Hypoalbuminaemia and colonic polyps: a case of protein-losing enteropathy with cap polyposis?

A 69-year-old woman was admitted in September 2005 dehydrated and unwell. She had a 6-month history of constipation, poor appetite and weight loss, and was hypoalbuminaemic (21 g/litre). She had initially been referred for colonoscopy in March to exclude colonic malignancy. Multiple pedunculated polyps up to the splenic flexure were seen, with histology felt to be consistent with hyperplastic polyps and mild inflammation. Her symptoms persisted, and by August she had lost 3 stone in weight. She started to experience loose stools, and repeat colonoscopy was planned. However, the bowel preparation made her feel unwell. She couldn't walk, and so presented to the acute medical take.

The patient looked pale and dehydrated. Her chest was clear, with a diffusely tender abdomen. Bowel sounds were present, and there were no palpable masses. Bloods showed a corrected calcium of 1.58 mmol/litre. Fluid resuscitation and calcium replacement was started. A malignant process was queried. Liver function tests showed a low albumin of 21 g/litre but were otherwise unremarkable. A computed tomography scan of the abdomen and chest were normal. A gastroscopy showed mild oesophagitis with Candida in the mid and lower oesophagus, gastritis in the antrum of the stomach with heavy Helicobacter pylori growth, and a normal duodenum. Biopsies showed no evidence of coeliac disease or giardia.

The patient's albumin fell to 8 g/litre. A 24-hour urine protein collection was 0.46 g, excluding nephrotic syndrome. Nasogastric feeding was commenced.

Gut hormones showed a modestly elevated chromogranin A (164 pmol/litre) and gastrin (307 pmol/ litre) but were not diagnostic of a neuroendocrine tumour. Amyloid was queried and the original colonic biopsies re-examined. This was not found, but cap polyposis was suggested.

The patient failed to improve and died 15 days after admission. Post mortem found the distal large bowel to contain multiple dark sessile polyps, looking like slugs, on exaggerated mucosal folds (Figure 1). The histological findings comprised elongated, tortorous and distended crypts, with evidence of inflammation and a 'cap' of granulation tissue, confirming cap polyposis. In addition the patient had a right haemothorax. This was caused by a dissection in the pulmonary artery, with evidence of atheroma identified. The right ventricle was hypertrophic, with the lungs showing multiple haemorrhagic infarcts. These changes suggested pulmonary hypertension. Whether this was related to the cap polyposis was unclear. A reasonable explanation is that the patient had showered off pulmonary emboli from a deep vein thrombosis (DVT) for some time, secondary to immobility associated with her poor state of health. This was supported by a right calf DVT identified at post mortem. The dissection of the pulmonary artery was probably secondary to the low protein state and pulmonary artery hypertension.

Ectopic adrenal tissue in the thorax: a case report with in situ hybridization and immunohistochemical studies

Ectopic or accessory adrenal tissues are usually found in the upper abdomen or along the path of descent of the gonads. The occurrence of supradiaphragmatic adrenal tissue is extremely rare. We report a case of ectopic adrenal tissue composed of both cortical and medullary cells in a 99-year-old woman. The lesion was found incidentally in the paratracheal region at autopsy. We performed in situ hybridization and immunohistochemistry to confirm that the ectopic adrenal tissue possessed the same steroidogenesis as a normal adrenal gland. The ectopic adrenal tissue was encapsulated by fibrous tissue and composed of cells expressing all steroidogenic enzyme mRNAs. The centrally located cells showed immunoreactivities for tyrosine hydroxylase (TH), dopamine beta hydroxylase (DBH), and phenylethanolamine-N-methyltransferase (PNMT). Expression of ACTH receptor (ACTHR) was also evident. These findings indicated that this ectopic adrenal tissue had the capability for steroid and catecholamine biosynthesis under the control of ACTH, and that it might function adequately even under a condition of bilateral adrenal insufficiency.

Comparison of three different methods of evaluation of metabolic acid-base disorders

OBJECTIVES

The Stewart approach states that pH is primarily determined by Pco2, strong ion difference (SID), and nonvolatile weak acids. This method might identify severe metabolic disturbances that go undetected by traditional analysis. Our goal was to compare diagnostic and prognostic performances of the Stewart approach with a) the traditional analysis based on bicarbonate (HCO3) and base excess (BE); and b) an approach relying on HCO3, BE, and albumin-corrected anion gap (AGcorrected).

DESIGN

Prospective observational study.

