title: Nonselective β-Blockers and Survival in Patients With Cirrhosis and Ascites: A Systematic Review and Meta-analysis.
abstract: Nonselective β-blockers (NSBBs), given to reduce the risk of variceal bleeding, have been associated with increased mortality in patients with cirrhosis and refractory ascites in some, but not all, studies. We performed a systematic review and meta-analysis to evaluate the effect of NSBBs on all-cause mortality in patients with cirrhosis and refractory ascites.
  
  
  
  We performed a comprehensive search of MEDLINE, Embase, Web of Science, and Scopus databases through January 2015, supplemented with a manual search. Trial-specific risk ratios (RRs) were pooled using the random-effects model.
  
  
  
  Our analysis included 3 randomized control trials and 8 observational studies of propranolol, carvedilol, nadolol, and metoprolol, reporting 1206 deaths among 3145 patients with ascites. The control groups received other interventions to prevent variceal bleeding. NSBB use was not associated with increased all-cause mortality in all patients with ascites (RR, 0.95; 95% confidence interval [CI], 0.67-1.35); nonrefractory ascites alone (RR, 0.96; 95% CI, 0.50-1.82), or refractory ascites alone (RR, 0.95; 95% CI, 0.57-1.61). Results were similar in randomized controlled trials and observational studies. Use of NSBBs was not associated with increased mortality at 6, 12, 18, and 24 months. Overall, the included studies had a medium to high risk of bias, except for 3 clinical trials in which the risk of biased was determined to be low.
  
  
  
  The use of NSBBs was not associated with a significant increase in all-cause mortality in patients with cirrhosis and ascites or refractory ascites. Certainty in the available estimates is low; a randomized trial of only patients with ascites is needed to answer this question. This meta-analysis does not support the position that NSBBs routinely be withheld from patients with ascites.
authors.affiliation: Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota; Division of Gastroenterology, Phramongkutklao Hospital and College of Medicine, Royal Thai Army, Bangkok, Thailand.
authors.forename: Sakkarin
authors.initials: S
authors.lastname: Chirapongsathorn
authors.affiliation: Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
authors.forename: Nelson
authors.initials: N
authors.lastname: Valentin
authors.affiliation: Division of Preventive Medicine, Mayo Clinic, Rochester, Minnesota.
authors.forename: Fares
authors.initials: F
authors.lastname: Alahdab
authors.affiliation: Division of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota.
authors.forename: Chayakrit
authors.initials: C
authors.lastname: Krittanawong
authors.affiliation: Mayo Clinic Libraries, Mayo Clinic, Rochester, Minnesota.
authors.forename: Patricia J
authors.initials: PJ
authors.lastname: Erwin
authors.affiliation: Division of Preventive Medicine, Mayo Clinic, Rochester, Minnesota.
authors.forename: Mohammad H
authors.initials: MH
authors.lastname: Murad
authors.affiliation: Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota. Electronic address: Kamath.patrick@mayo.edu.
authors.forename: Patrick S
authors.initials: PS
authors.lastname: Kamath
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000009:adverse effects* / Q000627:therapeutic use*; D001201:Ascites / Q000188:drug therapy*; D006801:Humans; D008103:Liver Cirrhosis / Q000188:drug therapy*; D016019:Survival Analysis
chemical_list: D000319:Adrenergic beta-Antagonists
keywords: Ascites; Cirrhosis; Refractory Ascites; Survival; β-Blockers