The Pulse - October 2025

Greetings Readers! In this monthly edition, we examine 3 practice changing studies.

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1. Beta Early Than On Time: The Case for Early β-Blocker Prophylaxis

   This single-center RCT suggests the benefits of nonselective β-blockade in cirrhosis may begin earlier than previously recognized. Among 104 patients with new-onset uncomplicated ascites and no or low-risk varices, early initiation of carvedilol significantly reduced ascites-related complications, the need for large-volume paracentesis, and all-cause mortality at one year compared with standard care alone. Improvements in hepatic venous pressure gradient supported a mechanistic rationale for these clinical gains. Though limited by open-label design and modest sample size, the data hint that carvedilol started at the onset of ascites could slow progression toward decompensation. If validated, this approach may prompt a rethinking of β-blocker timing in cirrhotic management algorithms. Khajuria R et al. Am J Gastroenterol 2025 Jul

   Study Type: open-label RCT conducted at a single center in India of 104 patients with uncomplicated, new-onset ascites with no or low-risk esophageal varices, randomized to either carvedilol or none in addition to standard treatment.

   Link

2. Press On, Peripherally: When Central Lines Can Wait

   The long-feared boogeyman of peripheral vasopressors—extravasation necrosis—may finally be losing its fangs. In this secondary analysis of the CLOVERS trial, most septic patients (84%) got their pressors through a peripheral IV, with complications nearly nonexistent (a mere 0.6%). Mortality was no worse than with central lines, and those started peripherally even received less fluid overall. While sicker patients were more likely to need central access, the findings suggest that starting pressors peripherally is both safe and sensible. In short, when the pressure’s on, you can push peripherally without losing your cool—or your patient’s digits. Munroe ES et al. JAMA Netw Open 2025 Aug

   Study Type: secondary analysis of the CLOVERS trial (Crystalloid Liberal vs Early Vasopressors in Sepsis), a prospective cohort study conducted in 60 US hospitals. While 1563 patients were included in CLOVERS, this secondary analysis focuses on 582 who received vasopressors due to septic shock within the first 24 hours - 84% peripherally and 16% centrally.

   Link

3. Don’t Wait for MELD to Ring: Early Referral for Liver Transplant

   Many patients with cirrhosis miss the transplant train because clinicians wait too long or never refer. This review emphasizes that any decompensation—ascites, variceal bleed, or encephalopathy—should trigger a transplant referral, regardless of MELD score. Mortality data are sobering: a second decompensation pushes 5-year mortality toward 80–90%, and 1-year mortality for refractory ascites hits 50%. Age, BMI, frailty, and even ongoing alcohol use are no longer hard stops—referral is about risk, not rigid cutoffs. Bottom line: earlier conversations about transplant save lives, and clinicians shouldn’t let misconceptions delay the discussion. King LY et al. Clin Gastroenterol Hepatol 2025 Aug

   Study Type: Review article from Clinical Gastroenterology and Hepatology

   Link 

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