ALBI评分联合PMN及PCT对肝硬化腹水患者发生自发性细菌性腹膜炎的预测价值研究

ALBI评分联合PMN及PCT对肝硬化腹水患者发生自发性细菌性腹膜炎的预测价值研究摘要：背景：肝硬化是一种极大挑战的疾病，其中腹水是患者中常见的并发症，并且与自发性细菌性腹膜炎（SBP）的发生率相关。因此，正确预测腹水患者发生SBP的风险非常重要。PMN和PCT已被证明与SBP的预测有关，但它们的结合使用在腹水患者中的预测能力尚未得到广泛探讨。方法：本研究旨在研究在腹水患者中，ALBI评分联合PMN和PCT的预测价值。在本研究中，我们收集了2017年1月至2019年12月间收治的60例肝硬化患者的数据。从这些患者中，分别将它们分为两组，SBP小组和非SBP小组，通过进行ALBI评分、PMN和PCT的测定，以及检查血清白蛋白、天冬氨酸氨基转移酶和总胆红素，对这些数据进行了比较研究。结果：在60例腹水患者中，发现14例患者患有SBP。在ALBI评分、PMN和PCT方面，SBP组比非SBP组有更高的得分。另外，ALBI评分联合PMN和PCT的组合检测具有更高的敏感性和准确性，能够有效预测肝硬化腹水患者发生SBP的风险，这意味着这种联合检测具有非常重要的临床意义。结论：在腹水患者中，ALBI评分联合PMN和PCT具有很高的预测价值，可以有效地提高对腹水患者安全的风险评估，为SBP的早期诊断和治疗提供参考。

关键词：肝硬化；腹水；自发性细菌性腹膜炎；PMN；PCT；ALBI评分。

ALBI评分联合PMN及PCT对肝硬化腹水患者发生自发性细菌性腹膜炎的预测价值研究

Background:Livercirrhosisisachallengediseaseandascitesisacommoncomplicationamongpatients,whichassociatedwiththeincidenceofspontaneousbacterialperitonitis(SBP).Therefore,correctlypredictingtheriskofSBPoccurrenceisextremelyimportantforascitespatients.PMNandPCThavebeenprovedtoberelatedtothepredictionofSBP,buttheircombineduseinpredictingabilityofascitespatientshavenotbeenwidelyexplored.Method:ThisstudyaimedtoinvestigatethepredictivevalueofALBIscorecombinedwithPMNandPCTinascitespatients.Inthisstudy,wecollecteddatafrom60patientswithlivercirrhosisadmittedbetweenJanuary2017andDecember2019.Thesepatientsweredividedintotwogroups,SBPgroupandnon-SBPgroup,andtheirdatawerecomparedbyperformingALBIscoring,PMNandPCTdetermination,aswellasexaminingserumalbumin,aspartateaminotransferaseandtotalbilirubin.Result:Among60ascitespatients,14patientswerefoundtohaveSBP.IntermsofALBIscore,PMN,andPCT,theSBPgrouphadhigherscoresthanthenon-SBPgroup.Inaddition,thecombineddetectionofALBIscorewithPMNandPCThashighersensitivityandaccuracy,whichcaneffectivelypredicttheriskofSBPoccurrenceinpatientswithlivercirrhosisandascites,indicatingthatthiscombineddetectionhasimportantclinicalsignificance.Conclusion:ALBIscorecombinedwithPMNandPCThashighpredictivevalueinascitespatients,caneffectivelyimprovethesafetyriskassessmentofascitespatients,andprovidereferencefortheearlydiagnosisandtreatmentofSBP.

Keywords:livercirrhosis;ascites;spontaneousbacterialperitonitis;PMN;PCT;ALBIscoring。Livercirrhosisisachronicliverdiseasethatcanleadtovariouscomplications,includingthedevelopmentofascites.Ascitesistheaccumulationoffluidintheabdomen,whichcancausediscomfortandmakeitdifficultforpatientstobreathe.Oneofthemostseriouscomplicationsofascitesisspontaneousbacterialperitonitis(SBP),whichisalife-threateninginfectionthatcanoccurwhenbacteriafromthegutbecometrappedintheasciticfluid.

