Risk factors, clinical features, and short-term prognosis of spontaneous fungal peritonitis in cirrhosis: A matched case-control study

doi:10.12998/wjcc.v7.i17.2438

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World Journal of Clinical Cases

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World J Clin Cases. Sep 6, 2019; 7(17): 2438-2449
Published online Sep 6, 2019. doi: 10.12998/wjcc.v7.i17.2438

Table 1 Comparison of clinical manifestations between spontaneous fungal peritonitis (case) and spontaneous bacteria peritonitis with a positive (control-1) or negative bacterial culture (control-2)

Variable	Case (n = 22)	Control-1 (n = 44)	P-value	Control-2 (n = 72)	P-value
Demographics data
Age (yr), M ± SD	60.0 ± 11.6	58.0 ± 12.5	0.55	56.9 ± 10.5	0.32
Sex (% male)	17 (77.3%)	37 (82.2%)	0.51	55 (74.3%)	1
Current smoking n (%)	7 (31.8%)	20 (45.5%)	0.43	32 (44.4%)	0.33
Alcohol abuse n (%)	7 (31.8%)	16 (36.4%)	0.79	30 (41.3%)	0.46
Aetiology of cirrhosis
Viral n (%)	14 (63.6%)	27 (61.4%)		44 (61.1%)
Alcohol n (%)	2 (9.1%)	8 (18.2%)	0.66	18 (25.0%)	0.334
Others n (%)	6 (27.3%)	9 (20.5%)		13 (18.1%)
Complication
Variceal bleeding n (%)	8 (36.4%)	6 (13.6%)	0.05	18 (25.0%)	0.41
Variceal bleeding n (%)	8 (36.4%)	6 (13.6%)	0.05	18 (25.0%)	0.41
Hepatorenal syndrome n (%)	8 (36.4%)	10 (22.7%)	0.26	9 (12.5%)	0.023
HE n (%)	8 (36.4%)	12 (27.3%)	0.57	14 (19.4%)	0.15
Charlson index (IQR)	4 (3.7-5.0)	4 (3.0-5.0)	0.46	3 (3-5)	0.007
Laboratory examination
WBC, 10⁹ cells/L (IQR)	11.7 (8.2-19.1)	5.6 (2.9-11.2)	0.001	6.2 (4.0-9.5)	<0.001
C-reactive protein, mg/L (IQR)	77.4 (55.9-138.2)	31.4 (14.7-50.6)	<0.001	22.7 (8.9-42.1)	<0.001
Creatinine, μmol/L (IQR)	98.0 (69.5-147.8)	86.0 (60.5-165.0)	0.75	81 (67.0-105.0)	0.228
Albumin, g/dL (M ± SD)	28.1 ± 4.1	26.6±7.5	0.41	29.8 ± 4.9	0.09
Total bilirubin, μmol/L(IQR)	103.5 (27.5-271.5)	85 (34.2-196.5)	0.96	59.5 (30.0-129.0)	0.51
INR (IQR)	1.40 (1.2-2.0)	1.6 (1.3-2.1)	0.37	1.5 (1.3-1.7)	0.56
Ascites PMN (IQR)	2550 (338-4700)	1800 (650-4500)	0.56	550 (302-1375)	0.004
Ascites albumin g/dL (M ± SD)	18.0±8.2	11.4 ± 7.3	0.002	13.1 ± 9.5	0.009
Clinical presentation
Abdominal pain	7 (31.8%)	17 (38.6%)	0.79	17 (23.6%)	0.578
Fever (T ≥ 38°C)	12 (54.5%)	22 (50.0%)	0.79	19 (26.4%)	0.02
Antibiotic treatment before peritonitis (d)	15.4 (3.8-24.8)	2 (0.3-10.0)	0.001	2 (0-8.0)	<0.001
PPI administration	8 (36.4%)	27 (61.4%)	0.07	43(59.7%)	0.086
Nosocomial infection	13 (59.1%)	30 (68.2%)	0.59	44 (61.1%)	1
ICU admission	1 (4.5%)	2 (4.5%)	1	1 (1.4%)	0.42
Septic shock n (%)	7 (31.8%)	8 (18.2%)	0.23	3 (4.2%)	0.001
SIRS n (%)	14 (63.6%)	20 (45.5%)	0.2	14 (19.4%)	<0.001
Concomitant bacterial infection	12 (54.5%)	13 (29.5%)	0.12	3 (4.2%)	<0.001
Blood infection	6 (27.2%)	9 (20.5%)	1	1 (1.4%)	<0.001
Pneumonia	3 (13.6%)	3 (6.8%)	0.39	2 (2.8%)	0.048
Bacterial peritonitis	9 (40.9%)	-	-	-	-
Other sites	1 (4.5%)	1 (2.3%)	-	1 (1.4%)	-
Severity score
SOFA (M ± SD)	7.1 ± 3.8	7.6 ± 4.7	0.65	5.2 ± 2.6	0.035
CLIF-SOFA	7.1 ± 3.4	8.1 ± 4.4	0.33	5.6 ± 3.0	0.048
APACHE II	7.6 ± 6.1	6.7 ± 5.4	0.58	3.0 ± 3.1	<0.001
MELD (IQR)	15.9 (7.5-25.2)	18.3 (9.3-25.9)	0.76	14.6 (9.7-20.3)	0.57
MELD-Na (IQR)	23.0 (10.4-35.1)	20.4 (9.7-31.1)	0.88	15.5 (10.1-25.0)	0.17
CTP (IQR)	11.0 (8-12.3)	11.5 (10.0-12.0)	0.39	10 (9.0-12.0)	0.48
15-d mortality	10 (45.1%)	9 (20.4%)	0.046	5 (6.9%)	<0.001

