Beneficial role of terlipressin in decompensated cirrhotics with spontaneous bacterial peritonitis Alberto Ferrarese a , Valerie Tikhonoff b , Edoardo Casiglia b , Patrizia Burra a and Marco Senzolo a , a Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology and b Department of Medicine, Padua University Hospital, Padua, Italy Correspondence to Marco Senzolo, MD, PhD, Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35100, Italy Tel: + 39 049 821 8726; fax: + 39 049 821 8727; e-mail: marcosenzolo@hotmail.com Received 6 October 2016 Accepted 10 October 2016 We have read with interest the manuscript by Salman et al. [1], who investigated different therapeutic approaches to treat spontaneous bacterial peritonitis (SBP) in patients with cirrhosis. The authors evaluated haemodynamic changes during SBP, showing an increase in cardiac output (CO) and a contemporary decrease in systemic vascular resistances (SVRs), 3 days after starting conventional therapy ( + 16.2 ± 10.3 and - 8.9 ± 9.9%, respectively). In this group, 2/50 patients did not recover from SBP; in addition, novel therapeutic approaches failed to increase survival, even though the use of terlipressin significantly improved haemodynamics. During SBP, several other factors can affect haemody- namics, such as the need for large volume paracentesis (LVP), which can further deteriorate this equilibrium. We evaluated intra-individual haemodynamic changes before and after resolution of nosocomial SBP in a 58-year-old patient admit- ted to our ward for end-stage alcoholic liver disease, while undergoing LVP. Before infection, LVP determined a 21% decrease of SVR in respect of baseline values (1857.5–1468.2 dyn × s/cm 5 ), with a contemporary slight increase in CO (3.9–4.0 l/min). In contrast, while LVP was performed during an episode of SBP, a signi ficantly greater decrease in SVR (675.9–464.5 dyn × s/cm 5 , - 31.2%) was noted; consequently, CO was increased at baseline in com- parison with the first LVP and there was a further increase after LVP (9.85–12.9 l/min) to counterbalance systemic vaso- dilation. During the third LVP, after SBP resolution, haemo- dynamics was similar to the values before infection (Fig. 1). This confirms the findings of the authors and in parti- cular the need for a preserved cardiac function to effec- tively increase CO and to counterbalance the lowering of SVR during LVP. In addition, our case showed a further decrease in SVR (- 50%) during sepsis. Thus, terlipressin introduction, which has been associated with a significant increase in SVR by 61% [2], may reduce the risk of renal impairment in these patients. Because of the published evidences that β-blockers could worsen the prognosis of decompensated cirrhosis [3,4], in particular, during infection [5], withdrawal of NSBB has been recommended. However, in the present study, mortality because of variceal bleeding was 9/200 (4.5%) and it is not known whether β-blockers were withdrawn after SBP. Furthermore, it could be interesting to evaluate whether the incidence of variceal bleeding was lower in the terlipressin groups. Therefore, even though in this study survival was not significantly different between groups, terlipressin could be considered an option in cirrhotics with SBP undergoing LVP or with impaired cardiac function or high-risk varices when withdrawal of β-blockers is recommended. Acknowledgements Conflicts of interest There are no conflicts of interest. References 1 Salman TA, Edrees AM, El-Said HH, El-Abd OL, El-Azab GI. Effect of different therapeutic modalities on systemic, renal, and hepatic hemodynamics and short-term outcomes in cirrhotic patients with spontaneous bacterial perito- nitis. Eur J Gastroenterol Hepatol 2016; 28:777–785. 2 Møller S, Hansen EF, Becker U, Brinch K, Henriksen JH, Bendtsen F. Central and systemic haemodynamic effects of terlipressin in portal hypertensive patients. Liver 2000; 20:51–59. 3 Ge PS, Runyon BA. The changing role of beta-blocker therapy in patients with cirrhosis. J Hepatol 2013; 60:643–653. 4 Ferrarese A, Tsochatzis E, Burroughs AK, Senzolo M. Beta-blockers in cir- rhosis: therapeutic window or an aspirin for all? J Hepatol 2014; 61:449–450. 5 Mandorfer M, Bota S, Schwabl P, Bucsics T, Pfisterer N, Kruzik M, et al. Non-selective beta blockers increase risk for hepatorenal syndrome and death in patients with cirrhosis and spontaneous bacterial peritonitis. Gastroenterology 2014; 146:1680–1690. DOI: 10.1097/MEG.0000000000000797 Systemic vascular resistances, dyn.s.cm −5 Cardiac Output, l/m 2.5 Pre Post 30.9% Pre Post 20.9% 6.4% 31.2% (a) (b) Fig. 1. Haemodynamic changes before and after three consecutive large volume paracentesis. (a) Systemic vascular resistances; (b) cardiac output. European Journal of Gastroenterology & Hepatology 2017, 29:366 ’ Letter to the Editor 0954-691X Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. 366 Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.