Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.
Centre for Information Management (ZIMT), Hannover Medical School, Hannover, Germany.
PLoS One. 2019 Aug 2;14(8):e0220666. doi: 10.1371/journal.pone.0220666. eCollection 2019.
BACKGROUND & AIMS: Bacterial infections, in particular a spontaneous bacterial peritonitis (SBP), are a major threat in patients with liver cirrhosis. Recently, it has been shown that the impact on mortality might be underestimated by established risk-scores. Onset of infection was suggested to define a distinct stage of cirrhosis. However, it remains unclear whether all stages of decompensated cirrhosis are equally affected. Moreover, if there is such a distinct stage, it must be determined whether it is reversible after the infection has resolved. In this study we aimed to further analyze the impact of a current as well as a resolved SBP in different stages of decompensated liver cirrhosis.
A number of 579 patients with liver cirrhosis and ascites were included. MELD-score was used to determine the stage of liver disease. Low (<15), intermediate (15-25) and high (>25) MELD-groups were compared. Patients were followed up for 90 days. Primary endpoint was overall mortality. Statistical analyses were performed using the log-rank test, Cox regression and competing risk analysis.
Mortality was significantly higher in patients with nosocomial-acquired SBP (nSBP) compared to patients without SBP (p<0.001;HR = 2.05). However, the most prominent difference in mortality was documented in the intermediate MELD-group (nSBP: p = 0.02;HR = 2.10). Importantly, mortality in nSBP patients remained increased even after the initial nSBP episode had resolved (p<0.01;HR = 1.90). Again, this was only significant in those with intermediate MELD-scores (p = 0.02;HR = 2.28). While a current as well as a resolved nSBP were significantly linked to a higher mortality, neither of them did increase the likelihood for liver transplantation.
Development of nSBP is independently associated with increased mortality supporting the concept of a distinct status of cirrhosis. Importantly, the prognosis remains unfavorable even after resolution of nSBP. This could be particularly relevant for patients with intermediate MELD-scores, who have limited chances for a donor liver.
细菌感染，尤其是自发性细菌性腹膜炎（SBP），是肝硬化患者的主要威胁。最近，已经表明，现有的风险评分可能低估了对死亡率的影响。感染的发生被认为定义了肝硬化的一个独特阶段。然而，目前尚不清楚失代偿期肝硬化的所有阶段是否受到同等影响。此外，如果存在这样一个独特的阶段，就必须确定在感染得到解决后是否可以逆转。在这项研究中，我们旨在进一步分析当前和已解决的 SBP 在失代偿期肝硬化不同阶段的影响。
共纳入 579 例肝硬化合并腹水患者。采用 MELD 评分确定肝病分期。比较低（<15）、中（15-25）和高（>25）MELD 组。患者随访 90 天。主要终点为全因死亡率。采用对数秩检验、Cox 回归和竞争风险分析进行统计学分析。
与无 SBP 患者相比，医院获得性 SBP（nSBP）患者的死亡率显著升高（p<0.001；HR=2.05）。然而，在中 MELD 组，死亡率的差异最为显著（nSBP：p=0.02；HR=2.10）。重要的是，即使在初始 nSBP 发作得到解决后，nSBP 患者的死亡率仍持续升高（p<0.01；HR=1.90）。同样，这仅在中 MELD 评分患者中具有统计学意义（p=0.02；HR=2.28）。虽然当前和已解决的 nSBP 与更高的死亡率显著相关，但它们都不会增加肝移植的可能性。
nSBP 的发生与死亡率的增加独立相关，支持肝硬化存在独特状态的概念。重要的是，即使 nSBP 得到解决，预后仍不佳。对于中 MELD 评分的患者来说，这可能尤为重要，因为他们获得供体肝脏的机会有限。
