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Guedes RR, Kieling CO, Dos Santos JL, da Rocha C, Schwengber F, Adami MR, Chedid MF, Vieira SMG. Severity of Ascites Is Associated with Increased Mortality in Patients with Cirrhosis Secondary to Biliary Atresia. Dig Dis Sci 2020; 65:3369-3377. [PMID: 31907773 DOI: 10.1007/s10620-019-06029-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 12/22/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Very few prior studies have investigated the presence of ascites as a prognostic factor in children with cirrhosis. To the best of our knowledge, there are no prior studies evaluating the relationship between severity of ascites and patient survival in children with biliary atresia and cirrhosis. AIMS To evaluate the association between severity of ascites and survival of children with cirrhosis and biliary atresia. METHODS All children with cirrhosis secondary to biliary atresia evaluated at our institution from 2000 to 2014 were included in this study. Patients were classified into four groups: NA = no ascites; A1 = grade 1 ascites; A2 = grade 2 ascites; and A3 = grade 3 ascites. The primary endpoint of the study was mortality within the first year after patient inclusion. Ninety-day mortality was also evaluated. Prognostic factors related to both endpoints also were studied. RESULTS One-year patient survival for NA was 97.1%, versus 80.8% for A1, versus 52% for A2, versus 13.6 for A3 (p < 0.001). The presence of ascites increased mortality by 17 times. In the multivariate analysis, clinically detectable ascites (HR 3.14, 95% CI 1.14-8.60, p = 0.026), lower sodium (HR 1.15, 95% CI 1.04-1.27, p = 0.006), higher bilirubin (HR 1.06, 95% CI 1.00-1.12, p = 0.023), and higher PELD score (HR 1.05, 95% CI 1.02-1.08, p = 0.001) were all associated with decreased survival. Lower serum sodium (HR 1.20, 95% CI 1.09-1.32, p < 0.001) and higher PELD score (HR 1.03, 95% CI 1.001-1.063, p = 0.043) were associated with increased 90-day mortality. CONCLUSIONS Clinically detectable ascites is associated with decreased 1-year survival of children with biliary atresia. These patients should be treated with caution and prioritized for liver transplantation.
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Affiliation(s)
- Renata R Guedes
- Pediatric Liver Transplantation Unit, Pediatric Service, Hospital de Clínicas de Porto Alegre, Postgraduation Program in Gastroenterology and Hepatology Sciences, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2350, Sala 1143, Porto Alegre, RS, 90035-903, Brazil.
| | - Carlos O Kieling
- Pediatric Liver Transplantation Unit, Pediatric Service, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350, Sala 1143, Porto Alegre, RS, 90035-903, Brazil
| | - Jorge L Dos Santos
- Health Science Research Centre, University of Beira Interior (CICS, UBI), Universidade da Beira Interior, R. Marquês de Ávila e Bolama, 6201-001, Covilhã, Portugal
| | - Carolina da Rocha
- Pediatric Service, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350, Sala 1045, Porto Alegre, RS, 90035-903, Brazil
| | - Fernando Schwengber
- Internal Medicine Service, Hospital de Clínicas de Porto Alegre, Rua Corte Real 82, Porto Alegre, RS, 90630-080, Brazil
| | - Marina R Adami
- Pediatric Liver Transplantation Unit, Pediatric Service, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350, Sala 1143, Porto Alegre, RS, 90035-903, Brazil
| | - Marcio F Chedid
- Postgraduation Program in Surgical Sciences, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2350, Sala 743, Porto Alegre, RS, 90035-903, Brazil
| | - Sandra M G Vieira
- Pediatric Liver Transplantation Unit, Pediatric Service, Hospital de Clínicas de Porto Alegre, Postgraduation Program in Gastroenterology and Hepatology Sciences, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2350, Sala 1143, Porto Alegre, RS, 90035-903, Brazil
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Santos BL, Souza CFMD, Schuler-Faccini L, Refosco L, Epifanio M, Nalin T, Vieira SMG, Schwartz IVD. Glycogen storage disease type I: clinical and laboratory profile. J Pediatr (Rio J) 2014; 90:572-9. [PMID: 25019649 DOI: 10.1016/j.jped.2014.02.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 02/28/2014] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To characterize the clinical, laboratory, and anthropometric profile of a sample of Brazilian patients with glycogen storage disease type I managed at an outpatient referral clinic for inborn errors of metabolism. METHODS This was a cross-sectional outpatient study based on a convenience sampling strategy. Data on diagnosis, management, anthropometric parameters, and follow-up were assessed. RESULTS Twenty-one patients were included (median age 10 years, range 1-25 years), all using uncooked cornstarch therapy. Median age at diagnosis was 7 months (range, 1-132 months), and 19 patients underwent liver biopsy for diagnostic confirmation. Overweight, short stature, hepatomegaly, and liver nodules were present in 16 of 21, four of 21, nine of 14, and three of 14 patients, respectively. A correlation was found between height-for-age and BMI-for-age Z-scores (r=0.561; p=0.008). CONCLUSIONS Diagnosis of glycogen storage disease type I is delayed in Brazil. Most patients undergo liver biopsy for diagnostic confirmation, even though the combination of a characteristic clinical presentation and molecular methods can provide a definitive diagnosis in a less invasive manner. Obesity is a side effect of cornstarch therapy, and appears to be associated with growth in these patients.
