Prevalence and prognostic value of hepatocellular carcinoma in cirrhotic patients presenting with spontaneous bacterial peritonitis

Prognosis of spontaneous bacterial peritonitis in patients with hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is the fourth leading cause of death from cancer worldwide. Spontaneous bacterial peritonitis (SBP) is associated with poor prognosis. This study aimed to evaluate risk factors, differences in clinical characteristics and prognosis of SBP in patients with HCC in comparison with non-HCC patients.

METHODS

This study was conducted on patients with cirrhosis who were admitted to hospital with SBP. The patients were divided into two groups: SBP group with HCC (n = 150) and SBP group without HCC (n = 250).

RESULTS

Men and women accounted for 72% and 28% (n = 108 and 42, respectively) of the population in SBP group with HCC with mean age 55.8 ± 13.1 years. They accounted for 68.4% and 31.6% (n = 171 and 79, respectively) in the SBP group without HCC with mean age 56.8 ± 10.5 years. In-hospital mortality was 25.3% in the SBP group with HCC and 18.8% in SBP group without HCC. Gastrointestinal bleeding was the most common cause of death in both groups. No significant difference was observed in patient outcomes between the two studied groups. The deceased patients had significantly higher levels of leukocytes and neutrophils in ascitic fluid as well as a higher frequency of positive culture results than in patients who survived (p < 0.001). However, there was no significant difference in protein level in ascitic fluid or causative organism between patients who survived and those who died (p = 0.63 and 0.19, respectively).

CONCLUSIONS

Prognosis of SBP in patients with HCC seemed similar to that in patients without HCC.

Initial treatment response and short-term mortality of spontaneous bacterial peritonitis in cirrhotic patients with hepatocellular carcinoma

This study aimed to investigate the initial treatment response and short-term mortality of spontaneous bacterial peritonitis (SBP) in cirrhotic patients with hepatocellular carcinoma (HCC) compared with those without HCC. A total of 245 patients with liver cirrhosis diagnosed with SBP between January 2004 and December 2020 were included. Of these, 107 (43.7%) were diagnosed with HCC. Overall, the rates of initial treatment failure, 7-day and 30-day mortality were 91 (37.1%), 42 (17.1%), and 89 (36.3%), respectively. While the baseline CTP score, MELD score, culture-positive rate, and rates of antibiotic resistance did not differ between both groups, patients with HCC had a higher rate of initial treatment failure than those without HCC patients (52.3% vs. 25.4%, P < 0.001). Similarly, 30-day mortality was also significantly higher in patients with HCC (53.3% vs. 23.2%, P < 0.001). In the multivariate analysis, HCC, renal impairment, CTP grade C, and antibiotic resistance were independent factors for initial treatment failure. Furthermore, HCC, hepatic encephalopathy, MELD score, and initial treatment failure were independent risk factors for 30-day mortality, with statistically significant poor survival outcomes in patients with HCC (P < 0.001). In conclusion, HCC is an independent risk factor for initial treatment failure and high short-term mortality in patients with cirrhosis with SBP. It has been suggested that more attentive therapeutic strategies are required to improve the prognosis of patients with HCC and SBP.

Platelet-to-lymphocyte ratio acts as a prognostic factor for patients with advanced hepatocellular carcinoma

The platelet count, as an inflammation marker, is involved in the progress of tumor invasion. However, the prognostic value of platelet counts and the platelet-to-lymphocyte ratio (PLR) has not been investigated in patients with advanced hepatocellular carcinoma (HCC). This study aimed to determine the prognostic value of platelet counts and PLR in HCC patients. A total of 243 ethnic Chinese advanced HCC patients from two major hospitals, not receiving systemic sorafenib, were analyzed retrospectively. The prognostic value of differential blood cell counts and PLR for overall survival (OS) was determined by integrating the Cancer of the Liver Italian Program (CLIP) score system and model for end-stage liver disease by using a stepwise model of multivariate Cox regression. The Kaplan-Meier method and receiver operating characteristic (ROC) curves were utilized accordingly. PLR was confirmed to be an independent predictor for OS (p < 0.01), while the remaining parameters had no predictive value. Then, advanced HCC patients were dichotomized into two groups based on the PLR value (≤111.23 or >111.23), according to ROC analysis. Patients with a high PLR had a lower 3-month survival rate (37.6 vs. 57.6%) compared with patients with a low PLR. PLR was associated with aggressive malignant behavior, characterized by distant metastasis and portal vein thrombosis. Additionally, PLR was not associated with the CLIP score and Child-Pugh grade. PLR was identified as an independent prognostic factor for advanced HCC patients not receiving systemic sorafenib; the predictive ability of PLR partially relies on its association with the aggressive nature of HCC.

