A case of severe hypoalbuminemia associated with chronic congestive heart failure: the role of the tricuspid regurgitation

Hypoalbuminemia is considered an independent predictor of mortality, especially in elderly patients. It is common in patients with congestive heart failure, when is due to several mechanisms: increased volume of distribution, significant stasis in the mesenteric circulation and altered protein metabolism in the liver. These alterations are even more pregnant when tricuspid regurgitation is associated or aggravated by different risk factors (recent infections, anemia, hyperthyroidism). We present the case of an elderly patient with severe hypoproteinemia and important hypoalbuminemia associated with congestive heart failure and aggravation of tricuspid regurgitation. The differential diagnosis concluded that hypoalbuminemia was influenced by tricuspid regurgitation as it enhanced liver dysfunction and enteral protein absorption due to increased stasis in mesenteric system. On the other hand, hypoalbuminemia contributed to the progression of heart failure by favoring myocardial edema, volume overload, and diuretic resistance. This is why correct management of this situation should include removal of subclinical excess of fluid and renutrition. A multidisciplinary approach is needed in order to achieve a good control of the symptoms and a significant improvement of quality of life.

Clinical indications for the albumin use: still a controversial issue

Human serum albumin (HSA) is the most abundant circulating protein and accounts for about 70% of the plasma colloid osmotic pressure. Beside the well known capacity to act as plasma-expander, HSA is provided of many other properties which are unrelated to the regulation of fluid compartmentalization, including binding and transport of many endogenous and exogenous substances, antioxidant function, immuno-modulation, anti-inflammatory activity, and endothelial stabilization. Treatment (hepatorenal syndrome) or prevention (renal failure after spontaneous bacterial peritonitis and post-paracentesis circulatory dysfunction after large volume paracentesis) of severe clinical complications in patients with cirrhosis and fluid resuscitation in critically ill patients, when crystalloids and non-proteic colloids are not effective or contra-indicated, represents the major evidence-based clinical indications for HSA administration. However, a large proportion of HSA prescription is inappropriate. Despite the existence of solid data against a real benefit, HSA is still given for nutritional interventions or for correcting hypoalbuminemia per se (without hypovolemia). Other clinical uses for HSA administration not supported by definitive scientific evidence are long-term treatment of ascites, nephrotic syndrome, pancreatitis, abdominal surgery, acute distress respiratory syndrome, cerebral ischemia, and enteric diseases. HSA prescription should be not uncritically restricted. Enforcement of clinical practice recommendations has been shown to allow a more liberal use for indications supported by strong scientific data and to avoid the futile administration in settings where there is a lack of clinical evidence of efficacy. As a result, a more appropriate HSA use can be achieved maintaining the health care expenditure under control.

Pre-operative hypoalbuminemia in colorectal cancer patients undergoing elective surgery - a major risk factor for postoperative outcome

BACKGROUND

The incidence of hypoalbuminemia in surgical patients varies in different studies with age, tumor stage, time interval to the first referral to a doctor, symptoms of disease and nutritional habits of the population. The main objective of this study was to evaluate the incidence of hypoalbuminemia in colorectal cancer patients undergoing scheduled surgery in an academic hospital in Romania and the impact of hypoalbuminemia on perioperative outcome. The secondary objective was to identify other possible risk factors for the post operative outcome.

MATERIAL AND METHODS

252 patients undergoing scheduled colorectal surgery with anastomosis have been enrolled in the study. Incidence of hypoalbuminemia (serum albumin 3.5 g dL), fistulas and other postoperative complications (e.g.infections) has been evaluated. LOS and 30-days mortality have also been evaluated comparatively in patients with normal and low serum albumin.