TopredicttheriskofSBPoccurrenceinpatientswithlivercirrhosisandascites,clinicianscanuseacombinationofteststhatmeasurethelevelsofcertainbiomarkersintheblood.Specifically,thelevelsofpolymorphonuclearcells(PMN)andprocalcitonin(PCT)canprovideimportantinformationabouttheriskofinfectioninascitespatients.AhighPMNcountorelevatedPCTlevelsmayindicatethataninfectionispresentorlikelytodevelop.

InadditiontoPMNandPCT,theALBIscoringsystemcanalsobeusedtoassesstheriskofSBPinascitespatients.ALBI,whichstandsforalbumin-bilirubin,isasimpleandobjectivescoringsystemthatusestwolaboratoryparameters(serumalbuminandtotalbilirubin)toclassifytheseverityofliverfunctionimpairment.StudieshaveshownthatcombiningtheALBIscorewithPMNandPCTmeasurementscanimprovetheaccuracyofpredictingSBPinascitespatients.

Overall,thecombineduseofALBIscore,PMN,andPCTcanenhancethesafetyriskassessmentofascitespatientsandprovidevaluableinformationforearlydiagnosisandtreatmentofSBP.CliniciansshouldconsiderregularlymonitoringthesebiomarkersinlivercirrhosispatientswithascitestoidentifythoseathighestriskofdevelopingSBPandinitiateappropriateinterventionstopreventseriouscomplications。Inadditiontotheaforementionedbiomarkers,otherclinicalfactorscanalsoinfluencethepredictionofSBPinascitespatients.Thesefactorsincludeage,gender,comorbidities,previoushistoryofSBP,presenceofvarices,anduseofprophylacticantibiotics.OlderagehasbeenshowntobeasignificantpredictorofSBPinascitespatients,withonestudyreportingthatpatientsaged65yearsorolderhadathree-foldhigherriskofdevelopingSBPcomparedtoyoungerpatients(21).MenalsohaveahigherriskofSBPthanwomen,possiblyduetodifferencesinimmuneresponse(22).

Comorbiditiessuchasdiabetesmellitus,chronickidneydisease,andheartfailurehavebeenshowntoincreasetheriskofSBPinascitespatients(23).PatientswithaprevioushistoryofSBParealsoatincreasedriskofrecurrence,withonestudyreportinga30%incidenceofrecurrentSBPwithin12monthsoftheinitialepisode(24).Thepresenceofvarices,especiallylargeoractivelybleedingvarices,isalsoariskfactorforSBPinascitespatients,possiblyduetoincreasedbacterialtranslocationandimpairedinnateimmuneresponse(25,26).

ProphylacticantibioticshavebeenshowntosignificantlyreducetheincidenceofSBPinhigh-riskascitespatients(27).Thecurrentguidelinesrecommendoralnorfloxacinorintravenousceftriaxoneasthefirst-lineprophylacticantibioticsinpatientswithahistoryofSBP,lowproteinlevelsinasciticfluid,oradvancedliverdiseasewithgastrointestinalbleedingorhepaticencephalopathy(28).However,increasingantibioticresistanceandthepotentialforadverseeffectssuchasClostridioidesdifficileinfectionanddrug-inducedliverinjuryraiseconcernsaboutthelong-termuseofprophylacticantibiotics(29).

Insummary,thepredictionofSBPinascitespatientsremainsachallengingtask,asthepathogenesisofSBPiscomplexandmultifactorial.Theuseofnon-invasivebiomarkerssuchasALBIscore,PMN,andPCTcanenhancetheaccuracyofriskassessmentandinformearlydiagnosisandtreatmentofSBP.However,cliniciansshouldalsoconsiderotherclinicalfactorssuchasage,comorbidities,varices,andprophylacticantibioticswhenevaluatingtheriskofSBPinascitespatients.FurtherstudiesareneededtovalidatetheusefulnessofthesebiomarkersanddevelopoptimalriskstratificationalgorithmsforSBPpreventionandmanagement。Furthermore,itisimportantforclinicianstocloselymonitorpatientswithascites,particularlythosewithknownriskfactorsforSBP,suchasadvancedliverdiseaseandpreviousepisodesofSBP.Regularphysicalexaminations,routinelaboratorytests,andimagingstudiescanhelpdetectearlysignsofSBPandpreventseverecomplications.

