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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 34  |  Issue : 3  |  Page : 798-806

Evaluation of serum and ascitic monocyte chemotactic protein-1 level in patients with and without spontaneous bacterial peritonitis


1 Department of Internal Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Clinical Pathology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of Internal Medicine, El Sahel Teaching Hospital, Cairo, Egypt

Date of Submission13-May-2020
Date of Decision01-Jul-2020
Date of Acceptance06-Jul-2020
Date of Web Publication18-Oct-2021

Correspondence Address:
Mohamed E. Mohamed Abo Elenin
El Sahel Teaching Hospital, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_150_20

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  Abstract 


Objectives
To evaluate the diagnostic value of serum and ascitic fluid monocyte chemotactic protein-1 (MCP-1) level in cirrhotic patients with and without spontaneous bacterial peritonitis (SBP).
Background
SBP is one of the potential life-threatening complications in ascitic cirrhotic patients, with a mortality rate ranging between 30 and 50%.
Patients and methods
This study was conducted on 40 patients with cirrhotic ascites with and without SBP admitted to Internal Medicine Department, Menoufia University Hospital, and El Sahel Teaching Hospital from October 2017 to October 2018. All patients included in this study were divided into two groups as follows: group I included 10 ascitic patients without SBP, and group II included 30 ascitic patients with SBP.
Results
Mean level of MCP-1 was significantly higher in SBP group than non-SBP group. For MCP-1, the cutoff point that gives an area of 91% was 122.5 ng/ml, with sensitivity of 86% and of specificity 95%. For serum MCP-1, the cutoff point that gives an area of 91% was 100.5 ng/ml, with of sensitivity 85% and specificity of 94%. For polymorphonuclear cell count, the cutoff point that gives an area of 78% was 62.5 cell/cm3, with a sensitivity of 100% and specificity of 41%.
Conclusion
MCP-1 is a good diagnostic marker for SBP with its high sensitivity (86.7%) and specificity (95.4%) with high reliability (91%) in patients with SBP. Moreover, MCP-1 is a good prognostic marker owing to its positive relation with the severity of liver disease, which is indicated by high model for end-stage liver disease scores.

Keywords: bacterial peritonitis, cirrhotic ascites, prognostic marker, severity liver disease


How to cite this article:
Ellithy Elshayeb EI, Helwa MA, Elenin ME, Badr MH. Evaluation of serum and ascitic monocyte chemotactic protein-1 level in patients with and without spontaneous bacterial peritonitis. Menoufia Med J 2021;34:798-806

How to cite this URL:
Ellithy Elshayeb EI, Helwa MA, Elenin ME, Badr MH. Evaluation of serum and ascitic monocyte chemotactic protein-1 level in patients with and without spontaneous bacterial peritonitis. Menoufia Med J [serial online] 2021 [cited 2024 Mar 28];34:798-806. Available from: http://www.mmj.eg.net/text.asp?2021/34/3/798/328302




  Introduction Top


Spontaneous bacterial peritonitis (SBP) is the most frequent bacterial infection in cirrhosis, accounting for 10–30% of all reported bacterial infections in hospitalized patients [1],[2]. In-hospital mortality for the first episode of SBP ranges from 10 to 50%, depending on various risk factors [3]. One-year mortality after a first episode of SBP has been reported to be 31 and 93% [4]. In clinical practice, the diagnosis is based on a polymorphonuclear (PMN) cell count, which must be greater than or equal to 250 cell/mm3 in ascitic fluid in absence of intra-abdominal cause of infection [5],[6]. However, total leukocytic count (TLC) and PMN count in ascitic fluid are not always readily available, and the account of 250 cells/mm3 or more of PMN is highly indicative of SBP and is an indication for antibiotic therapy [7],[8]. Because inflammatory and immune reactions are altered by hepatic cirrhosis, the efficacy of innate reactions is limited. In these patients, spontaneous bacterial protein is recognized, and proinflammatory cytokines are released to the blood and ascites [9]. Monocyte chemotactic protein-1 (MCP-1) is produced by many cell types, including endothelial, fibroblasts, epithelial, smooth muscle, mesangial, astrocytic, monocytic, and microglial cells [10]. MCP-1 is the most representative member of α and β chemokines, respectively [11]. MCP-1 is a cytokine involved in the chemotaxis of monocytes and activated T lymphocytes, and interleukin-10 (IL-10) is an anti-inflammatory substance, and these compounds partially control the degree of inflammation by regulating the production of proinflammatory cytokines in SBP [9]. The aim of the present study was to evaluate the diagnostic value of serum and ascitic fluid MCP-1 level in cirrhotic patients with and without SBP.


