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Kumar D, Taha Yaseen R, Panezai MQ, Naeem MU, Ismail H, Majid Z, Mehmood N, Ali Khalid M, Lail G, Hassan Luck N. Ascitic Fluid Lactate Level as a Predictor of Mortality in Cirrhotic Patients Having Spontaneous Bacterial Peritonitis (SBP). Cureus 2024; 16:e53243. [PMID: 38425592 PMCID: PMC10903966 DOI: 10.7759/cureus.53243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 03/02/2024] Open
Abstract
Introduction Limited studies are available for predicting mortality in patients with spontaneous bacterial peritonitis (SBP) based on ascitic fluid analysis. Recently, a proposition has been made regarding the role of ascitic fluid lactate as a better prognostic indicator of mortality in cirrhotic patients with SBP. Therefore, we aimed to evaluate the utility of ascitic fluid lactate in predicting mortality in cirrhotic patients with SBP. Methods This was a prospective, observational study that was conducted in the Hepato-Gastroenterology Department of Sindh Institute of Urology and Transplantation (SIUT), Karachi from 1 January 2022 to 31 December 2022. All the patients having liver cirrhosis with ascites, aged between 18 and 65 years, and presenting with fever and/or abdominal pain were recruited in the study in the first six months (i.e., from 1 January 2022 to 30 June 2022) and were followed for six more months for the outcome. However, those patients on dialysis or those with hepatocellular carcinoma, any other malignancy as per a history of solid organ transplant, a history of HIV infection, or those underlying systemic sepsis or infections other than SBP were excluded from the study. The presence or absence of SBP was confirmed by doing the ascitic fluid analysis. Ascitic fluid lactate levels were also requested in each patient. Mortality was assessed at one, two, three, and six months, respectively. All the data were analyzed using SPSS version 23.0. The area under the receiver operating curve (AUROC) was obtained for ascitic fluid lactate for predicting mortality in SBP. At an optimal cutoff, the diagnostic accuracy of ascitic fluid lactate was obtained. Results The total number of cirrhotic patients included in the study was 123. The majority of the patients belong to Child Turcotte Pugh (CTP) class C (n = 88; 71%). Two third of the patients (65.8%; n = 81) had viral hepatitis i.e., hepatitis B, D, and/or C, as the cause of cirrhosis. Overall mortality was observed in 51(41.5%) patients. Ascitic fluid lactate was significantly raised in patients with SBP than in patients with non-SBP (p = 0.004). The AUROC of ascitic fluid lactate was highest at three months (AUROC = 0.88) followed by six months (AUROC = 0.84), two months (AUROC = 0.804), and one month (AUROC=0.773). At an optimal cut-off of more than or equal to 22.4 mg/dl, ascitic fluid lactate had a sensitivity of 84.9%, specificity of 85.7%, positive predictive value (PPV) of 97.3%, negative predictive value of 42.8% with diagnostic accuracy of 85% in predicting overall mortality in patients with SBP. On sub-analysis, the diagnostic accuracy of ascitic fluid lactate was highest at six months followed by at three, two, and one month, respectively. Conclusion Ascitic fluid lactate showed a good diagnostic utility in predicting the overall mortality in patients with SBP with the best diagnostic accuracy in predicting long-term (six months) mortality. However, further studies are required to validate our results.
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Affiliation(s)
- Danish Kumar
- Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi, PAK
| | - Raja Taha Yaseen
- Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi, PAK
| | - Muhammad Qaiser Panezai
- Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi, PAK
| | - Muhammad Usman Naeem
- Department of Gastroenterology, Sheik Zayed Hospital, Lahore, PAK
- Department of Hepatology, Sheik Zayed Hospital, Lahore, PAK
| | - Hina Ismail
- Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi, PAK
| | - Zain Majid
- Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi, PAK
| | - Nasir Mehmood
- Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi, PAK
| | - Muhammad Ali Khalid
- Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, KARACHI, PAK
| | - Ghulamullah Lail
- Department of Medicine: Gastroenterology, Jinnah Medical & Dental College, Karachi, PAK
| | - Nasir Hassan Luck
- Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi, PAK
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Dawit L, Lee V, Lehoang D, Furey C, Chowdhury A, Mai TA, Angajala V, Park JH, Khadarian K, She R, Vergara-Lluri M, Kahn J, Dodge JL, Saito T. Clinical Significance of Ascitic Fluid Polymorphonuclear Leukocyte Percentage in Patients With Cirrhosis Without Spontaneous Bacterial Peritonitis. Clin Transl Gastroenterol 2023; 14:e00614. [PMID: 37436155 PMCID: PMC10522094 DOI: 10.14309/ctg.0000000000000614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 06/10/2023] [Accepted: 06/26/2023] [Indexed: 07/13/2023] Open
Abstract
