Lowering portal pressure improves outcomes of patients with cirrhosis, with or without ascites: a meta-analysis.

Abstract 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. Methods We collected data from 15 studies of primary or secondary prophylaxis of VH that reported data on VH and death in responders vs non-responders. We included studies in which data on ascites at baseline and on other relevant outcomes during follow up were available. We performed separate meta-analyses for patients with vs without ascites. Results Of the 1113 patients included in the studies, 968 patients (87%) had been treated with nonselective beta-blockers. In 993 patients (89%), HVPG response was defined as a decrease of more than 20% from baseline (more than 10% in 11% of patients) or to <12 mm Hg. In the 661 patients without ascites, responders (n=329, 50%) had significantly lower odds of events (ascites, VH, or encephalopathy) than non-responders (odds ratio [OR], 0.35; 95% CI, 0.22–0.56). Odds of death or liver transplantation were also significantly lower among responders than non-responders (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 non-responders (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. Conclusions In a meta-analysis of clinical trials, we found that patients with cirrhosis with and without ascites who respond to treatment with nonselective beta-blockers (based on reductions in HVPG) have a reduced risk of events, death or liver transplantation