Opinion Review
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jul 14, 2019; 25(26): 3283-3290
Published online Jul 14, 2019. doi: 10.3748/wjg.v25.i26.3283
Diuretic window hypothesis in cirrhosis: Changing the point of view
Anderson Brito-Azevedo
Anderson Brito-Azevedo, Liver Transplant Unit, São Lucas Hospital, Rio de Janeiro 22061-080, Brazil
Anderson Brito-Azevedo, Liver Transplant Unit, São Francisco na Providência de Deus Hospital, Rio de Janeiro 20520-053, Brazil
Anderson Brito-Azevedo, Liver Transplant Unit, Adventist Silvestre Hospital, Rio de Janeiro 22241-280, Brazil
Author contributions: Brito-Azevedo A designed, analyzed and wrote the paper.
Conflict-of-interest statement: The author declares that he does not have any conflict of interest to disclose.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Anderson Brito-Azevedo, MD, MSc, Doctor, Liver Transplant Unit, Adventist Silvestre Hospital, 274 Ladeira do Ascurra st, Rio de Janeiro 22241-280, Brazil. andersonbrito.a@gmail.com
Telephone: +55-21-3034-3397
Received: February 3, 2019
Peer-review started: February 6, 2019
First decision: April 5, 2019
Revised: May 9, 2019
Accepted: May 31, 2019
Article in press: June 1, 2019
Published online: July 14, 2019

Since the 1970s, non-selective beta-blockers (NSBB) have been used to prevent variceal upper bleeding in advanced cirrhotic patients. However, several recent studies have raised the doubt about the benefit of NSBB in end-stage cirrhotic patients. In fact, they suggested a detrimental effect in these patients that even reduced survival. All of these studies have been assembled to compose the “window therapy hypothesis”, in which NSBB would have traditional indication to be initiated to prevent variceal upper bleeding; however, treatment should be stopped (or not be initiated) in patients with end-stage cirrhosis. NSBB would reduce the cardiac reserve of these patients, worsening systemic perfusion and prognosis. However, it should be emphasized that these studies present important bias issues, and their results also suggested that diuretic treatment may also be behind the effects observed. In this opinion review, we changed the point of view from NSBB to diuretic treatment, based on a physiopathogenic approach of circulatory parameters of cirrhotic patients studied, and based on diuretic effect in blood pressure lowering and in other hypervolemic disease, as heart failure. We suggest a “diuretic window hypothesis”, composed by an open window in hypervolemic phase, an attention window when patient present in a normal plasma volume phase, and a closed window during the plasma hypovolemic phase.

Keywords: Cirrhosis, Non-selective beta-blockers, Diuretic, Window hypothesis, Baveno, Cardiac output

Core tip: The “window therapy hypothesis” for non-selective beta-blocker treatment was consolidated based on weak evidence. Nevertheless, it has helped to change clinical practice and the Baveno consensus about portal hypertension. In this opinion review, we detail the studies assembled to compose the hypothesis, demonstrating that another factor could be behind results and outcomes observed, the diuretic treatment factor. After careful analysis of the evidence, we suggest the “diuretic window hypothesis”.