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Affiliation(s)
- Berenice L Santos
- Post-Graduate Program in Child and Adolescent Health, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Carolina F M de Souza
- Medical Genetics Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Lavinia Schuler-Faccini
- Post-Graduate Program in Child and Adolescent Health, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil; Medical Genetics Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil; Department of Genetics, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Lilia Refosco
- Medical Genetics Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Matias Epifanio
- Pontifícia Universidade Católica do Rio Grande do Sul (PUC-RS), Porto Alegre, RS, Brazil; Hospital São Lucas, Porto Alegre, RS, Brazil
| | - Tatiele Nalin
- Post-Graduate Program in Genetics and Molecular Biology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Sandra M G Vieira
- Medical Pediatric Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil; Post-Graduate Program in Gastroenterology Science and Hepatology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Ida V D Schwartz
- Medical Genetics Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil; Department of Genetics, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.
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Dornelles CTL, Goldani HAS, Wilasco MIA, Maurer RL, Kieling CO, Porowski M, Ferreira CT, Santos JL, Vieira SMG, Silveira TR. Ghrelin, leptin and insulin in cirrhotic children and adolescents: relationship with cirrhosis severity and nutritional status. ACTA ACUST UNITED AC 2012; 180:26-32. [PMID: 23142314 DOI: 10.1016/j.regpep.2012.10.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Revised: 06/29/2012] [Accepted: 10/17/2012] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Ghrelin, leptin, and insulin concentrations are involved in the control of food intake and they seem to be associated with anorexia-cachexia in cirrhotic patients. The present study aimed to investigate the relationship between the nutritional status and fasting ghrelin, leptin and insulin concentrations in pediatric cirrhotic patients. METHODS Thirty-nine patients with cirrhosis and 39 healthy controls aged 0-15 years matched by sex and age were enrolled. Severity of liver disease was assessed by Child-Pugh classification, and Pediatric for End Stage Liver Disease (PELD) or Model for End-stage Liver Disease (MELD) scores. Blood samples were collected from patients and controls to assay total ghrelin, acyl ghrelin, leptin and insulin by using a commercial ELISA kit. Anthropometry parameters used were standard deviation score of height-for-age and triceps skinfold thickness-for-age ratio. A multiple linear regression analysis was used to determine the correlation between dependent and independent variables. RESULTS Acyl ghrelin was significantly lower in cirrhotic patients than in controls [142 (93-278) pg/mL vs 275 (208-481) pg/mL, P=0.001]. After multiple linear regression analysis, total ghrelin and acyl ghrelin showed an inverse correlation with age; acyl ghrelin was associated with the severity of cirrhosis and des-acyl ghrelin with PELD or MELD scores ≥15. Leptin was positively correlated with gender and anthropometric parameters. Insulin was not associated with any variable. CONCLUSION Low acyl ghrelin and high des-acyl ghrelin concentrations were associated with cirrhosis severity, whereas low leptin concentration was associated with undernourishment in children and adolescents with cirrhosis.