RESULTS

28.9% of our patients were hypoalbuminemic. The incidence of fistulas was 5.5 % in the study group and 2.3% and 13.3% in patients with normal serum albumin and hypoalbuminemic patients, respectively (p=0.001). Multivariate analysis showed that the OR was 6.65 [95% CI:2.01-21.96] inpatients with moderate hypoalbuminemia and 24.75 [95% CI:6.75-90.67] in patients with severe hypoalbuminemia.Association between alcohol consumption and smoking increased risk ratio to 1.96 [95% CI: 0.51-7.46].

CONCLUSION

The high incidence of hypoalbuminemia in our patients justifies preoperative nutritional interventions and specific surgical protocols in emergency cases. Further studies are needed to exactly quantify the impact of smoking and alcohol consumption on postoperative outcome.

Thromboembolism in childhood nephrotic syndrome: A rare but serious complication

The main clinical features of nephrotic syndrome (NS) are heavy proteinuria, hypoalbuminemia, hyperlipidemia and edema. In addition, multiple abnormalities in the coagulation pathway may be a consequence of the NS. Both arterial and venous thromboembolic complications (TEC) are relatively common and serious consequences of NS. In addition, arterial and venous thrombosis might be unexpected events during an exacerbation of NS. Embolic episodes may manifest in different regions of the body such as the brain or the lung. Hence, predisposing factors, personal and family history of TEC, thrombosis location and evolution should be always investigated in children with NS.

Let them eat during dialysis: an overlooked opportunity to improve outcomes in maintenance hemodialysis patients

In individuals with chronic kidney disease, surrogates of protein-energy wasting, including a relatively low serum albumin and fat or muscle wasting, are by far the strongest death risk factor compared with any other condition. There are data to indicate that hypoalbuminemia responds to nutritional interventions, which may save lives in the long run. Monitored, in-center provision of high-protein meals and/or oral nutritional supplements during hemodialysis is a feasible, inexpensive, and patient-friendly strategy despite concerns such as postprandial hypotension, aspiration risk, infection control and hygiene, dialysis staff burden, diabetes and phosphorus control, and financial constraints. Adjunct pharmacologic therapies can be added, including appetite stimulators (megesterol, ghrelin, and mirtazapine), anabolic hormones (testosterone and growth factors), antimyostatin agents, and antioxidative and anti-inflammatory agents (pentoxiphylline and cytokine modulators), to increase efficiency of intradialytic food and oral supplementation, although adequate evidence is still lacking. If more severe hypoalbuminemia (<3.0 g/dL) not amenable to oral interventions prevails, or if a patient is not capable of enteral interventions (e.g., because of swallowing problems), then parenteral interventions such as intradialytic parenteral nutrition can be considered. Given the fact that meals and supplements during hemodialysis would require only a small fraction of the funds currently used for dialysis patients this is also an economically feasible strategy.

Protein-losing nephropathy associated with Borrelia burgdorferi seropositivity in a soft-coated wheaten terrier: response to therapy

A soft-coated wheaten terrier was examined for lameness with subsequent identification of protein-losing nephropathy, hypoalbuminemia, hyperglobulinemia, and seroconversion to Borrelia burgdorferi. Following doxycycline therapy, the urine protein loss decreased significantly and serum albumin concentration remained close to or within the reference interval for over 3 years, contrary to the reported poor prognosis for renal disease associated with B. burgdorferi or protein-losing nephropathy of soft-coated wheaten terriers.

Hypoalbuminemia in peritoneal dialysis patients

Clinicians caring for patients on peritoneal dialysis (PD) have relied on a variety of laboratory measures to assess the health of patients and their response to treatment. Traditionally, serum albumin has been an indicator of nutrition status and has therefore been included in monthly blood testing in most centers. The development of hypoalbuminemia in dialysis patients has been associated with increased mortality and often leads to interventions such as trials of nutritional supplements. In PD, hypoalbuminemia combined with ongoing losses of protein into effluent raise particular concerns with clinicians. Serum albumin may be affected by a variety of non-nutrition factors such as inflammation, volume status, and comorbidities. Albumin synthesis in the liver exceeds, in most cases, albumin losses in urine or effluent. Interpreting the medical implications of declining serum albumin in PD patients can therefore be a challenge. This paper reviews protein balance in PD. The nutritional and non-nutritional factors affecting serum albumin are discussed, with specific emphasis on how membrane physiology contributes to dialysate protein losses. A general clinical approach to the PD patient developing hypoalbuminemia is discussed.

