RELATIONSHIP BETWEEN ABSOLUTE LYMPHOCYTE COUNT AND ASCITES IN PATIENTS WITH LIVER CIRRHOSIS

Background: Cirrhosis is the final stage of liver disease characterized by fibrosis and irreversible nodule formation due to chronic inflammation. The most common liver cirrhosis complication is ascites, where pathological fluid accumulates in the peritoneal cavity. In cirrhosis, lymphocytes infiltrate the liver and contribute to stellate cell activation, differentiation, and the fibrogenic response. Many recent studies have not studied a relationship between the absolute lymphocyte count and ascites in liver cirrhosis. Therefore, it is important to investigate the relationship between lymphocytes and ascites in liver cirrhosis. Method: This is an observational study with a cross-sectional design study. Held in August–October 2022 at Dr. Doris Sylvanus Hospital's Medical Record Installation. 64 samples were selected based on inclusion and exclusion criteria. Meanwhile, absolute lymphocyte count were measured from the patient's blood tests or by calculation. Ascites was diagnosed by physical examination and radiology. The relationship between absolute lymphocyte count and ascites was analyzed using the chi-square test, with the results considered statistically significant when the p-value < 0.05. Result: The medical records from April 2019 to April 2022, there were 64 samples, of which 15 and 49 were without and with ascites. Based on the chi-square test results, there was a significant relationship between absolute lymphocyte count and the incidence of ascites, with p = 0.02. Conclusion: This study concluded that there is a relationship between absolute lymphocyte count and ascites in patients with liver cirrhosis, where absolute lymphocyte count tends to decrease.


INTRODUCTION
Ascites is a condition with an accumulation of pathological fluid in the peritoneal cavity.It is one of the most common complications of the liver, resulting in a critical developmental stage of cirrhosis, marked by a decompensated phase.2][3] Furthermore, cirrhosis is the last stage of liver disease, characterized by fibrosis and the creation of permanent nodules due to persistent inflammation, which is the 11 th world's leading cause of death, compared to 2000. 4 The liver comprises two main components, parenchymal and non-parenchymal cells.When chronic inflammation damages hepatocytes and forms fibrous tissue, which activates stellate cells, and lymphocytes infiltrating the liver.The continuation of this complication can cause damage, resulting in organ malfunction. 5,6Additionally, fibrous and nodular tissue can increase intrahepatic resistance to portal blood flow, which is the primary cause of ascites. 7esearch conducted by Li et al involved 174 patients with liver cirrhosis, with the most common complication ascites in 114 patients (65.5%).The study found that patients who did not survive showed higher neutrophil counts and lower lymphocyte counts than the surviving group.Lymphocyte levels in the blood of cirrhotic liver patients with ascites have also been studied by Romaneli et al, which is the first study to describe differences between lymphocyte subsets in ascitic fluid of patients with either hepatitis C virus (HCV) or alcoholic liver disease (ALD)-related cirrhosis.This study also examined the subset of lymphocytes present in blood and found no significant differences in ascitic fluid and peripheral blood samples. 8,9Researchers have yet to find many recent studies examining the relationship between absolute lymphocyte count in blood and ascites in liver cirrhosis.On that basis, the researcher wanted to know whether there is a relationship between lymphocytes and the incidence of ascites in liver cirrhosis so that it can be considered as a parameter in assisting the diagnosis of ascites in patients with liver cirrhosis.

METHOD
This study was conducted from August to October 2022 at the Dr. Doris Sylvanus Hospital's Medical Record Installation using analytic observational with a cross-sectional design study.All medical records of patients with liver cirrhosis and with or without ascites complications treated as outpatients or inpatients between April 2019 and 2022 were included in the population.Patients with liver cirrhosis, medical records, complete laboratory examination data, and liver cirrhosis of any etiology were included in the sampling, while patients with incomplete medical records were excluded.
Based on the operational definition, ascites is a complication of liver cirrhosis diagnosed on physical and radiological examinations from medical records.Meanwhile, absolute lymphocyte count is the value of the cell in blood circulation, based on the tests or calculations with the formula absolute lymphocyte count (ALC) = white blood cell count x relative lymphocyte count.