INTRODUCTION Absolute polymorphonuclear leukocyte (PMN) count (PMN-C) ≥250 cells/mm 3 in ascites is the diagnostic hallmark of spontaneous bacterial peritonitis (SBP) and is associated with high morbidity and mortality. However, the clinical significance of ascitic PMN percentage (PMN-%) and PMN-C in the absence of SBP as additional biomarkers for mortality and future incidence of SBP has not been determined. METHODS This retrospective cohort included adults with cirrhosis undergoing first-recorded paracentesis with initial PMN-C < 250 cells/mm 3 at 2 tertiary medical centers between 2015 and 2020. Patients with prior SBP were excluded. Outcomes were death and SBP development. Cox regression estimated hazard ratios (HRs) for risk of death and SBP development and Akaike information criterion to compare model fit. RESULTS Three hundred eighty-four adults (73% male, median age 58 years, 67% with alcohol-associated cirrhosis, median PMN-C 14 cells/mm 3 [interquartile range 5-34], and median PMN-% 10% [interquartile range 4-20]) were included in this study. Univariate risk of death increased 10% per 25-unit increase in PMN-C (95% confidence interval 1.01-1.21, P = 0.03) and 19% per 10-unit increase in PMN-% (95% confidence interval 1.06-1.33, P = 0.003) with PMN-% demonstrating better model fit in assessing mortality risk (Akaike information criterion: 1,044 vs 1,048, respectively). In models adjusted for age, chronic hepatitis C virus infection, and Model for End-Stage Liver Disease-Sodium, PMN-% was associated with risk of death (PMN-% 10%-29%, HR 1.17, P = 0.50; PMN-% ≥ 30% group, HR 1.94, P = 0.03; vs PMN-% < 10%) and SBP development (PMN-% 10%-29%, HR 1.68, P = 0.07; PMN-% ≥ 30%, HR 3.48, P < 0.001; vs PMN-% < 10%). DISCUSSION Our results suggest PMN-% at first paracentesis represents a better biomarker compared with PMN-C for assessing risk of death and future SBP development in patients with PMN-C < 250 cells/mm 3 .
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Affiliation(s)
- Lillian Dawit
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Vivian Lee
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - David Lehoang
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Cameron Furey
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Aneesa Chowdhury
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Thu Anne Mai
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Varun Angajala
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Joo Hye Park
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Kevork Khadarian
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Rosemary She
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Maria Vergara-Lluri
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jeffrey Kahn
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jennifer L. Dodge
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- USC Research Center for Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Takeshi Saito
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- USC Research Center for Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Outcomes after hospitalisation with spontaneous bacterial peritonitis over a 13-year period: a retrospective cohort study. Eur J Gastroenterol Hepatol 2023; 35:384-393. [PMID: 36827533 DOI: 10.1097/meg.0000000000002524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
GOALS Assess outcomes in patients with an index presentation of spontaneous bacterial peritonitis (SBP) over a 13-year period. BACKGROUND SBP, a bacterial infection of ascites, has a poor prognosis. STUDY Retrospective cohort study assessing mortality (standardised to 32 months) and prognostic factors in patients with SBP during two periods: period 1 (June 2006-November 2012) and period 2 (December 2012-May 2019). RESULTS The study included 178 patients who were followed up for 11.6 (29.2) months. Mortality was high, with 12-, 24- and 32-month survival being 32%, 26% and 24%, respectively. Inpatient mortality was 36% with mortality in those surviving hospitalisation being 62%. Serum creatinine at the time of SBP diagnosis was an independent predictor of mortality at 32 months [hazard ratio (HR) 1.002, P = 0.023] and inpatient mortality (HR 1.003, P = 0.035). Positive ascitic fluid culture and ascitic fluid neutrophil count were independent predictors of 32-month (HR 1.679, P = 0.008) and inpatient mortality (HR 1.0001, P = 0.005), respectively. Patients in period 2 had lower ascitic fluid albumin (5.9 ± 3.3 g/L vs. 10.8 ± 5.4 g/L, P < 0.001), higher ascitic fluid neutrophil count (815.0 cells/mm3 vs. 345.0 cells/mm3, P < 0.001) and higher rates of hepatorenal syndrome-acute kidney injury (58 vs. 35%, P = 0.002). Mortality at 32 months and mortality in those surviving hospitalisation were similar at 78 vs. 73%, P = 0.392 and 66 vs. 58%, P = 0.355, for periods 1 and 2, respectively. CONCLUSIONS Despite more advanced initial presentations, mortality rates have remained similar over the last 13 years. Serum creatinine at the time of SBP diagnosis is an independent predictor of mortality.