Neutrophil-to-lymphocyte ratio acts as a prognostic factor for patients with advanced hepatocellular carcinoma

Few studies investigated the prognosis of patients with advanced hepatocellular carcinoma (aHCC). This study was aimed to determine the prognostic value of differential blood cell counts including blood white cells, neutrophil, lymphocyte, neutrophil-lymphocyte ratio (NLR), and platelet in patients with aHCC. A total of 205 ethnic Chinese aHCC patients receiving non-systematic sorafenib were analyzed retrospectively. The prognostic value of differential blood cell counts and NLR for overall survival (OS) was determined by integration into Cancer of the Liver Italian Program (CLIP) score system using backward elimination model of multivariate Cox regression. As a result, NLR was confirmed to be an independent predictor for OS (p = 0.001) with the rest parameters presented negative results. Then, aHCC patients were dichotomized into two groups according to NLR values ≤ 2.43 or >2.43. Patients with low NLR presented lower CLIP score and higher 6-month survival rate (56.1 vs 25.9%) compared with patients with high NLR level. Besides, low NLR level was associated with favorable prognostic factors such as lower α-fetoprotein, alkaline phosphatase, and total bilirubin, as well as decreased incidence of ascites, portal vein thrombosis, and metastasis. Besides, low NLR level was associated less white cells and neutrophil granulocytes, as well as more lymphocyte. In summary, the present study firstly indentified NLR as an independent prognostic factor in aHCC patients receiving no systematic sorafenib.

Effect of renal impairment on mortality of patients with cirrhosis and spontaneous bacterial peritonitis

BACKGROUND & AIMS

The effects of end-stage renal disease (ESRD) on the mortality of patients with cirrhosis and spontaneous bacterial peritonitis (SBP) have not been determined.

METHODS

We collected data from Taiwan's National Health Insurance Database on 2592 patients with cirrhosis who were hospitalized with SBP from January 1 to December 31, 2004. Patients were matched with individuals from a national mortality database; 30-day and 1-year mortalities were calculated for each group and compared to calculate hazard ratios (HRs).

RESULTS

Of the patients with cirrhosis and SBP, 300 (11.5%) had renal function impairment. Of these, 145 had acute renal failure, 70 had ESRD, and 75 had chronic kidney disease. Overall, 30-day and 1-year mortality were 21.3% and 51.7%, respectively. After adjusting for age, sex, and underlying comorbidities, HRs for 30-day mortality from renal function impairment, acute renal failure, ESRD, and chronic kidney disease were 3.00, 4.68, 1.93, and 1.37, respectively. The HRs for 1-year mortality from renal function impairment, acute renal failure, ESRD, and chronic kidney disease were 2.03, 2.78, 1.70, and 1.37, respectively. The adjusted HRs for 30-day and 1-year mortality of patients with acute renal failure were 2.6 and 1.6, respectively, compared with patients with ESRD.

CONCLUSIONS

Acute renal failure is a better determinant of 30-day and 1-year mortality than renal function impairment in cirrhotic patients with SBP.

Renal dysfunction is the most important independent predictor of mortality in cirrhotic patients with spontaneous bacterial peritonitis

BACKGROUND & AIMS

Spontaneous bacterial peritonitis (SBP) is the most common infection among patients with cirrhosis. To improve stratification of patient care, we performed a systematic review to identify the most robust predictors of mortality in cirrhotic patients with SBP.

METHODS

We reviewed prognostic studies (English language only) of adult patients with SBP, defined as a polymorphonuclear ascitic fluid cell count of 250 cells/mm(3) or more, with or without positive results from culture of ascitic fluid. We reviewed only studies that performed survival and multivariate analyses and reported in-hospital or mortalities within 30 days.

RESULTS

Of 2008 available references, 18 were included in the study (median, 115 patients per trial). The median age of patients was 56 years (68% male). The most common predictors of death were renal dysfunction, lack of SBP resolution, immunosuppressive factors, and hospital-acquired SBP. Sensitivity analysis using the 12 best-quality studies identified renal dysfunction and levels of blood urea nitrogen and creatinine as the most important variables. The mortality rate among patients with renal dysfunction was 67%, compared with only 11% of patients who maintained normal renal function.

