Neutrophil/Monocyte Ratio: A new predictor of inhospital mortality in patients with spontaneous ascites infections

Öz

Objective: To determine the clinical features and in-hospital mortality predictors of spontaneous ascites infection (SAI). Materials and Methods: In this retrospective study, 496 patients with liver cirrhosis hospitalized at the gastroenterology clinic between 2015-2019 were screened. Of the 304 cases with ascites, 80 diagnosed with SAI were included in the study. Results: Spontoneus ascites infections (SAI) was detected in 80 (16.1%) of 496 hospitalized patients with cirrhosis. In cirrhotic patients with SAI, the most common reason for presentation to the hospital was altered mental status, which was observed in 26 (32.5%) patients. Thirty-one (38.8%) patients were diagnosed with spontaneous bacterial peritonitis, 41 (51.2%) with culture-negative neutrocytic ascites, eight (10%) with monomicrobial non-neutrocytic bacteria ascites. In-hospital mortality was observed in 25 (31.3%) patients, and one-year mortality rate was 35% with total 28 patients. A high MELD-Na score, history of SAI, presence of hepatic encephalopathy at the time of hospitalization, and a neutrophil/monocyte ratio of >9.1 were determined as the predictors of in-hospital mortality. A neutrophil/monocyte ratio of >9.1 predicted in-hospital mortality at 72% sensitivity and 62% specificity. Conclusion: Successfully predicting mortality in SAI, easily calculated by a hemogram examination, and providing inexpensive, effective and fast results, neutrophil/monocyte ratio presents as a useful marker.

Anahtar Kelimeler

• cirrhosis
• ascites
• spontaneous ascites infection
• mortality
• neutrophil/monocyte ratio

Nötrofil/Monosit Oranı: Spontan assit enfeksiyonlarında hastane içi mortalite için yeni bir gösterge

Öz

Amaç: Bu çalışmanın amacı spontan assit enfeksiyonunun (SAI) klinik özelliklerinin ve hastane içi mortalite prediktörlerinin belirlenmesidir. Gereç ve Yöntem: Bu çalışma retrospektif bir çalışmadır. Ocak 2015-Haziran 2019 arasında Gastroenteroloji bilim dalında yatan 496 karaciğer siroz hastası taranmıştır. 304 assitli olgudan SAI saptanan 80 olgu çalışmaya dâhil edilmiştir. Hastaların demografik, klinik ve laboratuar verileri kaydedilmiştir. Bulgular: Siroz tanısı ile yatan 496 olgudan 80 (%16,1)’inde SAI saptanmıştır. En sık hastaneye başvuru nedeni bilinç bulanıklığı olup, 26 hastada (%32,5) gözlenmiştir. Hastaların 31 (%38,8)’i spontan bakteriyel peritonit, 41 (%51,2)’i kültür-negatif nötrositik assit ve 8(%10)’i monomikrobiyal non-nötrositik bakterassit tanısı almıştır. Hastane içi mortalite 25 (%31,3) hastada gözlenmiş olup, bir yıllık total mortalite %35 oranında, toplam 28 hastada görülmüştür. Yüksek MELD-Na skoru, öyküde SAI, yatışta hepatik ensefalopati varlığı ve nötrofil/monosit oranının >9,1 olması hastane içi mortalite prediktörleri olarak saptanmıştır. Nötrofil/monosit oranının >9,1 olması hastane içi mortaliteyi %72 sensitivite ve %62 spesifite ile predikte etmiştir. Sonuç: Nötrofil/monosit oranının, SAI’de mortaliteyi predikte etmesi, hemogram tetkikinden basit olarak hesaplanabilmesi, ucuz, efektif ve hızlı sonuç vermesi nedeniyle bir belirteç olarak kullanılabileceği düşünülmüştür.