Biliopancreatic diversion with transient gastroplasty and duodenal switch: long-term results of a multicentric study

BACKGROUND

Over the years, several modifications of the Scopinaro biliopancreatic diversion (BPD) have been proposed. This retrospective study reported the results of 15 years of follow-up after open BPD coupled with a type of transient gastroplasty (TG) and duodenal switch (DS), termed BPD-TG with DS.

METHODS

Data were analyzed for 874 patients operated on between January 1993 and May 2010 in 3 different surgical departments.

RESULTS

The median preoperative body mass index (BMI) was 52 kg/m² (range, 35-63). Comorbidities present were hypertension (57%), hypercholesterolemia (87%), hypertriglyceridemia (53%), type 2 diabetes (35%), and obstructive sleep apnea syndrome (OSAS; 9%). The mean follow-up was 11.9 ± 3.1 years. The median BMI decreased to 33.9 after 1 year from bariatric surgery, 31.1 after 2-5 years, 30.9 after 5-10 years, and 31.2 kg/m² after 10-15 years. Overall, 67% of diabetic patients were able to stop insulin and 97% were able to stop oral hypoglycemic drugs within 1 year. Blood pressure, triglyceride levels, and cholesterol levels became normal in >96% of patients within 1 year. OSAS was resolved within 8 months in all cases. One year postoperatively, but absent thereafter, we observed severe hypoalbuminemia (serum albumin <3 g/dL) in 1.7% of patients and severe iron-deficiency anemia in 1.9%. Incisional hernias were recorded in 30% and anastomotic ulcers in 2.4% of cases. Mortality was null.

CONCLUSION

Our results suggest considering BPD-TG with DS as a viable bariatric operation, with its excellent long-term outcome in terms of weight loss, improvement of obesity-related diseases, and quality of life.

Hypoalbuminemia is an independent prognostic factor for overall survival in myelodysplastic syndromes

We hypothesized that hypoalbuminemia is an independent prognostic factor in patients with myelodysplastic syndromes (MDS). We analyzed records of 767 patients treated at Moffitt Cancer Center between January 2001 and December 2009 to evaluate the relationship between serum albumin (SA) at the time of presentation and overall survival (OS). Patients (median age of 69 years) were stratified into three groups based on SA concentration (≤3.5, 3.6-4.0, and >4.0 g/dL). Two-thirds of the patients had low or intermediate-1 International Prognostic Scoring System (IPSS)-based risk for MDS. Median OS by SA concentration of ≤3.5, 3.6-4.0, and >4.0 g/dL was 11, 23, and 34 months, respectively (P < 0.005), whereas rate of acute myeloid leukemia progression was highest in patients with low SA (≤3.5 g/dL). The SA level offered prognostic discrimination for outcomes within the lower and higher IPSS risk groups, as well as with the MD Anderson risk model. In multivariable analysis, SA was a significant independent co-variate for OS after adjustment for IPSS, age, serum ferritin, and transfusion dependence (hazard ratio = 0.8; 95% CI 0.6-0.9; P = 0.004). Our findings indicate that hypoalbuminemia is an independent prognostic biomarker that may serve as a surrogate representative of disease biology or comorbidities in patients with MDS.

