantly different in NSBB+ (29) and NSBB- (32) patients. No significant difference was found between the 2 groups (NSBB+ vs NSBB-) regarding age (56 vs 52-y), gender (72 % vs 72% males), rate of MV (69% vs 75%), rate of RRT (41% vs 57%), rate of empirical antibiotics before admission (65% vs 52%), and rate of documented infection after admission (85% vs 78%). The proportion of patients who were transplanted was not significantly different in the 2 groups (20% vs 7%, p=0.1). Transplant free-survival (Kaplan-Meier) was significantly better in NSBB+ as compared to NSBB- patients (48% vs. 15% at 28-day, respectively, p=0.007). On multivariate analysis (Cox model including NSBB and MV), only NSBB was significantly and independently predictive of survival (p=0.02).
Conclusion: The results of this series suggest that NSBB intake at admission of patients with ACLF and circulatory failure requiring administration of vasopressors is associated with better outcome, irrespective of the presence or absence of bacterial infection.