M: Mean; SD: Standard deviation; IQR: Interquartile range; HE: Hepatic encephalopathy; INR: International normalized rate; PMN: Polymorphonuclear neutrophil; ICU: Intensive care unit; PPI: Proton pump inhibitor; SIRS: Systemic inflammatory response; SOFA: Sequential organ failure assessment; CLIF-SOFA: Chronic liver failure-sequential organ failure assessment; APACHE II: Chronic liver failure-sequential organ failure assessment; MELD: Model for end-stage liver disease; CTP: Child-Turcotte-Pugh.

Table 2 Comparison of clinical manifestations between spontaneous fungal peritonitis and fungiascites

Variable	Total (n = 35)	SFP (n = 22)	Fungiascites (n = 13)	P-value
Antibiotic treatment before peritonitis (d)	12 (5.0-23.0)	15.4 (3.8-24.8)	12.0 (6.0-22.0)	0.8
Anti-fungal therapy	15 (42.9%)	8 (36.4%)	7 (53.8%)	0.48
Septic shock n (%)	8 (22.9%)	7 (31.8%)	1 (4.2%)	0.21
WBC, 10⁹ cells/L (IQR)	9.4 (5.6-18.1)	11.7 (8.2-19.1)	6.8 (3.6-12.0)	0.046
C-reactive protein, mg/L (IQR)	69.0 (33.3-110.5)	77.4 (55.9-138.2)	36.6 (13.4-72.1)	0.01
SIRS n (%)	19 (54.3%)	14 (63.6%)	5 (38.5%)	0.18
Fungus
Candida spp.	26 (74.2%)	18 (81.8%)	8 (61.5%)	-
Trichosporon	2 (5.7%)	1 (4.5%)	1 (7.6%)	-
Aspergillus	5 (14.3%)	3 (13.6%)	2 (15.3%)	-
Cryptococcus laurentii	2 (5.7%)	0 (0%)	2 (15.3%)	-
Severity score
SOFA (M ± SD)	6.8 ± 3.5	7.1 ± 3.8	5.2 ± 2.6	0.77
MELD (IQR)	14.7 (8.0-24.3)	15.9 (7.5-25.2)	14.2 (8.8-24.8)	0.92
CTP (IQR)	11.0 (9.0-12.0)	11.0 (8.0-12.3)	11.0 (9.0-11.5)	0.7
15-d mortality	13 (37.1%)	10 (45.1%)	3 (23.7%)	0.28

M: Mean; SD: Standard deviation; IQR: Interquartile range; SOFA: Sequential organ failure assessment; MELD: Model for end-stage liver disease; CTP: Child-Turcotte-Pugh.

Table 3 Risk factors for spontaneous fungal peritonitis as determined by univariate logistic regression analysis

Variable	Control-1 group (n = 44) vs Case group (n = 22)		Control-2 (n = 72) vs Case group (n = 22)
Variable	OR (95%CI)	P-value	OR (95%CI)	P-value
Variceal bleeding	3.619 (1.065-12.296)	0.039	1.71 (0.619-4.751)	0.3
Hepatorenal syndrome	1.943 (0.635-5.947)	0.245	4.00 (1.312-12.194)	0.015
HE	1.524 (0.511-4.546)	0.45	2.367 (0.831-6.742)	0.107
Charlson index	0.936 (0.682-1.284)	0.681	1.266 (0.911-1.759)	0.16
chemoradiotherapy	2.048 (0.122-34.370)	0.618	3.381 (0.203-56.396)	0.396
Alcohol abuse	0.817 (0.275-2.422)	0.715	0.657 (0.237-1.798)	0.41
Length of hospital stay (d)	0.974 (0.944-1.004)	0.092	0.997 (0.969-1.035)	0.874
Antibiotic treatment before diagnosis (d)	1.063 (1.012-1.115)	0.014	1.054 (1.014-1.096)	0.008
PPI administration	0.436 (0.153-1.239)	0.119	0.467 (0.177-1.234)	0.124
Child C grade	0.551 (0.173-1.755)	0.313	1.211 (0.438-3.352)	0.712
MELD score	0.988 (0.942-1.035)	0.603	1.025 (0.970-1.083)	0.38

HE: Hepatic encephalopathy; PPI: Proton pump inhibitor; MELD: Model for end-stage liver disease; OR: Odds ratio; CI: Confidence interval.

