Tuberculous peritonitis, although common in Third World countries, remains an uncommon cause of ascites in the United States. Ascitic fluid adenosine deaminase (ADA) activity has been proposed as a useful diagnostic test. The aim of this retrospective study was to determine the clinical utility of ascitic fluid ADA activity in diagnosing tuberculous peritonitis in a U.S. patient population. A total of 368 ascitic fluid specimens from a well-characterized ascitic fluid bank, including tuberculous peritonitis (n = 7), tuberculous peritonitis in the setting of cirrhosis (n = 10), and consecutive specimens of widely varied etiologies (n = 351) were analyzed for ADA activity by ultraviolet spectrophotometry at 265 nm. The overall sensitivity of the ADA determination in diagnosing tuberculous peritonitis was only 58.8%, and the specificity was 95.4%. The accuracy of ADA determination (93.8%) compared favorably with that of the common ascitic fluid tests of white blood cell (WBC) count (>500/mm3), total protein (>2.5 g/dL), and combined WBC count and total protein (45.8%, 74.4%, and 81.3%, respectively). However, ADA was only 30% sensitive in detecting tuberculous peritonitis in the setting of cirrhosis, and cirrhosis was present in 59% of the tuberculous peritonitis patients in our population. In addition, malignancy-related ascites (13%) and bacterial peritonitis specimens (5.8%) occasionally yielded false-positive results. In conclusion, our results indicate that the ascitic fluid ADA activity has good accuracy but poor sensitivity and imperfect specificity in a U.S. patient population in which the prevalence of tuberculosis is low and underlying cirrhosis is common.

Six months of abstinence from alcohol is a commonly used criterion for liver transplantation eligibility for patients with alcoholic cirrhosis. There is limited evidence to document the validity of this criterion with regard to risk of alcoholism relapse. Ninety-one patients with alcoholic cirrhosis were interviewed for relapse risk using the High Risk Alcoholism Relapse (HRAR) Scale. The HRAR model can be used to predict relapse risk independent of duration of sobriety and therefore can be used to examine the validity of the 6 months of abstinence criteria in this clinical population. The two methods demonstrated poor to fair agreement. Agreement was highest with a cutoff allowing a 5% 6-month relapse risk when 79% agreement (c = 0.56) was demonstrated between the two methods. Using the 6-month abstinence criterion alone disallows a significant number of candidates who have a low relapse risk based on their HRAR score. The validity of the 6-month abstinence criterion is supported somewhat by comparison with the HRAR model. However, use of the 6-month abstinence criterion alone forces a significant number of patients with a low relapse risk by HRAR to wait for transplant listing. A relapse risk model based on an estimate of alcoholism severity in addition to duration of sobriety may more accurately select patients who are most likely to benefit from liver transplantation.

rently available ascitic fluid diagnostic tests are insensitive Tuberculous peritonitis, although common in Third in diagnosing tuberculous peritonitis. Culture of ascitic fluid World countries, remains an uncommon cause of ascites or culture of peritoneum obtained at laparoscopy is the gold in the United States. Ascitic fluid adenosine deaminase standard for the diagnosis of tuberculous peritonitis. 19 How-(ADA) activity has been proposed as a useful diagnostic ever, several weeks are usually required before the culture test. The aim of this retrospective study was to deterdemonstrates growth of mycobacteria. The high mortality mine the clinical utility of ascitic fluid ADA activity in rate in untreated patients (e.g., 50% in the prechemotherapy diagnosing tuberculous peritonitis in a U.S. patient popera) warrants a continued search for a rapid noninvasive ulation. A total of 368 ascitic fluid specimens from a wellscreening test for tuberculous peritonitis. characterized ascitic fluid bank, including tuberculous Adenosine deaminase (ADA) is an enzyme found in erythperitonitis (n Å 7), tuberculous peritonitis in the setting rocytes, lymphocytes, and the cerebral cortex. 20 Its activity of cirrhosis (n Å 10), and consecutive specimens of in body fluids is related primarily to the number, maturation, widely varied etiologies (n Å 351) were analyzed for ADA and level of stimulation of lymphocytes. 20,21 ADA activity has activity by ultraviolet spectrophotometry at 265 nm. The been used as a diagnostic test for tuberculous meningitis, overall sensitivity of the ADA determination in diagnospericarditis, and pleural effusions. [22][23][24][25][26][27] Previous studies pering tuberculous peritonitis was only 58.8%, and the specformed outside the United States in patients with tubercuificity was 95.4%. The accuracy of ADA determination lous peritonitis have suggested its usefulness as a diagnostic (93.8%) compared favorably with that of the common asassay. 8,24,[28][29][30][31][32] However, these studies were performed in councitic fluid tests of white blood cell (WBC) count (ú500/ tries in which tuberculous is endemic. The present study in- tested. Seven specimens were from patients with peritoneal tubercu- 1408-1412.)losis in the absence of cirrhosis; these were labeled ''isolated tuberculous peritonitis.'' Ten additional specimens were from patients with tuberculous peritonitis and cirrhosis. Another 351 consecutive ascitic Tuberculous peritonitis is a common cause of ascites in fluid samples were assayed. The ascitic fluid total protein (AFTP)Third World countries. 1 In 1991, more than 26,000 cases of and cell counts had been previously determined.tuberculosis were reported in the United States. 2 Tuberculo-ADA activity was determined by measuring the decrease in adenosis is increasing in the Western World because of increases sine concentration under the action of ADA. 34 The ascitic fluid speciin the numbers of homeless persons, prison inmates, immi-mens were labeled by code. Control and coded ascitic fluid specim...

Six months of abstinence from alcohol is a commonly used criterion for liver transplantation eligibility for patients with alcoholic cirrhosis. There is limited evidence to document the validity of this criterion with regard to risk of alcoholism relapse. Ninety-one patients with alcoholic cirrhosis were interviewed for relapse risk using the High Risk Alcoholism Relapse (HRAR) Scale. The HRAR model can be used to predict relapse risk independent of duration of sobriety and therefore can be used to examine the validity of the 6 months of abstinence criteria in this clinical population. The two methods demonstrated poor to fair agreement. Agreement was highest with a cutoff allowing a 5% 6-month relapse risk when 79% agreement (c = 0.56) was demonstrated between the two methods. Using the 6-month abstinence criterion alone disallows a significant number of candidates who have a low relapse risk based on their HRAR score. The validity of the 6-month abstinence criterion is supported somewhat by comparison with the HRAR model. However, use of the 6-month abstinence criterion alone forces a significant number of patients with a low relapse risk by HRAR to wait for transplant listing. A relapse risk model based on an estimate of alcoholism severity in addition to duration of sobriety may more accurately select patients who are most likely to benefit from liver transplantation.