CONCLUSIONS

Renal dysfunction is the main prognostic factor for cirrhotic patients with SBP, followed by the MELD score. Further studies are needed to determine whether these factors identified retain prognostic value in high-risk patients who receive albumin. Risk stratification might be used to select additional treatments, such as early vasoconstrictor therapy, for the highest-risk group.

Infections in patients with cirrhosis increase mortality four-fold and should be used in determining prognosis

BACKGROUND & AIMS

A staged prognostic model of cirrhosis based on varices, ascites, and bleeding has been proposed. We analyzed data on infections in patients with cirrhosis to determine whether it is also a prognostic factor.

METHODS

Studies were identified by MEDLINE, EMBASE, COCHRANE, and ISI Web of Science searches (1978-2009); search terms included sepsis, infection, mortality, and cirrhosis. Studies (n = 178) reporting more than 10 patients and mortality data were evaluated (225 cohorts, 11,987 patients). Mortality after 1, 3, and 12 months was compared with severity, site, microbial cause of infection, etiology of cirrhosis, and publication year. Pooled odds ratio of death was compared for infected versus noninfected groups (18 cohorts, 2317 patients).

RESULTS

Overall median mortality of infected patients was 38%: 30.3% at 1 month and 63% at 12 months. Pooled odds ratio for death of infected versus noninfected patients was 3.75 (95% confidence interval, 2.12-4.23). In 101 studies that reported spontaneous bacterial peritonitis (7062 patients), the median mortality was 43.7%: 31.5% at 1 month and 66.2% at 12 months. In 30 studies that reported bacteremia (1437 patients), the median mortality rate was 42.2%. Mortality before 2000 was 47.7% and after 2000 was 32.3% (P = .023); mortality was reduced only at 30 days after spontaneous bacterial peritonitis (49% vs 31.5%; P = .005).

CONCLUSIONS

In patients with cirrhosis, infections increase mortality 4-fold; 30% of patients die within 1 month after infection and another 30% die by 1 year. Prospective studies with prolonged follow-up evaluation and to evaluate preventative strategies are needed.

Characterisation of bacteria in ascites--reporting the potential of culture-independent, molecular analysis

Spontaneous bacterial peritonitis (SBP) is a severe complication of liver disease. A significant proportion of patients have culture-negative ascites, despite having similar signs, symptoms and mortality to those with SBP. Therefore, empirical antibiotic treatment for infection is often started without knowledge of the causative organisms. Here, we investigated the potential of molecular techniques to provide rapid and accurate characterisation of the bacteria present in ascitic fluid. Ascites samples were obtained from 29 cirrhotic patients undergoing clinically indicated therapeutic paracentesis. Bacterial content was determined by terminal restriction fragment length polymorphism (T-RFLP) analysis, quantitative polymerase chain reaction (PCR) and 16S ribosomal clone sequence analysis. Bacterial signal was detected in all samples, compared to three out of ten using standard methods. Bacterial loads ranged from 5.5 x 10(2) to 5.4 x 10(7) cfu/ml, with a mean value of 1.9 x 10(6) cfu/ml (standard deviation +/- 9.6 x 10(6) cfu/ml). In all but one instance, bacterial species identified by culture were also confirmed by molecular analyses. Preliminary data presented here suggests that culture-independent, molecular analyses could provide rapid characterisation of the bacterial content of ascites fluid, providing a basis for the investigation of SBP development and allowing early and targeted antibiotic intervention.

Role of host and bacterial virulence factors in Escherichia coli spontaneous bacterial peritonitis

OBJECTIVES

Host factors and bacterial virulence determinants may play a role in Escherichia coli (E. coli) spontaneous bacterial peritonitis. We evaluated the importance of these factors in the emergence of fluoroquinolone-resistant strains and outcome in cirrhotic patients with E. coli spontaneous bacterial peritonitis.

METHODS

E. coli spontaneous bacterial peritonitis was detected in a 2-year period in three tertiary hospitals. Clinical and bacteriological data were obtained. Phylogenetic group and 15 virulence genes of E. coli strains were analyzed by polymerase gene reaction and compared with 50 isolates from pyelonephritis patients.

RESULTS

Forty-seven E. coli spontaneous bacterial peritonitis patients were identified, 18 (38%) were fluoroquinolone-resistant, a 12% increase compared with our earlier series from 1997 to 2002. Fluoroquinolone resistance was associated with norfloxacin prophylaxis, increased resistance to trimethoprim-sulfamethoxazole and cefotaxime, and less bacterial virulence, as demonstrated by a higher prevalence of 'nonpathogenic' phylogenetic groups A+B1 (56 vs. 28%; P=0.04) and lower virulence scores in fluoroquinolone-resistant E. coli compared with fluoroquinolone-susceptible E. coli. E. coli strains from cirrhotic patients belonged more frequently to 'nonpathogenic' phylogenetic groups A+B1, had fewer virulence factors and higher rates of fluoroquinolone resistance than isolates from pyelonephytis patients. Immunosuppression was independently associated with in-hospital and 3-month mortality. Bacterial virulence factors were unrelated to mortality.

