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Risk stratification of spontaneous bacterial peritonitis in cirrhosis with ascites based on classification and regression tree analysis

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Abstract

Risk stratification for spontaneous bacterial peritonitis (SBP) in patients with cirrhosis and ascites helps guide care. Existing prediction models, such as end-stage liver disease (MELD) score, are accurate but controversial in clinical practice. We developed and validated a practical user-friendly bedside tool for SBP risk stratification of patients with cirrhosis and ascites. Using classification and regression tree (CART) analysis, a model was developed for prediction of SBP in cirrhosis with ascites. The CART model was derived on data collected from 676 patients admitted from January 2007 to December 2009 retrospectively, and then was prospectively tested in another independent 198 inpatients between January 2010 and December 2010. The accuracy of CART model was evaluated using the area under the receiver operating characteristic curve. The performance of the model was further validated by comparing its predictive accuracy with that of the MELD score. Furthermore, the model was used to stratify SBP among patients with MELD scores under 15. CART analysis identified four variables for prediction of SBP: creatinine, total bilirubin, prothrombin time and white blood cell count, and three risk groups: low (2.0%), intermediate (27.5–33.3%) and high (60.6–86.4%) risk. The accuracy of CART model (0.881) exceeded that of MELD (0.791). Subjects in the intermediate risk and high risk groups had 22.21-fold (95% confident interval (CI), 9.98–49.45) and 173.50-fold (95% CI, 77.68–634.33) increased risk of SBP, respectively, comparing with the low risk group. Similar results were found when this risk stratification was applied to the validation cohort. Cirrhotic patients with ascites at low, intermediate, and high risk for SBP can be easily identified using CART model, which provides clinicians with a validated, practical bedside tool for SBP risk stratification.

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Abbreviations

A/G:

Albumin/globulin ratio

AKP:

Alkaline phosphatase

ALT:

Alanine aminotransferase

AST:

Aspartate aminotransferase

AUROC:

Area under the receiver operating characteristic curve

CART:

Classification and regression tree

CI:

Confident interval

GGT:

γ-Glutamyltransferase

HBV:

Hepatitis B virus

HE:

Hepatic encephalopathy

INR:

International normalized ratio

MELD:

Model of end-stage liver disease

OR:

Odds ratio

PT:

Prothrombin time

s:

Second

SBP:

Spontaneous bacterial peritonitis

Scr:

Serum creatinine

TB:

Total bilirubin

WBC:

White blood cell

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Acknowledgments

This work was supported by grants from the Scientific Research Foundation of Wenzhou, Zhejiang Province, China (H20090014, Y20090269), Health Bureau of Zhejiang Province (2010KYB070), Research Foundation of Education Bureau of Zhejiang Province (Y201009942) Natural Science Foundation of Shandong Province (ZR2010HQ040), Independent Innovation Foundation of Shandong University (IIFSDU, 2010TS013) and Project of New Century 551 Talent Nurturing in Wenzhou.

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No conflicts of interest exist.

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Authors and Affiliations

  1. Department of Infection and Liver Diseases, Liver Research Center, The First Affiliated Hospital of Wenzhou Medical College, No. 2 Fuxue Lane, Wenzhou, 325000, China

    Ke-Qing Shi, Xian-Feng Lin, Mei Song, Ling-Fei Li, Xie-Yan Yu, Yong-Ping Chen & Ming-Hua Zheng

  2. Department of Hepatology, Qilu Hospital of Shandong University, Jinan, 250012, China

    Yu-Chen Fan

  3. Department of Ultrasonography, The First Affiliated Hospital of Wenzhou Medical College, Wenzhou, 325000, China

    Li Ying

  4. School of the First Clinical Medical Sciences, Wenzhou Medical College, Wenzhou, 325000, China

    Xian-Feng Lin, Ling-Fei Li & Xie-Yan Yu

  5. Institute of Hepatology, Wenzhou Medical College, Wenzhou, 325000, China

    Ke-Qing Shi, Mei Song, Yong-Ping Chen & Ming-Hua Zheng

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  1. Ke-Qing Shi
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  2. Yu-Chen Fan
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  9. Ming-Hua Zheng
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Correspondence to Ming-Hua Zheng.

Additional information

K.-Q. Shi and Y.-C. Fan are co-first author.

Electronic supplementary material

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Supplementary Table 1

Subgroup analysis of the patients with the MELD score (DOC 28 kb)

Supplementary Fig. 1

Predictors of SBP and risk stratification for the validation cohort. Terminal subgroups of patients discriminated by the analysis were numbered from one to six. PT prothrombin time, SBP spontaneous bacterial peritonitis, Scr serum creatinine, TB total bilirubine, WBC white blood cell (TIFF 976 kb)

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Shi, KQ., Fan, YC., Ying, L. et al. Risk stratification of spontaneous bacterial peritonitis in cirrhosis with ascites based on classification and regression tree analysis. Mol Biol Rep 39, 6161–6169 (2012). https://doi.org/10.1007/s11033-011-1432-8

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  • DOI: https://doi.org/10.1007/s11033-011-1432-8

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