Division of Gastroenterology, Azienda Ospedaliero, Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy; PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy.
Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain; Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain.
Clin Gastroenterol Hepatol. 2020 Feb;18(2):313-327.e6. doi: 10.1016/j.cgh.2019.05.050. Epub 2019 Jun 5.
BACKGROUND & AIMS: In unselected patients with cirrhosis, those with reductions in hepatic venous pressure gradient (HVPG) to below a defined threshold (responders) have a reduced risk of variceal hemorrhage (VH) and death. We performed a meta-analysis to compare this effect in patients with vs without ascites.
We collected data from 15 studies of primary or secondary prophylaxis of VH that reported data on VH and death in responders vs nonresponders. We included studies in which data on ascites at baseline and on other relevant outcomes during follow-up evaluation were available. We performed separate meta-analyses for patients with vs without ascites.
Of the 1113 patients included in the studies, 968 patients (87%) had been treated with nonselective β-blockers. In 993 patients (89%), HVPG response was defined as a decrease of more than 20% from baseline (>10% in 11% of patients) or to less than 12 mm Hg. In the 661 patients without ascites, responders (n = 329; 50%) had significantly lower odds of events (ascites, VH, or encephalopathy) than nonresponders (odds ratio [OR], 0.35; 95% CI, 0.22-0.56). Odds of death or liver transplantation were also significantly lower among responders than nonresponders (OR, 0.50, 95% CI, 0.32-0.78). In the 452 patients with ascites, responders (n = 188; 42%) had significantly lower odds of events (VH, refractory ascites, spontaneous bacterial peritonitis, or hepatorenal syndrome) than nonresponders (OR, 0.27; 95% CI, 0.16-0.43). Overall, odds of death or liver transplantation were lower among responders (OR, 0.47; 95% CI, 0.29-0.75). No heterogeneity was observed among studies.
In a meta-analysis of clinical trials, we found that patients with cirrhosis with and without ascites who respond to treatment with nonselective β-blockers (based on reductions in HVPG) have a reduced risk of events, death, or liver transplantation.
在未选择的肝硬化患者中，那些肝静脉压力梯度（HVPG）降低到特定阈值以下的患者（应答者），其静脉曲张出血（VH）和死亡风险降低。我们进行了一项荟萃分析，以比较有腹水和无腹水患者的这种效果。
我们从 15 项原发性或二级 VH 预防研究中收集数据，这些研究报告了应答者与无应答者之间 VH 和死亡的数据。我们纳入了基线时有腹水且在随访评估中有其他相关结局数据的研究。我们分别对有腹水和无腹水的患者进行了荟萃分析。
在纳入研究的 1113 例患者中，968 例（87%）接受了非选择性β受体阻滞剂治疗。在 993 例患者（89%）中，HVPG 应答定义为基线下降超过 20%（11%的患者下降超过 10%）或下降至<12mmHg。在 661 例无腹水的患者中，应答者（n=329；50%）发生事件（腹水、VH 或脑病）的可能性显著低于无应答者（比值比[OR]，0.35；95%CI，0.22-0.56）。与无应答者相比，应答者的死亡或肝移植的可能性也显著降低（OR，0.50，95%CI，0.32-0.78）。在 452 例有腹水的患者中，应答者（n=188；42%）发生事件（VH、难治性腹水、自发性细菌性腹膜炎或肝肾综合征）的可能性显著低于无应答者（OR，0.27；95%CI，0.16-0.43）。总体而言，应答者的死亡或肝移植的可能性较低（OR，0.47；95%CI，0.29-0.75）。各研究之间无异质性。
在一项临床试验的荟萃分析中，我们发现，接受非选择性β受体阻滞剂治疗（基于 HVPG 降低）后有应答的肝硬化伴或不伴腹水的患者，其事件、死亡或肝移植的风险降低。