Relationship Between Absolute Lymphocyte Count And Ascites In Patients With Liver Cirrhosis
In statistical analysis, the chi-square test was used and Fisher's exact test was used when it failed to meet the parameters.Data analysis was performed using Windows's statistical package for social sciences (SPSS) software.

RESULT
In this research, 64 samples of record fulfilled the inclusion criteria.The majority of respondents came from the age group of 56-65 years, with 20 patients at 31.3% and 49 male patients at 76.6%, as well as abnormal absolute lymphocyte count of 33 at 51.6 %, and a history of hepatitis B with 53 patients at 82.8%.
From Table 3, there were 31 patients with normal absolute lymphocyte count values (1.0-4.8 x 10 3 /µL), consisting of 11 and 20 at 35.5% and 64.5% without and with ascites.In contrast, those with abnormal absolute lymphocyte count values (< 1.0 x 10 3 /µL) were 33, consisting of 4 and 9 at 12.1% and 87.9% without and with ascites.The relationship between the absolute lymphocyte count and the incidence of ascites in individuals with liver cirrhosis was found to be p = 0.02 (p < 0.05).As a result, there is a relationship between the absolute lymphocyte count and the incidence of ascites in patients with liver cirrhosis.
The absolute lymphocyte count in patients without and with ascites had a mean value of 1.38 ± 0.72 and 1.3 ± 0.72 and a median of 1.17 (0.51-2.66) and 1.05 (0.28-3.1), respectively.

