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

Background & aims: Non-selective beta-blockers (NSBBs) are widely used to prevent decompensation in cirrhosis. Guidelines recommend discontinuing NSBBs in patients with cirrhosis and acute kidney injury (AKI), although this recommendation is based largely on expert opinion and limited evidence. We evaluated the impact of NSBB use on AKI outcomes in patients with cirrhosis. Methods: This multicenter study enrolled patients hospitalized for decompensated cirrhosis and AKI. Data on NSBB treatment, including type, dose, and continuation, discontinuation, or tapering, were collected. Outcomes were compared between patients receiving and not receiving NSBBs and between those who discontinued/tapered and those who did not. Inverse probability of treatment weighting (IPTW) was used to balance demographics, liver disease severity, hemodynamic parameters, AKI stage and acute-on-chronic liver failure (ACLF) grade. The main outcomes were AKI resolution and 28-day mortality. Results: Of 1,238 patients with AKI, 503 were on NSBBs (propranolol 55%; carvedilol 45%). After IPTW adjustment, NSBB treatment at AKI diagnosis was associated with higher likelihood of AKI resolution (subdistribution hazard ratio [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, NSBBs 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 (NSBBs) in patients with acute decompensation (AD) of 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 NSBBs on AKI outcomes in a large multicentre cohort of patients with AD and AKI. Treatment with NSBBs 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.