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Moon H, Kim HJ, Woo SM, Park IH, Sim SH. Discrimination of ascitic fluid infection in malignant ascites by polymorphonuclear neutrophil ratio and count: Investigating the validity of count ≥250/mm 3 as the one-size-fits-all criterion. Asia Pac J Clin Oncol 2020; 17:e87-e93. [PMID: 32762145 DOI: 10.1111/ajco.13344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 03/16/2020] [Indexed: 11/28/2022]
Abstract
AIM Neutrocytic ascites, traditionally defined as a polymorphonuclear neutrophil count ≥250/mm3 , is infrequently reported during paracenteses to relieve malignant ascites (MA). This study aims to explore new potential diagnostic criteria to discriminate ascitic fluid infection associated with MA and to examine the clinical and laboratory characteristics of neutrocytic ascites. METHODS The investigators retrospectively collected data on paracenteses to relieve MA at the Emergency Department of National Cancer Center, Korea, from January 2014 to February 2017. We analyzed the patients whose ascites fulfilled the traditional criteria for classification as neutrocytic ascites; polymorphonuclear neutrophils ≥250/mm3 with no history of either hepatocellular carcinoma or liver cirrhosis. RESULTS In total, 1467 patients underwent paracentesis to relieve MA. Excluding 98 follow-up paracenteses cases, 112 cases (8.2%) showed neutrocytic ascites. Of these 112 patients, 27 (24.1%) had positive culture results. Receiver-operating characteristic analysis indicated that the area under the curve (AUC) values were 0.90 (95% CI 0.82-0.95) and 0.86 (95% CI 0.78-0.92) for polymorphonuclear neutrophil ratio and count, respectively. The difference between the two AUCs was not statistically significant (P = .29). Moreover, the best cutoff points were 70% and 1500/mm3 for polymorphonuclear neutrophil ratio and count, respectively. In addition, extensive liver metastasis was a significant independent risk factor of MA associated with ascitic fluid infection. CONCLUSIONS Both polymorphonuclear neutrophil ratio and count had good discriminative abilities for culture results in MA. Polymorphonuclear neutrophil ratio was somewhat better despite lacking statistical significance compared to polymorphonuclear neutrophil count, with 70% as best cutoff.
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Affiliation(s)
- Hae Moon
- Department of Internal Medicine, National Cancer Center, Goyang, Republic of Korea
| | - Hak Jin Kim
- Department of Cardiology, Center for Clinical Specialty, National Cancer Center, Goyang, Republic of Korea
| | - Sang Myung Woo
- Center for Liver Cancer, National Cancer Center, Goyang, Republic of Korea
| | - In Hae Park
- Center for Breast Cancer, National Cancer Center, Goyang, Republic of Korea
| | - Sung Hoon Sim
- Center for Breast Cancer, National Cancer Center, Goyang, Republic of Korea
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Facciorusso A, Antonino M, Orsitto E, Sacco R. Primary and secondary prophylaxis of spontaneous bacterial peritonitis: current state of the art. Expert Rev Gastroenterol Hepatol 2019; 13:751-759. [PMID: 31304804 DOI: 10.1080/17474124.2019.1644167] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Spontaneous bacterial peritonitis represents a frequent and severe complication in cirrhotic patients with ascites. In daily practice, the diagnosis of spontaneous bacterial peritonitis might be challenging in the absence of the typical signs and symptoms of infection such as fever or leukocytosis. Areas covered: Aim of this review is to revise the current state of the art on primary and secondary spontaneous bacterial peritonitis. Literature search in Medline/Pubmed was performed. Expert opinion: Historically, gram-negative bacteria were the most frequent etiologic agents of spontaneous bacterial peritonitis, with Escherichia coli and Klebsiella spp. being the most frequently isolated bacteria. However, major changes in this regard occurred over the last few decades with an increasing prevalence of gram-positive, quinolone-resistant, and multidrug-resistant bacteria. In particular, the increasing prevalence of quinolone-resistant bacteria challenged the prominent role of norfloxacin in spontaneous bacterial peritonitis prevention. Given the high mortality rate and the risk of developing the hepatorenal syndrome, prophylaxis of spontaneous bacterial peritonitis is indicated in three high-risk populations: patients with acute gastrointestinal hemorrhage, patients with low total protein content in ascitic fluid and advanced cirrhosis, and patients with a previous history of spontaneous bacterial peritonitis (secondary prophylaxis).
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Affiliation(s)
- Antonio Facciorusso
- a Department of Medical Sciences, Ospedali Riuniti di Foggia , Foggia , Italy
| | - Matteo Antonino
- a Department of Medical Sciences, Ospedali Riuniti di Foggia , Foggia , Italy
| | - Eugenio Orsitto
- b Department of Radiology, Azienda Ospedaliero-Universitaria Pisana , Pisa , Italy
| | - Rodolfo Sacco
- a Department of Medical Sciences, Ospedali Riuniti di Foggia , Foggia , Italy
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