SETTING

A university-affiliated hospital intensive care unit (ICU).

PATIENTS

Nine hundred thirty-five patients admitted to the ICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The Stewart approach detected an arterial metabolic alteration in 131 (14%) of patients with normal HCO3- and BE, including 120 (92%) patients with metabolic acidosis. However, 108 (90%) of these patients had an increased AGcorrected. The Stewart approach permitted the additional diagnosis of metabolic acidosis in only 12 (1%) patients with normal HCO3, BE, and AGcorrected. On the other hand, the Stewart approach failed to identify 27 (3%) patients with alterations otherwise observed with the use of HCO3-, BE, and AGcorrected (16 cases of acidosis and 11 of alkalosis). SID and BE, and strong ion gap (SIG) and AGcorrected, were tightly correlated (R2 = .86 and .97, p < .0001 for both) with narrow 95% limits of agreement (8 and 3 mmol/L, respectively). Areas under receiver operating characteristic curves to predict 30-day mortality were 0.83, 0.62, 0.61, 0.60, 0.57, 0.56, and 0.67 for Sepsis-related Organ Failure Assessment (SOFA) score, SIG, AGcorrected, SID, BE, HCO3-, and lactates, respectively (SOFA vs. the rest, p < .0001).

CONCLUSIONS

In this large group of critically ill patients, diagnostic performance of the Stewart approach exceeded that of HCO3- and BE. However, when AGcorrected was included in the analysis, the Stewart approach did not offer any diagnostic or prognostic advantages.

Hypoalbuminemia is an important risk factor of hypotension during hemodialysis

Hypotension during hemodialysis (HD) is an important problem in patients on HD. To investigate the risk factors that contribute to the hypotension during HD, we compared background factors of hypotensive (HP) patients during HD. Among 58 patients undergoing HD in Tamura Memorial Hospital, 12 patients could not continue full HD because of hypotension. We compared the data of ultrafiltration volume, cardiothoracic ratio (CTR), total protein (TP), serum albumin, blood urea nitrogen (BUN), serum creatinine, total cholesterol (TC), hemoglobin (Hb), blood glucose (BS), brain natriuretic peptide (BNP), and cardiac function between HP patients (HP group; n=12) and sex- and age-matched control patients (NP group; n=12). There were no significant differences of age, sex, and duration of HD between the 2 groups. Cardiothoracic ratio is bigger and BNP is higher in the HP group compared with the NP group (CTR: HP 55.8+/-2.9% vs. NP 47.7+/-1.1%, p=0.0165; BNP: HP 602+/-171 vs. NP 147+/-38, p=0.0167). Serum albumin in the HP group is significantly lower compared with the NP group (HP 3.2+/-0.1 g/dL vs. NP 3.5+/-0.1 g/dL, p=0.0130). However, there were no significant differences of ultrafiltration rate (UFR), BS, TC, Hb, and cardiac function between the 2 groups. There is a significant negative correlation between changes of systolic blood pressure (delta systolic blood pressure) and serum albumin in these patients (r=-0.598, p=0.0016). From these data, we conclude that hypoalbuminemia is a major risk factor of hypotension during HD.

Effect of hypoalbuminemia on the increased serum cholesteryl ester transfer protein concentration in children with idiopathic nephrotic syndrome

OBJECTIVES

To examine the alteration of cholesteryl ester transfer protein (CETP) mass with the regression of albumin level in childhood nephrotic syndrome (NS) in order to clarify the effect of albumin on CETP in NS.

DESIGN AND METHODS

Serum concentrations of CETP, kidney parameters and lipid traits were determined in 110 children with idiopathic NS and 150 control subjects. Of the NS patients, 69 children with an active phase formed group 1, and 41 in remission formed group 2.

RESULTS

Group 1 presented severe hypoalbuminemia and hyperlipidemia, while group 2 exhibited marked recovery in both serum albumin level and lipid/lipoprotein profile. CETP concentration was significantly higher in group 1 (7.36+/-2.43 mg/L, compared with controls 3.38+/-1.83 mg/L, P<0.0001), and declined to within normal range in group 2 (2.91+/-1.77 mg/L). CETP concentration had a strong inverse correlation with serum albumin level (r=-0.688, P<0.0001) in NS patients. Furthermore, when multiple linear regression analysis was performed, in which albumin, proteinuria, lipid traits, and prednisone dose were treated as independent variables, albumin was the only variable showing a significant correlation with CETP in the NS patients (R(2)=0.587, beta=-0.475, P<0.0001).

