1. Dominique Valla, Richard Moreau, and Didier Lebrec
Journal conference
Deleterious Effects of Beta-Blockers on Survival in Patients With Cirrhosis and Refractory Ascites
Thomas Serste´ ,Christian Melot, Claire Francoz, Franc¸ ois Durand, Pierre-Emmanuel Rautou,
Dominique Valla, Richard Moreau, and Didier Lebrec
HEPATOLOGY 2010;52:
by the Tuberculosis Network European Trials Group (TBNET)
R2. 장원석

2. Korea National Diabetes Program
Background
Refractory ascites :
a lack of response to high doses of diuretics
the recurrence of side effects when lower doses of diuretics are given.
->The first-line treatment :repeated large-volume paracentesis.
The administration of nonselective beta-blockers for the prevention of gastrointestinal hemorrhaging is frequent when esophageal varices are present. However, this treatment may have deleterious effects on patients with ascites treated by large-volume paracentesis.
The aim of the present study was to evaluate the effect of the administration of nonselective beta-blockers on long-term survival in patients with cirrhosis and refractory ascites.
Korea National Diabetes Program

3. Korea National Diabetes Program
Patients and Methods
Study Population.
a single-center
observational
case-only
prospective study
January 2004 ~ December 2008
all consecutive patients who had cirrhosis
>18 years
refractory ascites
* Refractory ascites :
diuretic-resistant despite intensive diuretic therapy (spironolactone: 400mg/day+furosemide: 150mg/day)
dietary sodium restriction (90 mmol/day).
* metabolic abnormalities were diuretic induced
hepatic encephalopathy
hyponatremia (<serum sodium 125 mmol/L),
renal impairment (>serum creatinine 1.5 mg/dL),
abnormal serum potassium levels (serum potassium level 3~6 mmol/L).
Korea National Diabetes Program

4. Study Variables
demographic data
etiology of cirrhosis
physical examination findings, biochemical values,
Child-Pugh score, Model for End-Stage Liver Disease
MELD score
MELD-Na score
hospital course
laboratory values, and outcomes (renal dysfunction development, liver transplantation, or death)
hepatic venous pressure gradient (HVPG)
MELD x (135-Na) :Na 120~135

5. Korea National Diabetes Program
Results
Korea National Diabetes Program

6. 1. Characteristics of the Patients
총 151 명 대상이며
104명은 이뇨제로 조절되지 않는 복수를 갖고 있다.
46명(30.5%)은 renal dysfunction 이다.
58명(38.4%)은 hyponatremia 이다
모든 환자는 규칙적으로 복수천자를 통해 복수조절을 하고 있다.
77명(51%)는 GI hemorrge를 예방하기 위해 bblocker를 복용중이다.
양군의 child puch score 및 MELD /MELD na 차이는 없다.

7. 2. Outcome and Follow-Up of the Whole Group of Patients.
The median follow-up time 은 8 개월
The median survival time was 10 개월 (95% CI ¼ 8-12 months).
1 년 생존확율 41% 이며 2년 생존 확률은 28%
전체 151명중 97명 (64.2%)이 사망하였고 그중 50명은 sepsis였다.

8. 3. Outcome According to Beta-Blocker Therapy.
Bblocker 사용자 의 median survavial 은 5개월 있었으며 사용하지 않은 군은 20개월로 두군간의 유의한 차이를 보였다.
1년을 기점으로 하였을때 bblocker의 사용하지 않은 군은 64% 의 생존율을 보였으나 bblocker 를 투여한 군은 19%의 생존율을 보였으며
2년기점시 각군은 45% 와 9% 의 생존율의 차이를 보였다.

9. 4. Factors Associated With Mortality.
multivariate Cox regression model 을 통해 Motality factor 중 HR 유의한 차이를 보이는 몇가지 risk factor 가 있다.
밑줄 친 인자들은 P value가 <0.0001로 각 군의 유의한 차를 보였던 factor 들이다.
다른 figure는 높은 HR 순으로 나열 한 independent predictors 로 BB 를 사용시 HR 2.61 로 나타났으며 motality 에 중요한 인자임을 알 수 있다.

10. Korea National Diabetes Program
Conclusion
The use of beta-blockers is associated with poor survival in patients with refractory ascites. These results suggest that beta blockers should be contraindicated in these patients..
Korea National Diabetes Program