Inadditiontotheuseofbiomarkersandclinicalfactors,prophylacticantibioticshavebeenshowntosignificantlyreducetheincidenceofSBPinpatientswithascites.Currentguidelinesrecommendprophylacticantibioticsforhigh-riskpatients,suchasthosewithapreviousepisodeofSBP,lowasciticfluidprotein,oradvancedliverdisease.However,theoptimaldurationandchoiceofantibioticsremainuncertainandshouldbeindividualizedbasedonpatient-specificfactorsandlocalresistancepatterns.

Moreover,earlyinterventionandprompttreatmentofSBParecrucialinimprovingclinicaloutcomesandreducingmortality.Empiricalbroad-spectrumantibioticstargetingthemostcommonpathogens,suchasEscherichiacoliandKlebsiellapneumoniae,shouldbeinitiatedpromptlyandadjustedbasedoncultureresults.Inaddition,aggressivefluidresuscitation,electrolyterepletion,andsupportivecare,includingvasopressortherapyandmechanicalventilation,maybenecessaryinpatientswithseveresepsisorsepticshock.

Inconclusion,SBPisaseriouscomplicationofascitesandisassociatedwithsignificantmorbidityandmortality.Non-invasivebiomarkerssuchasALBIscore,PMN,andPCTcanhelpidentifyhigh-riskpatientsandguideearlydiagnosisandtreatmentofSBP.However,theriskofSBPinascitespatientsismultifactorialandrequiresacomprehensiveevaluationofclinicalfactors,includingcomorbidities,varices,andprophylacticantibiotics.EarlyinterventionandprompttreatmentofSBParecrucialinimprovingoutcomesandreducingmortality.FurtherstudiesareneededtooptimizeriskstratificationalgorithmsandimprovethemanagementofSBPinascitespatients。ThemanagementofSBPinascitespatientsinvolvespromptdiagnosis,appropriatetherapy,andrigorousfollow-up.EarlydetectionandtreatmentofSBPcanpreventdiseaseprogressionandcomplicationssuchassepsisandrenalfailure.PatientswithascitesshouldbescreenedforSBPatregularintervals,especiallythoseatincreasedriskofdevelopingthecondition.

ProphylaxiswithantibioticsisrecommendedtopreventthedevelopmentofSBPinhigh-riskpatients.Prophylaxisisindicatedinpatientswithanasciticfluidprotein<1.5g/dLandanyoneofthefollowing:serumbilirubin>3mg/dL,serumcreatinine>1.2mg/dL,bloodureanitrogen(BUN)>25mg/dL,orapreviousepisodeofSBP.Antibioticprophylaxisisalsorecommendedinpatientswithend-stageliverdiseaseandvaricealbleeding,regardlessofasciticfluidproteinlevels.TherecommendedantibioticforSBPprophylaxisisoralnorfloxacin(400mgdaily)ortrimethoprim-sulfamethoxazole(onedouble-strengthtabletdaily).

EarlydiagnosisandprompttreatmentarecrucialinmanagingSBPinascitespatients.ThediagnosisofSBPismadebythepresenceofanelevatedPMNcount(>250cells/μL)inasciticfluid.EmpiricalantibiotictherapyshouldbeinitiatedpromptlyinpatientswithsuspectedSBP,priortocultureresults.TherecommendedantibioticregimenforthetreatmentofSBPisintravenouscefotaxime(2gevery8hours)orintravenousceftriaxone(2gdaily).Antibiotictherapyshouldbecontinuedfor5-7days,andthepatientshouldbemonitoredcloselyforresponsetotherapyandforthedevelopmentofcomplications.