CONCLUSION

Fluoroquinolone-resistant E. coli spontaneous bacterial peritonitis prevalence is increasing because of norfloxacin prophylaxis. Strains from peritonitis are less virulent than strains from pyelonephritis because of a higher prevalence of A+B1 phylogeny and quinolone resistance. Mortality is related to immunosuppression, but not to bacterial virulence factors.

[Early diagnosis of liver cancer]

Hepatocellular carcinoma is a frequent neoplasm that usually develops in patients with liver cirrhosis. Because it is the main cause of death in these patients, they should be included in a surveillance program in order to identify these tumors at an early stage and be able to indicate curative treatment (liver transplantation, surgical resection or percutaneous ablation therapy) and to reduce mortality. Surveillance should include determination of alpha-fetoprotein and abdominal ultrasound every 6 months. This strategy should only be applied to patients suitable to receive curative treatment if diagnosed of hepatocellular carcinoma. Using this approach, 40-80% of tumors identified are solitary at diagnosis, although only half of these patients can benefit from curative treatment.

Long-term clinical outcome of large volume paracentesis with intravenous albumin in patients with spontaneous bacterial peritonitis: a randomized prospective study

BACKGROUND AND AIM

Large volume paracentesis (LVP) with plasma volume expansion has been used for tense or refractory ascites. However, still in question is whether it is safe and effective for the treatment of spontaneous bacterial peritonitis (SBP). We addressed this issue and conducted a study to assess safety and long-term outcome of LVP in cirrhotic patients with SBP.

METHODS

Forty-two randomly assigned cirrhotic patients with SBP were classified into two groups; Group 1 included 21 patients who were treated with LVP and intravenous albumin; and Group 2 included 21 patients who were treated with diuretics and intravenous albumin.

RESULTS

The overall cumulative survival rate was poor in patients with SBP (42.5% and 22.5% at 6 and 12 months, respectively). At 7 days after treatment, the blood tests were similar between the two groups. In the ascitic fluid, the white blood cell counts decreased significantly and the protein concentrations tended to increase in both groups. In-hospital days, resolution rate of SBP, and in-hospital mortality rate were similar between the two groups. Although complication rates tended to be slightly higher in Group 1, long-term cumulative survivals were similar between Group 1 and Group 2. LVP was effective in removing abdominal discomfort in patients with tense ascites without serious complication.

CONCLUSIONS

LVP with intravenous albumin was as effective as diuretics with intravenous albumin for the treatment of SBP with similar mortality. LVP with intravenous albumin might be feasible for the treatment of tense or refractory ascites in cirrhotic patients with SBP.

Staging systems in hepatocellular carcinoma

Staging systems are key to predict the prognosis of patients with cancer, to stratify the patients according to prognostic variables in the setting of clinical trials, to allow the exchange of information among researchers, and finally to guide the therapeutic approach. The current knowledge of the disease, however, prevents recommendation of a staging system that can be used world-wide. The conventional staging systems for hepatocellular carcinoma (HCC), such as the Okuda stage or the TNM stage have shown important limitations in classifying patients. Several new systems have been proposed recently, and only three of them have been validated at this point. The BCLC staging classification links the stage of the disease to a specific treatment strategy. The JIS score has been proposed and used in Japan, although it needs Western validation. The CLIP score is used in patients with advanced tumors. Several reasons explain the difficulty in identifying a world-wide system. First, HCC is a complex neoplasm inserted on a pre-neoplastic cirrhotic liver, and thus variables of both diseases leading to death should be taken into account. Second, the disease is very heterogeneous around the world, and this reflects different underlying epidemiological backgrounds and risk factors. Third, HCC is the sole cancer treated by transplantation in a small proportion of patients. Fourth, only around 20% of the cases are currently treated by surgery, thus precluding the wide use of pathology-based systems, such as TNM. Finally, the potential relevance of a molecular signature identified in terms of outcome prediction is unknown, and further research is needed to obtain this valuable biological information that may aid in classifying the patients.