Anahtar Kelimeler

• siroz
• assit
• spontan assit enfeksiyonu
• mortalite
• nötrofil/monosit oranı

Kaynakça

1. Gines P, Quintero E, Arroyo V, et al. Compensated cirrhosis: natural history and prognostic factors. Hepatology. 1987;7:122-8.
2. Reynolds TB. Ascites. Clin Liver Dis. 2000;4:151-68.
3. Lucena MI, Andrade RJ, Tognoni G, et al. Spanish Collaborative Study Group on Therapeutic Management in Liver Disease. Multicenter hospital study on prescribing patterns for prophylaxis and treatment of complications of cirrhosis. Eur J Clin Pharmacol. 2002;58:435-40.
4. Mowa CT, Stanley AJ. Review article: spontaneous bacterial peritonitis-diagnosis treatment and prevention. Aliment Pharmacol Ther. 2001;15:1851-9.
5. Wiest R, Garcia-Tsao G. Bacterial translocation (BT) in cirrhosis. Hepatology. 2005;41:422-33.
6. Llovet JM, Bartoli R, March F, et al. Translocated intestinal bacteria cause spontaneous bacterial peritonitis in cirrhotic rats: molecular epidemiologic evidence. J Hepatol. 1998;28:307-13.
7. Fiuza C, Salcedo M, Clemente G, et al. In vivo neutrophil dysfunction in cirrhotic patients with advanced liver disease. J Infecti Dis. 2000;182:526-33.
8. Taneja SK, Dhiman RK. Prevention and management of bacterial infections in cirrhosis. Int J Hepatol. 2011;2011:784540.