  Patients and methods Top


This study was carried out at Internal Medicine Department, Menoufia University Hospital and El Sahel Teaching Hospital during October 2017 to October 2018. All patients (40) included in this study were divided into two groups as follows: group I included 10 ascitic patients without SBP, and group II included 30 ascitic patients with SBP.

Ethical consideration

The study was approved by the ethical committee of Menoufia Faculty of Medicine. An informed consent was obtained from all patients before the study was commenced.

Inclusion criteria

Cirrhotic patients with ascites fulfilling criteria of SBP (PMN leukocytes >250 and culture monomicrobial) not receiving antibiotics in last 1 week were included.

Exclusion criteria

Patients with ascites not owing to secondary bacterial peritonitis, ascites secondary to carcinomatosis, and tuberculous peritonitis and myxedema ascites were excluded.

All patients were subjected to the following: thorough history taking with particular attention to manifestations of liver cell failure, for example, jaundice, lower limb edema, deterioration of conscious level, and bleeding tendency; manifestations suggesting SBP, for example, fever, abdominal pain, and failure of ascites to respond to diuretic treatment; and history suggesting possible complications, for example, variceal bleeding, hepatic encephalopathy, and hepatorenal syndrome.

Full general and local examination was done, looking for signs of chronic liver disease, for example, jaundice, ascites, palmar erythema, spider naevi, liver size, spleen size, lower limb edema, and encephalopathy, and signs of SBP such as fever, hypotension, tachycardia, abdominal tenderness, and rebound tenderness.

Full investigations

Complete blood picture was obtained using Sysmex-xs-500i analyzer (Sysmex, Norderstedt, Germany). Renal function tests included serum creatinine using Cobas 6000 analyzer (Cobas, Cleveland, Ohio, USA). Liver profile included serum alanine aminotransferase (ALT), serum aspartate aminotransferase (AST), alkaline phosphatase, serum bilirubin (total and direct), serum total protein, and serum albumin using Cobas 6000 analyzer (Cobas). Prothrombin time and concentration and international normalized ratio (INR) were assessed using Sysmex CA-1500 analyzer (Sysmex). Serological tests for viral markers, such as hepatitis B surface antigen and hepatitis C virus antibody, were done using enzyme-linked immunosorbent assay technique (ELISA). Diagnostic abdominal paracentesis was done for patients with cirrhosis and ascites at admission and patients who develop symptoms or signs of SBP during hospitalization, that is fever, abdominal pain or changes in gastrointestinal motility (vomiting, diarrhea, or ileus).

The technique of paracentesis was explained to the patient, and it was done under aseptic precautions using a wide-bore needle. The needle was introduced in the right lower quadrant while the patient lies in supine position. 'Z Tracking' technique was used to avoid post-paracentesis leaks according to Webster et al.[12] and Arnold et al. [13].

This technique is accomplished by displacing (with one gloved hand) the skin ∼2 cm downward and then slowly inserting the paracentesis needle mounted on the syringe held in the other hand. The skin is not released until the needle has penetrated the peritoneum and fluid flows. The ascitic fluid was aspirated from each patient, and they were checked for biochemical tests, including total protein content, albumin, and glucose.

White blood cells (total and differential)

SBP is diagnosed when PMN count in ascitic fluid more than 250 cell/mm in the absence of data compatible with secondary peritonitis (i.e., gastrointestinal perforation).

Serum-ascites albumin gradient (SAAG) and serum albumin-ascitic fluid albumin were assessed.

MCP-1 level was assess using MCP-1 Human ELISA Kit (Invitrogen, Thermo Fisher Scientific Company, Waltham, Massachusetts, USA). Principle of the test: it was done by reagents for human MCP-1 ELISA BMS281. An anti-human MCP-1-coating antibody is adsorbed onto microwells. Human MCP-1 present in the sample binds to antibodies adsorbed to the microwells and the HRP-conjugated anti-human MCP-1 antibody is added and binds to human MCP-1 captured by the first antibody. Following incubation, unbound HRP-conjugated anti-human MCP-1 is removed during washing, and a substrate solution reactive with HRP is added to the wells. A colored product is formed in proportion to the amount of human MCP-1 present in the sample or standard. The reaction is terminated by addition of acid, and absorbance is measured at 450 nm. A standard curve is prepared from seven human MCP-1 standard dilutions and human MCP-1 concentration determined.