Nitric oxide and renal function in cirrhotic patients with ascites: from physiopathology to practice

Patients with cirrhosis and ascites show systemic and splanchnic arterial vasodilation, which causes a reduction in effective arterial blood volume and the activation of hormonal anti-natriuretic systems. Renal impairment is the most important predictor of hospital mortality in cirrhotic patients with SBP. In patients with SBP, the inflammatory response to the infection (TNF-alpha, IL-6) may be an important mechanism of renal dysfunction. Ascitic-fluid NO metabolites are related independently to the development of renal impairment. Treatment of SBP with intravenous albumin in addition to cefotaxime prevents renal impairment and reduces mortality in comparison with treatment with cefotaxime alone. As soon as ascites develops, liver transplantation should be considered in eligible patients, especially when local mean waiting times exceed life expectancy. Nitric oxide (NO), tumour necrosis factor alpha (TNF-alpha) and interleukin-6 (IL-6) have been implicated in the pathogenesis of circulatory alterations observed in cirrhotic patients with ascites. Kidney failure is one of the main factors associated with mortality in patients with end-stage liver disease developing complications, particularly severe infections and variceal haemorrhage. Renal impairment occurs in patients with the highest concentration of cytokines in plasma and ascitic fluid and is associated with marked activation of the renin-angiotensin system. In patients with spontaneous bacterial peritonitis (SBP), serum and ascitic fluid levels of NO metabolites (nitrites and nitrates) were higher than those of patients with sterile ascites, and renal impairment is considered to be caused by a decrease in effective arterial blood volume as a result of the infection. The administration of albumin prevents deterioration of renal function and reduces mortality in these patients. However, SBP and renal dysfunction are late complications in the course of liver cirrhosis. As soon as ascites develops, liver transplantation should be considered in eligible patients, especially when local mean waiting times exceed life expectancy. A better knowledge of metabolic disorders associated with the early stage of cirrhosis is essential for the development of optimal therapeutic strategies for the prophylaxis and treatment of portal hypertension and its complications.

Hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cause of cancer, and its incidence is increasing worldwide because of the dissemination of hepatitis B and C virus infection. Patients with cirrhosis are at the highest risk and should be monitored every 6 months. Surveillance can lead to diagnosis at early stages, when the tumour might be curable by resection, liver transplantation, or percutaneous treatment. In the West and Japan, these treatments can be applied to 30% of patients, and result in 5-year survival rates higher than 50%. Resection is indicated among patients who have one tumour and well-preserved liver function. Liver transplantation benefits patients who have decompensated cirrhosis and one tumour smaller than 5 cm or three nodules smaller than 3 cm, but donor shortage greatly limits its applicability. This difficulty might be overcome by living donation. Most HCC patients are diagnosed at advanced stages and receive palliative treatments, which have been assessed in the setting of 63 randomised controlled trials during the past 25 years. Meta-analysis shows that only chemoembolisation improves survival in well-selected patients with unresectable HCC.

Gray-scale ultrasound in hepatic cirrhosis and chronic hepatitis: diagnosis, screening, and intervention

Chronic hepatitis and hepatic cirrhosis are pathologies with high prevalence in the world population. Ultrasound (US) allows for a quick and precise examination of the liver parenchyma, the vascular structures, the biliary tract, and the abdominal cavity. Changes can be detected in the pattern of liver echostructure that suggest the presence of chronic liver disease, portal hypertension, and the presence of liver tumors. Moreover, US guidance provides an easy way for performing interventional procedures, such as biopsies for classifying the degree and type of liver disease, biopsies of focal liver lesions, and the application of percutaneous treatments for hepatocellular carcinoma (HCC). In this article we discuss the multiple applications of US in the management of patients with chronic liver disease.

Early diagnosis and treatment of hepatocellular carcinoma

The incidence of hepatocellular carcinoma is increasing world-wide. Although there are no randomized controlled trials showing benefits from surveillance programmes, these strategies have been widely practised by hepatologists, and most early tumours are diagnosed in the setting of such a policy. In this chapter we summarize the surveillance schedule and recall the policy applied in our Unit. Diagnosis at an early stage is crucial to allow the application of curative treatments that are the only hope for increasing the life expectancy of the patient. Surgical resection and liver transplantation are considered the first-line options for early tumours, although there is no agreement on which is the best approach. Resection is limited by the high recurrence rate, whereas the increasing waiting times have decreased the intention-to-treat outcomes of transplantation. Percutaneous treatments are reserved for patients with single non-surgical tumours. Clinical trials assessing treatments for patients with advanced tumours have not shown any survival benefits.