Hypoalbuminemia

Hypoalbuminemia is frequently observed in hospitalized patients and it can be associated with several different diseases, including cirrhosis, malnutrition, nephrotic syndrome and sepsis. Regardless of its cause, hypoalbuminemia has a strong predictive value on mortality and morbidity. Over the years, the rationale for the use of albumin has been extensively debated and the indications for human serum albumin supplementation have changed. As the knowledge of the pathophysiological mechanisms of the pertinent diseases has increased, the indications for intravenous albumin supplementation have progressively decreased. The purpose of this brief article is to review the causes of hypoalbuminemia and the current indications for intravenous administration of albumin. Based on the available data and considering the costs, albumin supplementation should be limited to well-defined clinical scenarios and to include patients with cirrhosis and spontaneous bacterial peritonitis, patients with cirrhosis undergoing large volume paracentesis, the treatment of type 1 hepatorenal syndrome, fluid resuscitation of patients with sepsis, and therapeutic plasmapheresis with exchange of large volumes of plasma. While albumin supplementation is accepted also in other clinical situations such as burns, nephrotic syndrome, hemorrhagic shock and prevention of hepatorenal syndrome, within these contexts it does not represent a first-choice treatment nor is its use supported by widely accepted guidelines.

Analysis of 15 patients with systemic lupus erythematosus manifesting with negative immunofluorescence anti-nuclear antibodies after treatment

The purpose of this study was to investigate the clinical and laboratorial characteristics of patients with systemic lupus erythematosus (SLE) manifesting with negative immunofluorescence anti-nuclear antibodies (IFANA) after treatment for the better understanding of negative conversion of IFANA. Demographic characteristics, clinical and laboratory data of hospitalized SLE patients between March 2006 and May 2011 were retrospectively reviewed. Fifteen cases with negative IFANA were identified in 960 patients. All of the 15 patients were severe, 11 patients manifested with nephritic range proteinuria and hypoalbuminemia, 8 patients were complicated with severe infection and all of the patients had been treated with glucocorticoid and immunosuppressant. Anti-ENA antibodies were positive in 4 of 15 patients. Eight patients died after average 1-year follow-up. Collectively, negative IFANA is mainly attributed to nephritic-range proteinuria; and large-dose glucocorticoid, immunosuppressant and severe infection are also important factors for negative IFANA. Antinuclear antibody can be detected in some SLE patients with negative IFANA by changing the detection method and titer. Negative conversion of IFANA often indicates unfavorable prognosis for severe patients.

Significance of albumin and C-reactive protein variations in 300 end stage renal disease patients in Tehran University of Medical Sciences Hospitals during year 2010

Protein- energy malnutrition, wasting and inflammation are frequent complication among patients with end-stage renal disease (ESRD). Malnutrition is associated with cardiac co-morbidity, inflammation and poor survival in ESRD patients. Serum albumin is a well-known marker of nutrition in ESRD patients. Serum albumin is still the most commonly used nutritional marker in ESRD patients. C-reactive protein (CRP), the major acute phase response (APR) protein is elevated in these patients. High CRP levels are linked to the degree of atherosclerosis in coronary, peripheral, and extracranial brain arteries. The aim of the present study was to investigate nutritional factor (albumin) and CRP levels in ESRD patients. In this cross- sectional study a total of 300 patients who had ESRD and had been on hemodialysis treatment for at least 6 months were selected. The laboratory tests consisted of measurement of CRP and albumin using high sensitive ELISA kits. The study patients included 157 males (52.3%) and 143 females (47.7%) with average age of 41.5 ± 14.3 years. Mean CRP level was 7.96 mg/ dl (±1.52), mean serum albumin was 4.07 g/dl (±0.19).Of 300 patients, 21 died (7%). These were patients with serum albumin <4 g/dl and CRP>9.5 mg/dl. This study showed that low albumin and high CRP levels are the main predictors for death. There was a significant difference between CRP and albumin levels in ESRD patients (P<0.0001). Measuring CRP as a marker of inflammation can be helpful in managing these patients.

[Protein-losing gastroenteropathy: unremembered cause of hypoalbuminemia?]

Protein-losing gastroenteropathy (PLE) consists on an active digestive tract protein loss syndrome and it is related to some diseases. After a wide research into bibliography (MEDLINE - Pubmed),we have found few references to this gastroenteropathy as a cause of hypoalbuminemia related to malnutrition. This has motivated us to review this entity, detailing some recent clinical cases of our experience.