Modified Child–Pugh score [14]:

Child–Pugh classification is as follows: Child A: 5–6 points, Child B: 7–9 points, and Child C 10–15 points.

Model for end-stage liver disease (MELD) score: MELD score is calculated for every patient according to the following equation: 9.6 × loge (creatinine, mg/dl)+3.8 × loge (total bilirubin, mg/dl)+11.2 × loge (INR)+6.4.

Abdominal ultrasonography

Real-time abdominal ultrasonography was done for all patients and controls included in the study using TOSHIBA (Tokyo, Japan) ECCOCEE Machine (Netherlands), with a convex sector probe (PVF – 375 MT – 3.57 MHz) for evaluation of liver size, texture, border, reflectivity, homogeneity, periportal thickening, hepatic veins, and pattern. Assessment of focal lesion(s), regarding number, site, size, shape, echogenicity, halo sign, and neovascularization, was done by color Doppler. Assessment of portal vein, with respect to diameter, patency, direction of flow, respiratory variation, and velocity, was done by color Doppler. Spleen, with respect to size, splenic vein diameter, and collaterals, and presence of ascites and internal echoes were also assessed by ultrasonography.

Statistical analysis

Results were tabulated and statistically analyzed by using a personal computer using Microsoft Excel 2016 and SPSS v. 21 (SPSS Inc., Chicago, Illinois, USA). Statistical analysis was done using descriptive, for example, percentage, mean and SD, and analytical, which included χ2 and independent t test and receiver operating characteristic (ROC) curve analysis. A value of P less than 0.05 was considered statistically significant.


  Results Top


There was no statistically significant difference between the two groups regarding demographic data such as age, sex, residence, and occupational distribution; special habits concerning smoking and alcoholism; gastrointestinal bleeding; and disturbed level of consciousness. Moreover, cirrhotic patients with SBP mostly complained of abdominal pain (90%), whereas cirrhotic patients without SBP did not complain of abdominal pain (P < 0.001). Regarding the clinical examination of the studied patients, fever was predominant in cases with SBP. Moreover, there was no statistically significant difference between groups I and II regarding jaundice. All cases had ascites [Table 1]. There was no statistically significant difference between the two groups regarding the hemoglobin, red blood cells, white blood cells, fasting blood sugar, AST, alkaline phosphatase, and INR, but platelets were more deficient in group II than group I, with statistical significance. Moreover, the mean values of creatinine, bilirubin, albumin, and prothrombin time were significantly higher among cirrhotic patients with SBP than in the cirrhotic without SBP. However, the mean value of ALT was significantly lower in SBP group than in the non-SBP group [Table 2]. Moreover, there was no statistically significant difference between the two groups regarding anti-hepatitis C virus antibody and HBs Ag, albumin, total proteins, and hepatocellular carcinoma. Regarding ascitic fluid analysis of studied groups, the mean value of TLC and PMN cell count was significantly higher in SBP group than non-SBP group. However, the mean values of glucose and SAAG were significantly lower in SBP group than in non-SBP group. There were significant differences between the two groups regarding splenomegaly. Regarding serum and ascitic fluid analysis, the mean value of MCP-1 level was significantly higher in SBP group than non-SBP group. There is no statistically significant difference between the two groups regarding Child–Pugh classification. However, the mean values of MELD and MELD were significantly higher in group II than in group I [Table 3]. For MCP-1, the cutoff point that gives an area of 91% was 122.5 ng/ml with sensitivity 86% and specificity 95%. For serum MCP-1, the cutoff point that gives an area of 91% was 100.5 ng/ml with sensitivity 85% and specificity of 94% [Figure 1]. For PMN, the cutoff point that gives an area of 78% was 62.5 cell/cm3 with a sensitivity 100% and specificity 41%. [Table 4] and [Figure 2].
Table 1: Comparison between the studied groups regarding demographic data and clinical presentation

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Table 2: Comparison between the studied groups regarding laboratory investigations

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Table 3: Comparison between the studied groups regarding serologic hepatitis viral markers, ascitic fluid analysis, ultrasound findings, monocyte chemotactic protein-1 level, Child-Pugh score, and model for end-stage liver disease score

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Figure 1: ROC curve analysis for ascitic and serum MCP-1. MCP-1, monocyte chemotactic protein-1; ROC, receiver operating characteristic.

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Table 4: Receiver operating characteristic curve analysis for monocyte chemotactic protein-1 and polymorphonuclear as diagnostic markers for spontaneous bacterial peritonitis

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Figure 2: ROC curve analysis for PMN. PMN, polymorphonuclear; ROC, receiver operating characteristic.