CONCLUSIONS

The results demonstrate that the decreased serum albumin level might be a main determinant of the increased CETP concentration in pediatric NS.

Prevalence of Incontinence and Associated Skin Injury in the Acute Care Inpatient

PURPOSE

We examined the prevalence of incontinence and skin injury in areas exposed to incontinence among inpatients at 2 hospitals.

SUBJECTS AND SETTING

Acute care patients in medical, surgical, and intensive care units at a community and teaching hospital were surveyed to determine the rates of urinary and fecal incontinence and the prevalence of incontinence-associated dermatitis or skin ulceration.

INSTRUMENT

A data collection form that queried patient characteristics was completed. The presence of hypoalbuminemia (< or = 3.4 g/dL) and nutrition, friction and shear, and mobility status (using Braden scale scores) were also recorded. This instrument was designed by this research team and tested in a pilot study.

RESULTS

A total of 608 patients age 4 years and older were surveyed. The overall prevalence of incontinence in the survey was 19.7% (120 of 608). One hundred seven patients (17.6%) were incontinent of stool. Fecal incontinence was more frequent than urinary incontinence overall, by gender and across the different age groups. However, 201 (33%) of the inpatients had indwelling urinary catheters and were counted as continent of urine. The highest prevalence of incontinence was found in the oldest age group (80+ years). Some type of injury to the skin was observed in 42.5% of the 120 patients who were incontinent. Hypoalbuminemia and poor nutritional status were more commonly noted in patients with skin injury associated with fecal incontinence.

CONCLUSION

Fecal and urinary incontinence are common among patients in the acute care setting. Fecal incontinence is associated with hypoalbuminemia and poor nutritional status and is associated with a higher rate of skin injury.

Evaluation of a Protocol for Prevention of Facility-Acquired Heel Pressure Ulcers

OBJECTIVE

We sought to determine whether identification of comorbidities (in addition to daily Braden scale assessment and early aggressive pressure reduction interventions) would impact the development of facility-acquired pressure ulcers (FAPU) of the heel.

METHODS

Patients admitted to a 333-bed community hospital located 20 miles west of Chicago. Overall, 70 medical records were reviewed, while 242 adult patients (46 in the intervention groups and 196 in the control groups) and 24 nurses participated in the study. The study was conducted in 4 phases, including a retrospective chart audit, 2 prospective interventions, and a product evaluation. Phase 1 entailed a retrospective chart review of patients who were admitted with or developed heel pressure ulcers over a 2-year period to identify factors most predictive of skin breakdowns. Phase 2 included two 10-day aggressive assessment and tailored intervention periods. Phase 3 involved prevalence day assessments of effectiveness of interventions as compared to patients on control nursing units. Phase 4 involved a staff survey comparing effectiveness and satisfaction of the current and trial heel pressure-relieving products.

FINDINGS

Risk factors for development of heel ulcers during hospital stay or prior to admission included type 2 diabetes mellitus (T2DM), peripheral vascular disease (PVD), low albumin, and Braden scale score. During implementation of phase 2 (two 10-day assessment and tailored intervention periods), no heel FAPU were associated with the intervention. During the phase 3 FAPU prevalence assessment, 3 patients had facility-acquired heel ulcers; 2 were in the control group and would have met inclusion criteria if included in the intervention. One patient was in the intervention group but was not following the protocol. During phase 4, there were significant preferences for the trial heel pressure relief device on effectiveness, as well as patient and staff satisfaction.

CONCLUSION

A pressure ulcer prevention protocol that incorporated accurate assessment of risk factors (Braden Scale and comorbidities) with frequent documentation of heel skin integrity had a positive impact on the incidence of heel FAPU. In addition, early aggressive implementation of pressure-reducing and pressure-relieving devices was effective in reducing FAPU rates.

Hypoalbuminemia is a predictor of delayed postoperative bowel function and poor surgical outcomes in right-sided colon cancer patients

PURPOSE

To determine the relationship between preoperative serum albumin and postoperative bowel function as well as surgical outcomes in right-sided colon cancer patients.

METHODS

This retrospective study in a university hospital included 84 patients who underwent elective right hemicolectomy for adenocarcinoma of the right-sided colon between January 2004 and December 2005. The patients had a preoperative serum albumin assessment. Serum albumin less than 3.5 g/dL was regarded as hypoalbuminemia. Postoperative outcomes were classified into mortality, morbidity (infectious and noninfectious complications), time to first bowel movement, time to resume normal diet, and hospital stay.