Early severe hypoalbuminemia is an independent risk factor for intestinal failure in gastroschisis

OBJECTIVE

This study attempted to evaluate the association of early hypoalbuminemia with the risk of intestinal failure in gastroschisis patients.

PATIENTS AND METHODS

Neonates with gastroschisis treated at a tertiary children's hospital over a 10-year period were initially categorized into groups based on the lowest serum albumin measurement during the first 7 days of life. Based on preliminary analysis, patients with serum albumin <1.5 g/dL were considered to have early severe hypoalbuminemia. Intestinal failure was defined as inability of the patient to wean from parenteral nutrition (PN) during the initial hospital admission, thus requiring home PN. Logistic regression modeling was performed to adjust for sex, gestational age, birth weight, and concomitant intestinal complications.

RESULTS

One hundred and thirty-five gastroschisis patients were included, of whom 21% had early severe hypoalbuminemia. Patients with early severe hypoalbuminemia had a significantly higher risk of intestinal failure compared to those with higher albumin levels (26 vs. 8%, p = 0.015). On multivariable logistic regression modeling, early severe hypoalbuminemia was strongly associated with intestinal failure (OR 6.4, 95% CI 1.8-23.3, p = 0.005).

CONCLUSIONS

Early severe hypoalbuminemia appears to be an independent risk factor for long-term intestinal compromise rather than merely an indicator of overall illness. Further interventional studies are needed to determine whether clinical protocols utilizing judicious fluid administration, exogenous albumin, and early enteral feeding can improve clinical outcomes in gastroschisis.

[Serum albumin and heart failure: recent advances on a new paradigm]

Hypoalbuminemia is a common condition in patients with heart failure and is mainly related to the malnutrition-inflammation complex syndrome. Other causal factors can be involved, which include hemodilution, liver dysfunction, increased transcapillary escape rate, renal and enteral loss. Evidence is growing that hypoalbuminemia independently predicts incident heart failure in patients with end-stage renal disease and elderly patients, as well as mortality in patients with heart failure regardless of left ventricular ejection fraction and clinical presentation. Hypoalbuminemia induces a low plasma oncotic pressure, which facilitates pulmonary edema in patients without critical increase in pulmonary capillary hydrostatic pressures. Hypoalbuminemia may also contribute to the progression of heart failure by favoring myocardial edema, volume overload, diuretic resistance and exacerbation of oxidative stress and inflammation. If relevant, removal of subclinical excess of fluid and renutrition may be indicated in patients with heart failure and hypoalbuminemia. Additional research is warranted to determine the specific role of serum albumin in the pathophysiologic process of heart failure and the potential benefits of targeted therapeutic interventions.

Albumin loss under the use of the high-performance membrane

Beta-2-microglobulin (β(2)M) clearance has been improved in recent dialysis membranes and minimum albumin leakage has been achieved in most membranes today since dialysis membranes are now classified by β(2)M clearance in terms of the reimbursement by health insurance. Kawanishi et al. suggested that 'the desirable albumin leakage in one treatment is less than 4 g '. Function classification type IV or type V dialysis membranes have leakages as low as 3 g, while most resulted in < 1 g leakage. However, some high-performance membranes (HPMs) have around 8 g of leakage, which requires further study of the clinical efficacy using such dialysis membranes. The comparison of albumin leakage in one dialysis treatment (4 h: blood flow volume of 250 ml/min) revealed that PES-210D has an overwhelmingly high albumin leakage of 7.69 ± 1.01 g. The data were without any significant difference between the PES-D membrane user group and the non-PES-D membrane user group for hemoglobin, hematocrit, β(2)M protein, catabolic rate, body mass index, and muscle mass. However, the PES-D membrane user group had a significantly lower number of hospitalizations and other complication events. When comparing the event contents, the PES-D membrane user group had no cardiac failure and lower DRA, however it had more vascular access problems. In normal renal function, approximately 10 g of albumin is filtered in the glomerulus per day, decomposed in the renal tubule and reabsorbed as amino acid, and re-synthesized into albumin in the liver. On the contrary, in dialysis patients, albumin that is bound to biologically active substances and/or the oxidized form of albumin that has lost its antioxidant effect cannot be filtered from the kidney and accumulate. Therefore, the idea regarding albumin leakage is to remove biologically active substances that bind to albumin and function as uremic toxin, remove albumin without the antioxidant effect, and facilitate synthesis of new albumin with an antioxidant effect.