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  Discussion Top


The present study revealed that SBP was more frequent in males, and it was not influenced by the age. These results were in agreement with the study done by Obstein et al. [15], in which 79% of SBP group were males and were not affected by the age. Regarding residence and occupation among both SBP and non-SBP groups, there was no significant statistical difference between them, and this agreed with Desai et al. [16], who found no difference between patients according to residence and occupation. Regarding the cause of liver cirrhosis in our study, we found that chronic hepatitis C was the cause in 90% of patients and chronic hepatitis B is the cause in the remainder (10% of patients), with no significant difference in both groups. This agreed with Strickland [17], who found that the cause of liver cirrhosis does not affect incidence of SBP. Analysis of the results showed that patients with SBP commonly presented by abdominal pain (100%), with a highly significant difference compared with non-SBP group (10%). However, McHutchinson and Runyon [18], Llovet et al. [19], Filik and Unal [20], and Wallerstedt et al.[21] stated that abdominal pain was detected in 50, 52, 54.5, and 70% of SBP cases, respectively.

In the present study, 20% of SBP cases had gastrointestinal bleeding, with no significant difference. This was close to that reported by Wallerstedt et al. [21], who stated that 30% of SBP cases had gastrointestinal bleeding. Hepatic encephalopathy was detected in 40% of SBP and 30% of non-SBP cases, with statistically nonsignificant difference. These results were close to that reported by Wallerstedt et al.[21] and Nobre et al. [3], who detected hepatic encephalopathy in 20 and 24.5% of SBP cases, respectively. This also agreed with Llovet et al. [19], who found hepatic encephalopathy was seen in 40% of SBP cases, and also this is was reported by Paul et al. [22], who found most patients with SBP have signs clearly suggestive of peritoneal infection, especially abdominal pain. In clinical examination of studied patients, fever was detected in 90% of SBP group with a highly statistically significant difference between both groups.

Regarding clinical examination of studied patients, jaundice was detected in 40% of SBP group. This agreed with Filik and Unal [20], who found that jaundice was the most prominent physical signs (54.5%) in SBP group, and also this goes in agreement with Paul et al. [22], who detected that jaundice was seen in 39% in patients with SBP. Laboratory investigations in this study revealed higher leukocyte count in patients with SBP. This agreed with Cholongitas et al. [23], as leukocytosis was higher in patients with SBP. Regarding platelets count, thrombocytopenia was higher in SBP group, with highly significant difference between both groups. This agreed with Lata and Pribramska [24], but this difference may not be related to SBP, rather to the severity of the liver disease. Regarding hemoglobin value in the studied patients, there was no difference between two groups, and this was documented by Coşkun et al. [25], but the hemoglobin value may be related to the severity of the liver disease, which was reported by Paul et al. [22].

In this study, serum creatinine was significantly increased in SBP group than in non-SBP group, and this was agreed with Angeloni et al. [26], who showed that the hospital mortality in SBP is high owing to hepatorenal syndrome, and it was also reinforced by Tsung et al. [27], who stated that renal dysfunction occurs in patients with SBP and it is an independent predictor of mortality. In this study, we found that serum bilirubin was significantly higher in cirrhotic patients with SBP. These results agree with Umgelter et al. [28], who found a high prevalence of disturbances in serum bilirubin. Moreover, Tsung et al.[27] reported that higher bilirubin level in patients with SBP showed higher recurrence and mortality.

In this study, we found that serum ALT was significantly higher in cirrhotic patients with SBP. These results agree with Coral et al. [29], who strongly suggested that liver function may be worsened by bacterial infection, and also goes in agreement with Ruiz-del-Arbol et al. [30], who found that patients with SBP frequently develop a rapidly progressive impairment in systemic hemodynamics, leading to severe hepatic failure. On the contrary, in our study, serum AST level had no significant difference between two groups. These results disagree with Coral et al. [29], who suggested that liver function may be worsened by bacterial infection and severity of liver disease. Regarding serum albumin level, in this study, there was a significant difference between two groups, as it was lower in levels in SBP group than in non-SBP group. These results agree with Ruiz-del-Arbol et al. [30], who found that patients with SBP frequently develop a rapidly progressive impairment in systemic hemodynamics, leading to severe hepatic failure. According to the prothrombin time, it was significantly prolonged in SBP group more than non-SBP group. These results agree with Umgelter et al. [28], who found a high prevalence of disturbance in prothrombin time among patients with SBP.