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Affiliation(s)
- Cristina T L Dornelles
- Experimental Laboratory of Gastroenterology and Hepatology, Centro de Pesquisas do Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.
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Gonzales ACS, Vieira SMG, Maurer RL, Silva FAAE, Silveira TR. Use of monoclonal faecal elastase-1 concentration for pancreatic status assessment in cystic fibrosis patients. J Pediatr (Rio J) 2011; 87:157-62. [PMID: 21503378 DOI: 10.2223/jped.2075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Accepted: 12/15/2010] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE To assess the concentration of faecal elastase-1 (EL-1) in pediatric patients with cystic fibrosis with mutation DeltaF508. METHODS Cross-sectional study with samples collected consecutively from 51 patients aged 4 months to 17 years old (mean 9.11±4.74); 32 (62.8%) patients were male. Clinical-demographic data were collected, as well as data on the type of mutation. Exocrine pancreatic insufficiency was established by the activity of faecal EL-1 < 200 µg/g. EL-1 was quantified through the monoclonal ELISA method (ScheBo Biotech AG, Germany). Pancreatic supplements were used in 46 (90.2%) patients. RESULTS Forty-one (80.4%) patients presented with pancreatic insufficiency (EL-1 fecal < 100 µg/g): 17 (41.5%) were homozygous, 14 were heterozygous (34.1%) and 10 were non-DeltaF508 (24.4%). Regarding the mutation, there was a statistically significant association of homozygosity with faecal EL-1 concentration < 100 µg/g (p = 0.010). All patients considered to be pancreatic insufficient (n = 41) by the test were using pancreatic supplements. Ten (19.6%) presented faecal EL-1 > 200 µg/g, and 5/10 (50%) used enzymes. CONCLUSIONS The activity of faecal EL-1 < 100 µg/g, indicating pancreatic insufficiency, was observed in 17/17 (100%) of homozygous patients, as expected, and was less frequent in patients who were heterozygous for DeltaF508 and in patients without the mutation. There was no association of faecal EL-1 concentration with age and sex of patients. The test was standardized, is easy to execute, and can be used to assess the pancreatic status of patients with cystic fibrosis.
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Affiliation(s)
- Andréa C S Gonzales
- Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcellos 2350, Porto Alegre, RS, Brazil.
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Araujo TE, Vieira SMG, Carvalho PRA. Stress ulcer prophylaxis in pediatric intensive care units. J Pediatr (Rio J) 2010; 86:525-30. [PMID: 21140039 DOI: 10.2223/jped.2046] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Accepted: 09/22/2010] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE To assess use of stress ulcer prophylaxis in patients admitted to five pediatric intensive care units (PICUs) in Porto Alegre, Brazil. METHODS This was a multicenter, prospective, cross-sectional observational study. PICUs were visited on randomly defined days between April 2006 and February 2007, and the medical records of admitted patients were reviewed. Patients whose records had been previously assessed were excluded, as were those with upper gastrointestinal bleeding on admission. Data were collected on age, gender, admission diagnosis, severity of illness, administration of stress ulcer prophylaxis, rationale for prophylaxis, and first-line prophylactic agent of choice. Variables were described as absolute and relative frequencies, mean and standard deviation, or median and interquartile range as appropriate. Pearson's chi-square test for linear trend or Fisher's exact test were used to assess possible associations. The level of significance was set at 5% (p ≤ 0.05). RESULTS 398 patients (57% male) were assessed [median age, 16 months (IQR 4-65); median length of PICU stay, 4 days (IQR 1-9)]. Respiratory illness was the main reason for admission (32.7%). Most patients received stress ulcer prophylaxis (77.5%; range, 66-91%). Mechanical ventilation (22.3%) was the most common rationale provided, followed by informal routine use of prophylaxis (21.4%). Only one of the participating PICUs had a specific care protocol for use of stress ulcer prophylaxis. Ranitidine was the most commonly used drug (84.5% of cases). Evidence of minor gastrointestinal bleeding was found in 3% of patients; none had clinically significant bleeds. CONCLUSIONS Administration of stress ulcer prophylaxis is a common practice in the participating PICUs, with ranitidine the most commonly used drug. Among the various rationales provided, mechanical ventilation and informal routine use were the most prevalent.
