Ascitic fluid polymorphic nuclear cell count impacts on outcome of cirrhotic patients with ascites

Abstract

Background: Spontaneous bacterial peritonitis (SBP) is defined as an ascitic polymorphonuclear cell count (A-PMN) > 250 cells/ml. Objective: We aimed to investigate the prognostic value of ascitic fluid cell counts in patients without SBP. Patients and methods: A total of 178 patients were included and stratified by ascitic cell counts at index paracentesis: A-LEUK-low (<250/ml), A-LEUK-intermediate (250-500/ml) and A-LEUK-SBP (>500/ml) for leukocytes; A-PMN-low (<125/ml), A-PMN-intermediate (125-250/ml) and A-PMN-SBP (>250/ml) for PMN cells. Results: One-year mortality was comparable between group A-LEUK-SBP (53.9%) and patients with subclinical cell counts (34.5% for A-LEUK-low, 43.5% for A-LEUK-intermediate, log-rank p ¼ 0.547). However, we observed an increase in one-year mortality already in group A-PMN-intermediate with 75% and A-PMN-SBP with 80.9% (vs 40.5% for A-PMN-low, log-rank p ¼ 0.016). Importantly, increases of A-PMN cell counts between two paracenteses were associated with increased mortality: per 100 cells/ml increase of absolute A-PMN cell count: hazard ratio (HR): 1.03 (95% confidence interval (CI): 1.01-1.06), p ¼ 0.005; per 5% increase of relative PMN cell count: HR: 1.15 (95% CI: 1.06-1.26), p ¼ 0.001. Conclusion: Patients with PMN cell counts of 125-250/ml are at high risk for mortality, which was very similar to SBP patients with PMN cell counts >250/ml. This highlights the need for preventive strategies. The prognostic value of changes in relative ascitic PMN cell counts should be evaluated in future studies. Key summary1. Summary a. Spontaneous bacterial peritonitis (SBP) is the most frequent infection among patients with cirrhosis and ascites. b. SBP is defined by an ascitic polymorphonuclear (A-PMN) cell count higher than 250/ml in the absence of an intraabdominal source of infection. c. Development of bacteriascites was associated with an increase of relative A-PMN cell counts.

Outcomes after hospitalisation with spontaneous bacterial peritonitis over a 13-year period: a retrospective cohort study

“…Over the 13-year study duration (period 1 vs. period 2), patients with SBP presented with more severe clinical disease as reflected by lower serum sodium, higher ascitic fluid polymorphonuclear cell count and higher HRS-AKI prevalence. These factors have all been previously shown to be associated with increased mortality in patients presenting with SBP [30,31,35]. Despite this, mortality at 32 months, inpatient mortality and mortality in those surviving hospitalisation were lower in period 2, although, no statistically significant difference was found.…”

Clinical Significance of Ascitic Fluid Polymorphonuclear Leukocyte (PMN) Percentage in Cirrhosis Patients without Spontaneous Bacterial Peritonitis (SBP)

“…This study concluded that PMN-C is an independent predictor of subsequent SBP development with a relative risk of 1.352 (1.162–1.499) per 50 cells/mm 3 increase. Another study of 178 subjects stratified by PMN-C at index paracentesis (<125 cells/mm 3 , 125–250 cells/mm 3 , and >250 cells/mm 3 ) also found that patients with PMN-C > 125 cells/mm 3 are at high risk for 1-year mortality, with rates similar to those of patients with SBP ( 37 ). These findings, along with ours, suggest the necessity of lowering the diagnostic threshold of SBP or considering PMN-C ≥ 115 cells/mm 3 as an indication for SBP prophylaxis, given the comparable death rates of patients with PMN-C 115–249 cells/ mm 3 with those of patients with SBP (PMN-C ≥ 250 cells/mm 3 ) who were treated with standard-of-care antibiotics therapy.…”

Discrimination of ascitic fluid infection in malignant ascites by polymorphonuclear neutrophil ratio and count: Investigating the validity of count ≥250/mm3 as the one‐size‐fits‐all criterion

“…As such, ascites PMN count could be a good surrogate marker for a quick tentative diagnosis of SBP, representing clinical outcomes and culture results in advance 11 . The definition of NA as a PMN count ≥250/mm 3 in the fluid has well served for the purpose for more than 30 years although a recent study reported that PMN counts below the traditional SBP threshold were associated with patient outcomes 12 . In contrast, ascites secondary to peritoneal carcinomatosis, are the so‐called MA that result from inflammations or high impedance to lymphatic flow, or both, associated with widespread malignant cells on the surface of the serosal membranes rather than portal hypertension.…”