DISCUSSION
In this research, most liver cirrhosis patients were 56-65 years old, and the highest frequency of ascites was found.This is in line with study by Vaz et al, involving 598 patients in Halland, Sweden, with the highest incidence in the 60-69 years range. 10Similarly, Sepanlou et al found that the number of compensated cases peaks at 45-49, 40-44, and 50-54 years in females, males, and both genders. 11Referring to the research by Wang et al, hepatitis B has the highest prevalence of 40-49 years and can develop liver cirrhosis in 10-20 years.Therefore, in the 50-69 age group, there will be many hepatitis patients with liver cirrhosis complications.In this research, 56-65 years has the highest frequency for liver cirrhosis patients. 12,13n older patients, the incidence decreases because victims have a lower life expectancy due to higher complications, resulting in liver changes that lead to death. 14Any sources have not explained the incidence of ascites in this age group.However, ascites is the most common complication due to portal hypertension.][17][18] Based on gender, male patients were higher than females, with 49 patients at 76.6%, and had the highest frequency of ascites, with 38 at 59.4%.This result is in line with the study conducted by Nababan et al, who analyzed 241 victims of decompensated cirrhosis, with a male predominance of 74.3%. 19Rubin et al further examined the effect of gender on the clinical description of hospitalized cirrhotic patients and found that ascites complications were commonly found in males. 20This research found that males dominate many cases of liver cirrhosis patients with a history of hepatitis, one of the common causes associated with etiology.It has a higher prevalence due to sex hormones on inflammatory cytokine release in the opposite ways because estrogen induces pro-inflammatory cytokines while androgens suppress the responses.Another research stated that after prophylactic vaccination against hepatitis B virus (HBV), males have lower antibodies than females, hence hepatitis tends to be higher.Liver cirrhosis is also higher in this gender due to higher-risk behaviors such as alcohol consumption. 11he result of absolute lymphocyte count value reported 29 patients with ascites at 45.3%.There was no research on the lymphocyte value in liver cirrhosis patients with ascites.Meanwhile, some research used a variable ratio of neutrophil lymphocytes. 17,21Chronic liver injury causes the generation of pro-inflammatory mediators and leukocyte infiltration, especially lymphocytes, in the subendothelial region.Interactions with endothelial cells stimulate lymphocyte recruitment from circulation, controlled by various chemokines.Through surface integrins, lymphocytes can interact with extracellular matrix components and endothelial cells during pathogenesis, contributing to cell activation, differentiation, and fibrogenic responses.Chemoattractant molecules attract lymphocytes to the injury site after moving through the endothelium via a complicated method.Myofibroblasts release lymphocyte migration-promoting cytokines such as IL-6, hepatocyte growth factor, and TGF-β.As a result, the value in the plasma may drop during fibrogenesis owing to liver infiltration. 6oncerning the history of hepatitis, 53, 2, and 9 patients at 82.8%, 3.1%, and 14.1% had a history of hepatitis B, C, and no history, respectively.Pravitasari et al found that out of 78 samples, 54 and 15 patients, 62.4% and 19.23% have a history of hepatitis B and C. 22 The high history is because this disease is the leading cause of cirrhosis.Hepatitis B was found to be higher because hepatitis B virus (HBV) is highly contagious and can be transmitted in more ways than other viruses. 23The hepatitis virus that replicates in hepatocytes induces hepatocyte cell death and inflammation in the liver.Chronic inflammation by HBV further causes hepatic stellate cell activation and differentiates into myofibroblasts, the main extracellular matrix that produces cells in the liver.Furthermore, increased extracellular matrix production results in hepatic fibrosis formation.Even though this fibrogenesis maintains tissue integrity, chronic fibrosis that persists can progress to liver cirrhosis. 24bsolute lymphocyte count and the incidence of ascites in patients with liver cirrhosis were significantly correlated, with p = 0.02 (p < 0.05).As a result, there is a relationship between the occurrence of ascites in patients and the absolute lymphocyte count.The immune response and the hepatic fibrotic process are closely related to cirrhosis.Hepatic fibrosis has been linked to T lymphocytes, including Th1, Th2, Th17, regulatory T cells, and mucosa-associated invariant T cells.These immune cells may be profibrotic or antifibrotic during fibrosis. 25,26eiss et al discovered that patients with acute chronic liver failure (ACLF) have dysregulation in systemic immune cells, including leukocytosis generated by neutrophils and monocyte subsets and decreased count associated with memory lymphocyte, CD8 T cell, and natural killer cell depletion.ACLF patients also developed decompensated cirrhosis. 27ow lymphocyte counts in the blood can also be produced by those in the liver, which plays a part in necroinflammatory processes.They get localized due to contact with endothelial cells, where numerous chemokines regulate the processes.Surface integrins allow lymphocytes to interact with extracellular matrix components and endothelial cells, promoting differentiation and the fibrogenic response. 6,28 robust innate immune response develops during the shift from compensated to decompensated states, boosting circulating neutrophils.Furthermore, neutrophils have a mechanism that inhibits lymphocyte production via arginase, nitric oxide synthase (NOS), and reactive oxygen species (ROS).It has a high arginase concentration in azurophilic granules, whereas T-cell activation depends on arginine availability in the body.The release of neutrophil arginase by degranulation or death reduces body arginine, which inhibits T-cell activation. 21A decrease in lymphocytes can be caused by spontaneous bacterial peritonitis in patients with ascites.Popoiag et al found a relationship between the neutrophil-lymphocyte ratio (NLR) and the incidence of painful bladder syndrome (PBS), where neutrophils and lymphocytes decreased, causing NLR to increase during PBS. 29

CONCLUSION
According to this study, there is a significant relationship between absolute lymphocyte count and the incidence of ascites in liver cirrhosis patients at Dr. Doris Sylvanus General Regional Hospital, with a value of p = 0.02 (p < 0.05).The absolute lymphocyte count tends to decrease in liver cirrhosis patients with ascites.
Further research is necessary to analyze the relationship between absolute lymphocyte count and liver diseases such as cirrhosis with larger samples and broader locations.Other variables, such as neutrophils and monocytes in blood and ascites fluid, are also recommended.