9. Ogutu EO. Spontaneous bacterial peritonitis in patients with liver diseases and ascites as seen at Kenyatta National Hospital. East Afr Med J. 1988;4:547-51.
10. Andreu M, Sola R, Sitges-Serra A, et al. Risk factors for spontaneous bacterial peritonitis in cirrhotic patients with ascites. Gastroenterology. 1993;104:1133-8.
11. Akriviadis EA, Runyon BA. The value of an algorithm in differentiating spontaneous from secondary bacterial peritonitis. Gastroenterology. 1990;98:127-33.
12. Runyon BA. Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012. Hepatology. 2013;57:1651-3.
13. Fernández J, Bauer TM, Navasa M, et al. Diagnosis, treatment and prevention of spontaneous bacterial peritonitis. Best Pract Res Clin Gastroenterol. 2000;14:975-90.
14. Ferenci P, Lockwood A, Mullen K, et al. Hepatic encephalopathy-definition. nomenclature. diagnosis. and quantification: Final report of the working party at the 11th World Congresses of Gastroenterology. Hepatology. 2002;35:716-21.
15. Li Y, Yin L, Peng Y, et al. The association of blood pressure with estimated urinary sodium, potassium excretion and their ratio in hypertensive, normotensive, and hypotensive Chinese adults. Asia Pac J Clin Nutr. 2020;29:101-16.
16. Pugh RN, Murray-Lyon IM, Dawson JL, et al. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg. 1973;60:646-9.
17. Runyon BA, Montano AA, Akriviadis EA, et al. The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Ann Intern Med. 1992;117:215.
18. Çelik F, Tekin F, Ünal NG, Özütemiz Ö. Retrospective analyses of 225 patients with liver cirrhosis: A single center experience. The Turkish Journal of Academic Gastroenterology. 2016;16:47-53.
19. Duah A, Nkrumah KN. Prevalence and predictors for spontaneous bacterial peritonitis in cirrhotic patients with ascites admitted at medical block in Korle-Bu Teaching Hospital, Ghana. Pan Afr Med J. 2019;16:33-5.
20. Bor S, Erdem I, Özgüder T, et al. Spontaneous ascitis fluid infections in cirrhotic patients. Türkiye Klinikleri J Gastroenterohepatol. 1996;7:45-50.
21. Na SH, Kim EJ, Nam EY, et al. Comparison of clinical characteristics and outcomes of spontaneous bacterial peritonitis and culture negative neutrocytic ascites. Scand J Gastroenterol. 2017;52:199-203.
22. Iliaz R, Ozpolat T, Baran B, et al. Predicting mortality in patients with spontaneous bacterial peritonitis using routine inflammatory and biochemical markers. Eur J Gastroenterol Hepatol. 2018;30:786-91.
23. Duah A, Nkrumah KN. Prevalence and predictors for spontaneous bacterial peritonitis in cirrhotic patients with ascites admitted at medical block in Korle-Bu Teaching Hospital, Ghana. Pan Afr Med J. 2019;33:35.
24. Carey WD, Boayke A, Leatherman J. Spontaneous bacterial peritonitis: clinical and laboratory features with reference to hospital-acquired cases. Am J Gastroenterol. 1986;81:1156-61.
25. Hoefs JC, Canawati HN, Sapico FL, et al. Spontaneous bacterial peritonitis. Hepatology. 1982;2:399-407.
26. Runyon BA, Hoefs JC. Culture-negative neutrocytic ascites: a variant of spontaneous bacterial peritonitis. Hepatology. 1984;4:1209-11.
27. Akriviadis EA, Runyon BA. The value of an algorithm in differentiating spontaneous from secondary bacterial peritonitis. Gastroenterology. 1990;98:127-33.
28. Musskopf MI, Fonseca FP, Gass J, et al. Prognostic factors associated with in-hospital mortality in patients with spontaneous bacterial peritonitis. Ann Hepatol. 2012;11:915-20.
29. Poca M, Alvarado-Tapias E, Concepción M, et al. Predictive model of mortality in patients with spontaneous bacterial peritonitis. Aliment Pharmacol Ther. 2016;44:629-37.
30. Tüzün Y, Kılınç I, Akın D, et al. Mortality Related Factors in Patients with Spontaneous Bacterial Peritonitis. Dicle Med J. 2008;35:10-5.
31. Ensaroğlu F, Korkmaz M, Geçkil AÜ, et al. Factors Affecting Mortality and Morbidity of Patients With Cirrhosis Hospitalized for Spontaneous Bacterial Peritonitis. Exp Clin Transplant. 2015;13:131-6
32. Nobre SR, Cabral JE, Gomes JJ, et al. In-hospital mortality in spontaneous bacterial peritonitis: a new predictive model Eur J Gastroenterol Hepatol. 2008;20:1176-81.
33. Follo A, Llovet JM, Navasa M, et al. Renal impairment after spontaneous bacterial peritonitis in cirrhosis: incidence, clinical course, predictive factors and prognosis Hepatology. 1994;20:1495-1501.
34. Soylu AR, Dokmeci G, Tezel A, et al. Predictors of short-term outcome of spontaneous bacterial peritonitis in Turkish cirrhotic patients. J Gastroenterol Hepatol. 2005;20:657-60.
35. Terg R, Gadano A, Cartier M, et al. Serum creatinine and bilirubin predict renal failure and mortality in patients with spontaneous bacterial peritonitis: a retrospective study. Liver Int. 2009;29:415-9.
36. Luo J, Wu X, Zhang Y, et al. Role of ascitic prostaglandin E2 in diagnosis of spontaneous bacterial peritonitis and prediction of in-hospital mortality in patients with decompensated cirrhosis. Medicine (Baltimore). 2019;98:e16016.
37. Poca M, Alvarado-Tapias E, Concepción M, et al. Predictive model of mortality in patients with spontaneous bacterial peritonitis. Aliment Pharmacol Ther. 2016;44:629-37.
38. Tito L, Rimola A, Gines P, et al. Recurrence of spontaneous bacterial peritonitis in cirrhosis: frequency and predictive factors. Hepatology. 1988;8:27-31.
39. Llovet JM, Planas R, Morillas R, et al. Short-term prognosis of cirrhotics with spontaneous bacterial peritonitis: multivariate study. Am J Gastroenterol. 1993;88:388-92.
40. Zahorec R. Ratio of neutrophil to lymphocyte counts rapid and simple parameter of systemic inflammation and stress in critically ill. Bratisl Lek Listy. 2001;102:5-14.
41. Goodman DA, Goodman CB, Monk JS. Use of the neutrophil:lymphocyte ratio in the diagnosis of appendicitis. Am Surg. 1995;61:257-9.
42. Tamhane UU, Aneja S, Montgomery D, et al. Association between admission neutrophil to lymphocyte ratio and outcomes in patients with acute coronary syndrome. Am J Cardiol. 2008;102:653-7.
43. Bhutta H, Agha R, Wong J, et al. Neutrophil-lymphocyte ratio predicts medium-term survival following elective major vascular surgery: a cross-sectional study. Vasc Endovascular Surg. 2011;45:227-31.
44. Azab B, Jaglall N, Atallah JP, et al. Neutrophil-lymphocyte ratio as a predictor of adverse outcomes of acute pancreatitis. Pancreatology. 2011;11:445-52.
45. Erre GL, Paliogiannis P, Castagna F, et al. Meta-analysis of neutrophil-to-lymphocyte and platelet-to-lymphocyte ratio in rheumatoid arthritis. Eur J Clin Invest. 2019;49:130-7.