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Affiliation(s)
- Taisa E Araujo
- Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.
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Abstract
We retrospectively analysed 33 children and adolescents who had been hospitalized in a liver transplant unit within the previous 10 years for acute liver failure (ALF). The patients' age varied between 2 months and 15 years of age (median 6.2 +/- 5.3), and 21 (63%) were male. Thirteen patients (39%) were immunoglobulin-M anti-hepatitis A virus (HAV) sero-positive. Eleven cases (33%) had an undetermined aetiology. The 13 children with HAV ALF were between 17 months and 15.6 years of age (median 5.8 +/- 4.6) and eight were male (61.5%). All were on a list for urgent liver transplant. Of these, five (38%) died while waiting for a liver. Only one patient recovered spontaneously. Seven patients received a liver transplant; three died in the immediate postoperative period and one died 45 days after transplant. Three children are alive 1, 2 and 5 years after transplant. We conclude that HAV was the most frequent cause of ALF, which had high mortality even when a liver transplant was possible. The results support universal HAV vaccination in this area.
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Affiliation(s)
- C T Ferreira
- Pediatric Liver Transplant Unit, Hospital de Clínicas, Porto Alegre, Brazil.
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Abstract
OBJECTIVE To analyze the age at surgery for children with biliary atresia and their survival periods without need for liver transplantation. The study was performed at Hospital de Clínicas de Porto Alegre, in Porto Alegre, state of Rio Grande do Sul, Brazil. METHODS The medical records of patients operated between 1982 and 2007 who were residents of the state of Rio Grande do Sul were reviewed. RESULTS Of the 112 cases of children with biliary atresia studied, 38 (33.9%) occurred between 1982 and 1989, 46 (41.1%) between 1990 and 1999 and 28 (25.0%) after 2000. Portoenterostomy was not performed for 12 cases (10.7%). Age at surgery ranged from 25 to 297 days (median: 80.5; IQR25-75: 61.3-109.0 days); for 20.5% of cases, the age was below 60 days. There was no age difference at diagnosis for the three decades in the study. Patients from the countryside (median: 87.0; IQR25-75: 69.0-115.0 days) were referred significantly later (p = 0.007) than those living in Porto Alegre and the metropolitan area (median: 68.0; IQR25-75: 55.5-98.0 days). The ratio of patients younger than 60 days was significantly lower (p = 0.013) for those from the countryside. Survival periods with native liver for all patients was 46.2% in 2 years, falling continuously until reaching 15.3% in 20 years. Patients operated before reaching 60 days of age had longer survival periods with native livers (log rank < 0.0001). CONCLUSIONS Late performance of portoenterostomy was a constant in the past 25 years, and this delay led to shorter survival periods with native livers for biliary atresia patients.
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Affiliation(s)
- Carlos O Kieling
- Serviço de Pediatria, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil.
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Vieira SMG, da Silveira TR, Matte U, Kieling CO, Ferreira CT, Taniguchi A, Oliveira FDS, Barth AL. Amplification of bacterial DNA does not distinguish patients with ascitic fluid infection from those colonized by bacteria. J Pediatr Gastroenterol Nutr 2007; 44:603-7. [PMID: 17460494 DOI: 10.1097/mpg.0b013e318031d602] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate 16S ribosomal RNA (rRNA) gene amplification to diagnose spontaneous bacterial peritonitis (SBP). PATIENTS AND METHODS According to a retrospective protocol, 31 patients with portal hypertensive ascites (serum to ascites albumin gradient > or = 1.1 g/dL) were studied. Ascitic fluid was analyzed as follows: Gram stain, aerobic and anaerobic cultures, polymorphonuclear cell count, and biochemical tests. Bacterial DNA was detected by polymerase chain reaction. RESULTS There were 8 episodes of SBP and 4 episodes of bacterascites (BA). Culture was positive in 4 of 8 cases of SBP and bacterial DNA was positive in 7 of 8 cases of SBP. Bacterial DNA was positive in 3 of 4 cases of BA and in 8 of 28 cases of culture-negative non-neutrocytic ascites (CNNNA). The PELD score, serum to albumin ascites gradient, and mortality showed no statistical difference between patients with CNNNA and the result of the bacterial DNA analysis. CONCLUSIONS Although the 16S rRNA gene amplification was better than culture to diagnose SBP, bacterial DNA does not seem to allow a distinction between ascites infection and ascites colonization.