Table 4 Cox regression analyses of risk factors associated with 15-d mortality (dead: n = 13; alive: n = 22) in patients with spontaneous fungal peritonitis or fungiascites

	Univariate		Multivariate
	HR (95%CI)	P-value	HR (95%CI)	P-value
Age	0.959 (0.918-1.003)	0.066
Variceal bleeding	0.872 (0.285-2.666)	0.81
Hepatorenal syndrome	7.3 (2.216-24.435)	0.001	5.328 (1.050-18.900)	0.01
HE	2.654 (0.889-7.925)	0.08
Charlson index	1.155 (0.742-1.796)	0.523
WBC, 10⁹ cells/L	1.064 (1.009-1.122)	0.023	1.062 (0.933-1.137)	0.081
C-reactive protein, mg/L	1.003 (0.992-1.015)	0.564
INR	1.201 (0.520-2.776)	0.668
Total bilirubin, μmol/L	1.005 (1.003-1.008)	<0.001	1.005 (1.002-1.008)	0.002
Creatinine, μmol/L	1.010 (1.003-1.017)	0.005
Serum sodium, mmol/L	0.883 (0.814-0.958)	0.003	0.949 (0.867-1.039)	0.256
Concurrent bacterial infection	0.715 (0.240-2.129)	0.546
Anti-fungal therapy	0.758 (0.248-2.319)	0.627
SIRS	3.458 (0.948-12.611)	0.06
SOFA	1.305 (1.132-1.505)	<0.001
MELD	1.080 (1.021-1142)	0.008
CTP	1.727 (1.214-2.483)	0.002
APACHE II	1.113 (1.025-1.207)	0.01

HE: Hepatic encephalopathy; INR: International normalized rate; SIRS: Systemic inflammatory response; SOFA: Sequential organ failure assessment; APACHE II: Chronic liver failure-sequential organ failure assessment; MELD: Model for end-stage liver disease; CTP: Child-Turcotte-Pugh; OR: Odds ratio; CI: Confidence interval; HR: Hazard ratio.

Table 5 Performance of six prognostic scoring systems in predicting mortality in patients with spontaneous fungal peritonitis / fungiascites

Prognostic model	Auroc (95%CI)	Sensitivity (95%CI)	Specificity (95%CI)	Z score	P-value
SOFA	0.850 (0.707-0.993)	61.5 (31.8-86.1)	90.9 (70.8-98.9)
CLIF-SOFA	0.825 (0.686-0.964)	84.6 (54.6-98.1)	77.3 (54.6-92.2)	0.498	0.619
CTP	0.825 (0.675-0.975)	69.2 (38.6-90.9)	86.4 (65.1-97.1)	0.42	0.674
APPACHE II	0.722 (0.521-0.923)	61.5 (31.6-90.9)	86.4 (65.1-97.1)	1.335	0.182
MELD-Na	0.759 (0.556-0.962)	76.9 (46.2-95.0)	77.3 (54.6-92.2)	0.723	0.469
MELD	0.724 (0.514-0.934)	69.2 (38.6-90.9)	86.4 (65.1-97.1)	1.035	0.301
SIRS	0.680 (0.496-0.864)	76.9 (46.2-95.0)	59.1 (36.4-79.3)	1.429	0.153

SIRS: Systemic inflammatory response; SOFA: Sequential organ failure assessment; CLIF-SOFA: Chronic liver failure-sequential organ failure assessment; APACHE II: Chronic liver failure-sequential organ failure assessment; MELD: Model for end-stage liver disease; CTP: Child-Turcotte-Pugh.

Citation: Huang CH, Pang LT, Xu LC, Ge TT, Xu QM, Chen Z. Risk factors, clinical features, and short-term prognosis of spontaneous fungal peritonitis in cirrhosis: A matched case-control study. World J Clin Cases 2019; 7(17): 2438-2449
URL: https://www.wjgnet.com/2307-8960/full/v7/i17/2438.htm
DOI: https://dx.doi.org/10.12998/wjcc.v7.i17.2438