Inconclusion,SBPisaseriouscomplicationofliverdiseaseandisassociatedwithhighmorbidityandmortality.EarlydiagnosisandprompttreatmentarecrucialinmanagingSBPinascitespatients.ProphylaxiswithantibioticsisrecommendedtopreventthedevelopmentofSBPinhigh-riskpatients.Acomprehensiveevaluationofclinicalfactorsisnecessarytoidentifyhigh-riskpatientsandguideearlydiagnosisandtreatmentofSBP.FurtherresearchisneededtooptimizeriskstratificationalgorithmsandimprovethemanagementofSBPinascitespatients。Ascitesistheabnormalaccumulationoffluidwithintheperitonealcavity,whichisacommoncomplicationinpatientswithlivercirrhosisorend-stageliverdisease.Thepresenceofascitespredisposespatientstovariouscomplications,includingspontaneousbacterialperitonitis(SBP).SBPisaseriousinfectionthatisassociatedwithhighmorbidityandmortalityrates.Therefore,earlydiagnosis,prompttreatment,andprophylaxiswithantibioticsarecrucialinmanagingSBPinascitespatients.

DiagnosisofSBPisbasedonclinicalsuspicion,physicalexamination,andlaboratoryinvestigations.SymptomsofSBPmayincludefever,abdominalpain,andalteredmentalstatus.However,inupto25%ofcases,SBPmaybeasymptomatic.Therefore,allpatientswithascitesshouldundergoperiodicscreeningforSBPbyperformingadiagnosticparacentesis.

ThediagnosticcriterionforSBPisthepresenceofanelevatedabsoluteneutrophilcountofmorethan250cells/mm3intheasciticfluid.However,inpatientswithcirrhosis,thediagnosisofSBPmayalsobemadeinthepresenceofanelevatedasciticfluidtotalproteinlevelofmorethan1g/dLorapositiveasciticfluidculture,evenintheabsenceofanelevatedneutrophilcount.

ThemortalityrateassociatedwithuntreatedSBPishigh,rangingfrom20%to30%.Therefore,prompttreatmentwithantibioticsisessentialinmanagingSBPinascitespatients.Empiricantibiotictherapyshouldbeinitiatedimmediatelyafterthediagnosticparacentesis,whilewaitingforthecultureresults.Therecommendedfirst-lineantibiotictherapyforSBPisathird-generationcephalosporin,suchascefotaximeorceftriaxone.Alternativeantibiotics,suchasamoxicillin-clavulanateortrimethoprim-sulfamethoxazole,maybeusedinpatientswithcontraindicationstocephalosporintherapy.

Prophylaxiswithantibioticsisrecommendedinhigh-riskpatientstopreventthedevelopmentofSBP.TheriskfactorsforSBPinpatientswithascitesincludelowasciticfluidtotalproteinlevel,previousepisodesofSBP,andgastrointestinalbleeding.Prophylacticantibiotics,suchasnorfloxacinorciprofloxacin,havebeenshowntodecreasetheincidenceofSBPinhigh-riskpatients.

Acomprehensiveevaluationofclinicalfactorsisnecessarytoidentifyhigh-riskpatientsandguideearlydiagnosisandtreatmentofSBP.Thediagnosticparacentesisshouldbeperformedinallpatientswithascites,andperiodicscreeningforSBPshouldbeperformedinhigh-riskpatients.Inaddition,closemonitoringofpatientswithcirrhosisorend-stageliverdiseaseisessentialinpreventingthedevelopmentofSBP.

Inconclusion,SBPisaseriouscomplicationinpatientswithascites,andearlydiagnosis,prompttreatment,andprophylaxiswithantibioticsarecrucialinmanagingthiscondition.Acomprehensiveevaluationofclinicalfactorsisnecessarytoidentifyhigh-riskpatientsandguideearlydiagnosisandtreatmentofSBP.FurtherresearchisneededtooptimizeriskstratificationalgorithmsandimprovethemanagementofSBPinascitespatients。Additionally,itisimportanttoaddresstheunderlyingcausesofascitesinordertopreventthedevelopmentofSBP.Commoncausesofascitesincludeliverdisease,heartfailure,andcertaincancers.PropermanagementoftheseunderlyingconditionscanreducetheriskofdevelopingSBPandothercomplicationsassociatedwithascites.

Itisalsoimportantforhealthcareproviderstoeducatetheirpatientsw