Hypoalbuminemia in a cystic fibrosis patient with severe erosive esophagitis

An 8-year-old patient with cystic fibrosis presented with hypoalbuminemia as the main symptom of severe erosive esophagitis. Extensive evaluation failed to reveal a nutrition, pancreatic, intestinal, or renal explanation of his hypoalbuminemia. Identification and treatment of the esophagitis led to resolution of the hypoalbuminemia.

Hand-assisted laparoscopic removal of a nephroblastoma in a horse

A 3-year-old Thoroughbred was presented for evaluation of hematuria post exercise. On physical examination, an enlarged kidney was identified, as well as serum biochemical abnormalities such as an elevated creatine kinase (CK) and hypoalbuminemia. The kidney was removed laparoscopically and a nephroblastoma was identified.

A case report of systemic capillary leak syndrome (Clarkson's disease)

Systemic capillary leak syndrome (SCLS) is a very rare disorder also known as Clarkson's disease. The condition is characterized by recurrent episodes of severe capillary hyperpermeability resulting in severe hemoconcentration, hypoalbuminemia, hypovolemia and shock. We describe a 41-year-old previously healthy man who was admitted to hospital on several occasions with rapidly developing hypovolemic shock accompanied by extreme hemoconcentration and hypoalbuminemia. Our case is similar to other reports describing patients with SCLS where the initial suspicions have been pointing towards septic shock. He received a combination of prophylactic treatment with theophylline, beta-agonists, immunoglobulins and statins but eventually died after a severe episode of SCLS that ended with recurrent cardiac arrest. Clinical autopsy revealed pulmonary edema and acute and chronical organic fluid overload. SCLS should be kept in mind when treating patients suffering from attacks of severe idiopathic edema and mimics recurrent septic shock where no pathogen is found. The pathogenesis is unknown and the attacks may be lethal.

Catastrophic calciphylaxis in a patient with lupus nephritis and recent onset of end-stage renal disease

Painful violaceous skin lesions that progress to non-healing ulceration and gangrene characterize calciphylaxis. These lesions are associated with secondary hyperparathyroidism and generally occur in patients on dialysis for more than one year. Hyperphosphatemia and hypoalbuminemia are the major risk factors for calciphylaxis. It is usually resistant to medical treatment although parathyroidectomy can help in controlling the disease. The mortality rate of calciphylaxis is very high due to uncontrollable sepsis. In our case, a young female with systemic lupus erythematosus (SLE) developed calciphylaxis within a short period after the onset of hemodialysis; she had a short period of hyperphosphatemia prior to dialysis. The serum phosphate was 4.24 mmol/L, calcium was 1.66 mmol/L, parathormone was 38 and calcium-phosphate was 7.0 mmol/L. It is likely that SLE provoked the development of calciphylaxis. The patient was treated medically but unfortunately died secondary to sepsis.

Improving first-year mortality in patients on dialysis: a focus on nutrition and exercise

Early mortality is a significant concern for patients initiating dialysis. Nutrition and exercise are two factors that affect mortality rates that can be significantly influenced by a successful partnership between the healthcare team and the patient. This article provides an overview of current data on the importance of appropriate nutritional and exercise regimens for patients initiating dialysis, as well as tips for how nurses and other members of the healthcare team can work to incrementally improve these components of care.