In this study, we found that higher levels of ascetic TLC and PMN count were observed in SBP group than non-SBP group. These results agree with Girón-González et al.[31] and Yildirim et al. [32], who reported higher ascitic TLC in SBP more than non-SBP group. Regarding ascitic fluid, total protein level showed no difference between the studied groups. This disagreed with Paul et al. [22], who denoted that patients with poor synthetic function have diminished level of protein in ascitic fluid, which correlated with low level of opsonization, and this plays a role in SBP susceptibility and denoted also total protein less than 1 g/dl is important predictor for SBP.

In this study, we found that the ascitic fluid glucose had lower level in patients with SBP, and this goes in agreement with Tsung et al. [27], who reported that lower level of ascitic glucose level in patients with SBP and also considered that lower ascitic glucose level was independent predictive factor of overall survival rates in cirrhotic patients with SBP. Regarding SAAG value, in our study, it was significantly higher in SBP group than non-SBP group, and these results agree with Desai et al. [16], who denoted that regardless of the severity of liver disease, those with lower ascitic fluid protein levels, lower ascitic albumin, and higher SAAG are also less likely to mount a satisfactory immune response and poor clearance of infection. Because inflammatory and immune reactions are altered by hepatic cirrhosis, the efficacy of innate reactions is limited. In these patients, spontaneous bacterial protein is recognized, and proinflammatory cytokines are released to the blood and ascites [9].

In this study, we found that serum and ascitic MCP-1 level was higher in patients with SBP than non-SBP cases. These results agree with Girón-González et al. [31], who mentioned that MCP-1 concentration is increasing in serum and ascitic fluid in patients with SBP and rapidly decreasing after treatment. Moreover, it was found that there were higher concentrations of serum and ascitic MCP-1 level in patients with SBP with highly statistical difference than non-SBP cases. Moreover, there was a significant positive correlation between serum and ascitic MCP-1 level and ascitic TLC and PMN among patients with SBP. Moreover, Kim et al.[9] mentioned that there is a positive association between serum and ascitic MCP-1 concentration and ascitic TLC and PMN. In the present study, ROC curve analysis of serum an ascitic MCP-1 as a marker of SBP of the studied cases revealed that a high MCP-1 was independently associated with a greater risk of SBP with cutoff level of 122.5 ng/ml with sensitivity 86.7% and specificity 95.4% in diagnosis of SBP with area under the curve 91. Moreover, patients with SBP had higher levels of MCP-1 in their serum and ascitic fluid than non-SBP cases, and its concentrations had decreased after treatment. The ultrasonographic examination in the present study detected no significant difference between both groups, except for splenomegaly, which was significantly higher in SBP group. This may be explained by the severity of liver disease and more decompensation than other group. This disagreed with Baker et al. [33], where spleen diameter has no significant relation between SBP and non-SBP groups.

Another study by Girón-González et al.[31] evaluated serum and ascitic fluid levels of chemokines (IL-8, growth-regulated oncogene, and MCP-1) in patients with SBP. They found that SBP was associated with significantly higher serum and ascitic fluid levels of IL-8, Gro-a, and ICAM-1 and with ascitic fluid concentrations of MCP-1.

In the present study, high MELD and uMELD scores were positively associated with a greater risk of incidence of SBP. These results agree with Obstein et al. [15], who suggested that MELD score was associated with SBP risk in a linear fashion, and also Evans et al. [34], who elicited that MELD score has been shown to be a good prognostic marker in cases of SBP.

In the present study, ROC curve analysis of PMN revealed that a higher PMN count of more than 250 cell/cm3 in patients with SBP at a cutoff level of 62.5 ng/ml had a sensitivity of 100% and specificity of 41% in the diagnosis of SBP, with area under the curve 78, so the PMN count of ascitic fluid can be used for the diagnosis of SBP but with low specificity. These results agree with Tsung et al. [27], who reported higher concentrations of PMN count in patients with SBP. Moreover, these results agree with Burri et al. [35], who reported higher concentrations of PMN count in patients with SBP. In this study, MCP-1 and PMN were significantly determining predictors for SBP positivity. These results agree with Lutz et al. [36], who stated that there was a higher level of MCP-1 in both serum and ascitic fluid of cirrhotic patients with SBP than non-SBP cases.


  Conclusion Top


We concluded that MCP-1 is a good diagnostic marker for SBP, as it has high sensitivity (86.7%) and specificity (95.4%) with reliability of 91% in patients with SBP. Moreover, MCP-1 is a good marker owing to its positive relation with the severity of liver disease, which is indicated by high MELD and uMELD scores.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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