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Publications

Journal Article Ahead of print

PubMed: 42457041 DOI: 10.1016/j.jhep.2026.06.043

Impact of non-selective beta-blockers on acute kidney injury outcomes in patients with decompensated cirrhosis.

J Hepatol

Authors: Simone Incicco, Kavish R Patidar, Adrià Juanola, Ann T Ma, Anna Barone, Anand V Kulkarni, José Luis Pérez Hernández, Sumeet K Asrani, Brian Wentworth, Carlo Alessandria, Nadia Abdelaaty Abdelkader, Yu Jun Wong, Qing Xie, Nikolaos T Pyrsopoulos, Sung-Eun Kim, Yasser Fouad, Aldo Torre, Eira Cerda Reyes, Javier Díaz-Ferrer, Rakhi Maiwall, Douglas A Simonetto, Maria Papp, Eric S Orman, Giovanni Perricone, Cristina Solé, Christian M Lange, Alberto Queiroz Farias, Gustavo Pereira, Sebastian Marciano, Paolo Caraceni, Thierry Thévenot, Nipun Verma, Jeong Han Kim, Julio D Vorobioff, Jacqueline Cordova-Gallardo, Vasilisa R Greshnikova, Raoel Maan, Juan Pablo Roblero, Claudio Toledo, Stefania Gioia, Eduardo Fassio, Mónica Marino, Puria Nabilou, Victor Vargas, Manuela Merli, Luciana Lofego Goncalves, Liane Rabinowich, Aleksander Krag, Lorenz Balcar, Adrian Gadano … and 6 other authors

Affiliations

  • Unit of Internal Medicine and Hepatology, Department of Medicine, University and Hospital of Padova, Padova, Italy.
  • Sherrie and Alan Conover Center for Liver Disease and Transplantation, J.C. Walter Jr. Transplant Center, Houston Methodist Hospital, Houston, United States.
  • Liver Unit, Hospital Clínic of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Catalunya, Spain; School of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalunya, Spain.
  • Liver Unit, Hospital Clínic of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Catalunya, Spain; School of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalunya, Spain; Hepatology & Liver Intensive Care, Beaujon Hospital, Clichy, University Paris Cité, Paris, France.
  • Department of Hepatology, AIG Hospitals, Hyderabad, India.
  • Department of Gastroenterology and Hepatology, Hospital General de México Dr. Eduardo Liceaga, Ciudad de México, México.
  • Baylor University Medical Center, Dallas, TX, United States.
  • Division of Gastroenterology & Hepatology, University of Virginia School of Medicine, Charlottesville, VA, United States.
  • Division of Gastroenterology and Hepatology, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy.
  • Department of Tropical Medicine, Ain Shams University, Cairo, Egypt.
  • Department of Gastroenterology and Hepatology Changi General Hospital, Singapore; Duke-NUS Medical School, Singapore.
  • Department of Infectious Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
  • Division of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, NJ, United States; Liver Disease in New Jersey, NYU Grossman School of Medicine, NYU Langone Transplant Institute, New York, USA.
  • Division of Gastroenterology and Hepatology, Hallym University College of Medicine, Chuncheon, Republic of Korea.
  • Department of Gastroenterology, Hepatology and Endemic Medicine, Minia University, Minia, Egypt.
  • Gastroenterology Department, ABC Medical Center, Mexico City, México.
  • Central Military Hospital, México City, México.
  • Departamento del Aparato Digestivo, Hospital Edgardo Rebagliati-Clínica Internacional, Lima, Perú.
  • Institute of Liver and Biliary Sciences, New Delhi, India.
  • Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, United States.
  • Division of Gastroenterology, Kalman Laki Doctoral School of Biomedical and Clinical Sciences, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
  • Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, United States.
  • Hepatology and Gastroenterology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
  • Gastroenterology and Hepatology department. Parc Taulí University Hospital. Institut d'investigació i innovació Parc Taulí (I3PT-CERCA). Universitat Autònoma de Barcelona (UAB). CIBEREHD, Sabadell, Spain.
  • Department of Medicine II, LMU University Hospital Munich, Munich, Germany.
  • Department of Gastroenterology, University of São Paulo, São Paulo, Brazil.
  • Gastroenterology and Hepatology Unit, Bonsucesso Federal Hospital, Rio de Janeiro, Brazil.
  • Liver Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
  • Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; Unit of Semeiotics, Liver and Alcohol-related diseases, IRCSS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
  • Department of Hepatology, Centre Hospitalier Régional et Universitaire de Besançon, Besançon, France.
  • Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
  • Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea.
  • Gastroenterology Department and Liver Unit, University of Rosario Medical School, Rosario, Argentina.
  • Department of Gastroenterology, Hospital General Dr Manuel Gea Gonzalez, Tlalpan, México.
  • Department of Internal Medicine, Sechenov First Moscow State Medical University, Moscow, Russia.
  • Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, Netherlands.
  • Departamento de Gastroenterología, Hospital Clínico Universidad de Chile, Santiago, Chile.
  • Gastroenterology Unit, Universidad Austral de Chile, Valdivia, Chile.
  • Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy.
  • Gastroenterology Department and Liver Unit, Hospital Nacional Prof. Alejandro Posadas, El Palomar, Buenos Aires, Argentina.
  • Liver Unit, Carlos Bonorino Udaondo Hospital, Buenos Aires, Argentina.
  • Gastro Unit, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.
  • Liver Unit, Hospital Vall d'Hebron, Universitat Autònoma, CIBEREHD, Barcelona, Spain.
  • Serviçio de Gastroenterologia, University Hospital-Federal University of Espirito Santo, Vitòria, Brazil.
  • Liver Unit, Department of Gastroenterology, Tel Aviv Sourasky Medical Center, affiliated to the Faculty of Medical and Health science Tel Aviv University, Tel Aviv, Israel.
  • Institute of Clinical Research, University of Southern Denmark, Odense, Denmark; Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.
  • Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.