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Affiliation(s)
- Sandra M G Vieira
- Unit of Pediatric Gastroenterology, Hospital de Clínicas de Porto Alegre, Brazil.
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Goldani HAS, Matte US, Ramos ARL, Costa TG, Winkelmann LV, Meurer L, Vieira SMG, Kieling CO, Silveira TR. The role of food restriction on CCl4-induced cirrhosis model in rats. ACTA ACUST UNITED AC 2007; 58:331-7. [PMID: 17275271 DOI: 10.1016/j.etp.2006.11.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2006] [Accepted: 11/11/2006] [Indexed: 12/14/2022]
Abstract
Effects of food restriction on susceptibility to the toxic effect of some chemicals are controversial. In order to identify an exposure model that could maximize cirrhosis and minimize mortality rate, this study aimed to evaluate the effect of food restriction on tetrachloride carbon (CCl(4))-induced cirrhosis model in rats. Fifty-three male Wistar rats received CCl(4) 0.25 ml/kg weekly intragastrically once a week. Thirty-three had 44% food restriction (group 1); 10 rats had 25% food restriction (group 2); and 10 rats received ad libitum food (group 3). After 10 weeks, the animals were sacrificed and liver sections were collected for histology. Of the 53 animals enrolled for the study, 22 (41.5%) died before completing 10-week CCl(4). Mortality rate was significantly higher in group 1 compared to other groups (p<0.05). Cirrhosis was significantly more prevalent in group 1 than in group 3 (p<0.01), but without significant difference between groups 1 and 2 (p=0.624). We concluded that food restriction is an important issue to be considered when establishing a CCl(4)-induced cirrhosis model in rats. Moreover, there is an ideal range of food intake that predisposes to liver damage without increasing mortality leading to a more effective model.
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Affiliation(s)
- Helena A S Goldani
- Laboratório de Hepatologia Experimental, Centro de Pesquisas do Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, 90035-003 Porto Alegre-RS, Brazil.
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Abstract
OBJECTIVES To determine the prevalence of spontaneous bacterial peritonitis, ascites with bacterial infection and noninfected ascites in pediatric patients with portal hypertensive ascites and to compare the clinical and laboratory features of infected and noninfected ascites. METHODS Forty-one episodes of portal hypertensive ascites (serum-ascites albumin gradient >1.1 g/dL) in 31 patients were studied. Median age was 2.9 years. Twenty-four (77.4%) patients were cirrhotic and 20 (83.3%) were classified as Child-Pugh C. Median pediatric end-stage liver disease score was 18.5. The following ascites features were assessed: polymorphonuclear neutrophil cell count, cytology, pH, concentration of glucose, lactic dehydrogenase, total protein and albumin, Gram stain and bacteriological culture. Blood was sampled for complete blood count, coagulation studies, liver and renal function tests. Groups were compared by Mann-Whitney and chi tests (P < 0.05). RESULTS Noninfected ascites were observed in 29 of 41 samples, spontaneous bacterial peritonitis in eight of 41 and ascites with bacterial infection in four of 41. The most prevalent clinical features were fever, voluminous ascites and encephalopathy, but there were no significant differences in the clinical features of the groups. All patients with infected ascites were cirrhotic. There was no statistical difference in Child-Pugh or pediatric end-stage liver disease status between patients with infected and noninfected ascites. Culture of ascetic fluid was positive in four of eight cases of spontaneous bacterial peritonitis. Gram-negative rods were the most prevalent bacteria cultured. Except for serum albumin, no statistical differences in biochemical markers were observed between patients with infected and noninfected ascites. CONCLUSIONS The prevalence of infected ascites was 29.2%. With the exception of serum albumin, there were no differences in the clinical and biochemical features of patients with infected ascites and noninfected ascites.
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