# Increased Mortality with Intermediate Ascitic Polymorphonuclear Cell Counts Amongst Patients with Cirrhosis: Time to Redefine the Care Approach

## TL;DR

Patients with cirrhosis and intermediate levels of certain cells in their abdominal fluid have higher mortality rates, suggesting current diagnostic thresholds may need reevaluation.

## Contribution

The study identifies intermediate ascitic polymorphonuclear cell counts as a significant mortality risk factor, challenging current SBP diagnostic criteria.

## Key findings

- Intermediate A-PMN counts (51–249 cells/HPF) were linked to higher 90- and 365-day mortality risks.
- Low ascitic albumin levels independently increased 365-day mortality risk.
- Binary thresholds for diagnosing SBP may not fully capture mortality risk in cirrhotic patients.

## Abstract

Background: Spontaneous bacterial peritonitis (SBP) is a serious complication in patients with decompensated cirrhosis and ascites. Diagnosis typically relies on an ascitic polymorphonuclear (A-PMN) cell count ≥ 250 cells/high-power field (HPF). Methods: In this retrospective cohort study, 117 hospitalized patients with acute decompensation of chronic liver disease and a diagnostic paracentesis were evaluated. Clinical, laboratory, and imaging data were collected. Patients were stratified by A-PMN counts of ≤50, 51–249, or ≥250 cells/HPF. Additional analysis was performed with patients stratified by ascitic white blood cell (WBC) count and albumin. Mortality risk was assessed at 28, 90, and 365 days. Results: Patients with A-PMN ≤ 50 cells/HPF had the lowest 28-day mortality (8%). At 90 and 365 days, mortality risk was significantly higher for the A-PMN 51–249 cells/HPF group (90-day hazard ratio (HR) 3.55, p = 0.01; 365-day HR 2.43, p = 0.02), but not A-PMN ≥ 250 cells/HPF group (90-day HR 2.95, p = 0.1; 365-day HR 2.95, p = 0.2). Ascitic WBC count did not significantly predict mortality, though higher counts were associated with extraperitoneal infections. Ascitic fluid albumin ≤ 1.0 g/dL was independently associated with increased 365-day mortality (HR 3.53, p = 0.03). Conclusions: Binary SBP A-PMN thresholds may not adequately capture mortality risk in cirrhotic patients with ascites. Low ascitic albumin and intermediate A-PMN counts are associated with increased long-term mortality, suggesting the need for more nuanced diagnostic and prognostic criteria in SBP evaluation.