Abstract

BACKGROUND AND AIMS

Non-selective beta-blockers (NSBB) are widely used to prevent decompensation in cirrhosis. Guidelines recommend discontinuing NSBB in patients with cirrhosis and acute kidney injury (AKI), although based largely on expert opinion and limited evidence. We evaluated the impact of NSBB on AKI outcomes in patients with cirrhosis.

METHODS

This multicenter study enrolled patients hospitalized for decompensated cirrhosis and AKI. Data on NSBB treatment, type and dose and continuation/discontinuation/tapering were collected. Outcomes were compared between patients receiving and not receiving NSBB and between those who discontinued/tapered and those who did not. Inverse probability of treatment weighting (IPTW) balanced demographics, liver disease severity, hemodynamic parameters, AKI stage and acute-on-chronic liver failure (ACLF) grade. Main outcomes were AKI resolution and 28-day mortality.

RESULTS

Out of 1,238 patients with AKI, 503 were on NSBB (propranolol 55%; carvedilol 45%). After IPTW adjustment, NSBB treatment at AKI diagnosis was associated with higher likelihood of AKI resolution (sHR=1.29 [95% CI=1.12-1.48], p<0.001) and reduced 28-day mortality (sHR=0.70 [95% CI=0.55-0.91], p=0.006). At 48-72 hours from AKI diagnosis, NSBB were continued in 122 patients (24%) and discontinued/tapered in 349 (69%); 4 patients died, and data were not available for the remaining 28 patients. After excluding patients in whom NSBB continuation was not clinically feasible (n=59), IPTW-adjusted analysis showed no evidence of an association between NSBB continuation and AKI resolution (sHR=0.84 [95% CI=0.57-1.25], p=0.391) or 28-day mortality (sHR=0.51 [95% CI=0.23-1.11], p=0.089).

CONCLUSION

NSBB use at AKI diagnosis was associated with improved renal recovery and survival in patients with acutely decompensated cirrhosis and AKI. Continuation during hospitalization does not appear harmful, supporting careful individualized management rather than systematic withdrawal.

IMPACT AND IMPLICATIONS

Owing to potential adverse hemodynamic effects, current guidelines recommend discontinuation of non-selective beta-blockers (NSBB) in patients with Acute Decompensation (AD) of liver cirrhosis and Acute Kidney Injury (AKI). However, this recommendation relies largely on expert opinion, since robust clinical evidence is lacking. This study prospectively evaluated the impact of NSBB on AKI outcomes in a large multicentre cohort of patients with AD and AKI. Treatment with NSBB at AKI diagnosis was associated with greater likelihood of AKI resolution and lower risk of 28-day mortality, while no evidence of an association between early discontinuation and improved outcomes was observed. These findings support a personalized approach to NSBB management in decompensated patients with AKI and highlight the need to identify patients who may benefit most from NSBB discontinuation.

MeSH

Liver Diseases, Carvedilol, Liver Transplantation, Mortality, Acute-On-Chronic Liver Failure, Propranolol, Kidney, Liver, Sepsis, Diagnosis, Therapeutics, Renal Replacement Therapy, Hemodynamics, Acute Kidney Injury