RESULTS

Forty males (48%) and forty-four females (52%) with a mean age of 64 (range, 27-89) years were included. Forty-eight patients (57%) had hypoalbuminemia. No 30-day postoperative mortality occurred. All 14 postoperative complications occurred in hypoalbuminemic cases. Therefore, 29% of the hypoalbuminemics had complications whereas none occurred in nonhypoalbuminemics (p=0.001). In univariate analysis, hypoalbuminemia and postoperative complications were the risk factors for delayed postoperative recovery of bowel function and prolonged length of hospital stay. In multivariate analysis, hypoalbuminemia was the significant risk factor for postoperative complications (p<0.001) and delayed time to first bowel movement (p=0.018) whereas postoperative complications were the significant risk factor for delayed time to resume normal diet (p<0.001) and prolonged hospital stay (p<0.001).

CONCLUSION

Hypoalbuminemia is a potential predictor of delayed recovery of bowel function postoperatively and significantly associated with postoperative complications in right-sided colon cancer patients undergone right hemicolectomy.

Spinocerebellar ataxia with ocular motor apraxia and DNA repair

At least four disorders, ataxia telangiectasia (AT), an ataxia-telangiectasia-like disorder, early-onset ataxia with ocular motor apraxia and hypoalbuminemia (EAOH)/ ataxia with oculomotor apraxia type 1 (AOA1), and ataxia with oculomotor apraxia type 2, are accompanied by ocular motor apraxia (OMA), which is an impairment of saccadic eye movement initiation. The characteristic pathological findings of EAOH/AOA1 and AT are a severe loss of Purkinje cells, severe myelin pallor of the posterior columns, and moderate neuronal loss in the dorsal root ganglia and anterior horn. Purkinje cells stimulate the fastigial nucleus and suppress omnipause neurons to initiate saccadic eye movement. The selective loss of Purkinje cells might cause OMA and disturb the cancellation of the vestibulo-ocular reflex. These disorders have the following common clinical features: ataxia, involuntary movements, and peripheral neuronopathy. In addition, the causative genes for these disorders are associated with the DNA/RNA quality control system. The impairment of DNA/ RNA integrity results in selective neuronal loss in these recessive-inherited ataxias.

[Investigation of the risk factors and prevention of nosocomial tracheobronchitis in elderly patients on mechanical ventilation in surgical intensive care unit]

OBJECTIVE

To investigate the incidence, the risk factors and the outcome of nosocomial tracheobronchitis (NTB) in patients age over 65 years of age receiving mechanical ventilation (MV).

METHODS

Using prospective cohort study to collect and analyse the clinical information of elderly patients who received mechanical ventilation in surgical intensive care unit (ICU) of Zhongshan Hospital, from November 2002 to July 2004. Patients with first episodes of NTB were compared with those without NTB by univariate analysis and logistic regression.

RESULTS

There were 35 elderly patients diagnosed as having NTB (53.0%). The differences in serum albumin, nasal feeding, the length of ICU stay, the duration of MV days, the acute physiology and chronic health evaluation II (APACHE II) score and the kinds of the antibiotic used between patients with NTB and without NTB were significant. The results of the univariate analysis showed that nasal feeding, low serum albumin, the duration of the MV>4 days, the length of ICU stay >9 days, the kinds of antibiotics used and the APACHE II score higher than 9 were the risk factors of NTB. However the logistic regression suggested that nasal feeding, MV days >4 days, nasal feeding and the kinds of the antibiotics used >2 are the independent risk factors of NTB.

CONCLUSION

There is high incidence of NTB in ventilated patients in surgical ICU. Low albumin level, nasal feeding, prolonged MV and ICU stay days, high APACH II score and administration of too much antibiotics are the important risk factors of NTB.

Association between serum albumin and periodontal disease in community-dwelling elderly

AIM

The purpose of this study was to evaluate the relationship between periodontal disease and general health status in community-dwelling elderly using serum albumin concentration as a criterion index of the severity of an underlying disease and nutrition status.

METHODS

Serum albumin level was detected by the bromcresol green albumin (BCG) method and the data for serum albumin were available in 368 subjects aged 75 years. Pressure-sensitive probes were used to measure loss of attachment (LA) on six sites of all teeth present. Information relevant to gender and smoking habit was obtained by means of a personal interview, while body mass index (BMI) and biochemical serum markers were investigated.

RESULTS

Serum albumin concentration ranged from 3.2 to 4.8 g/dl with a mean of 4.1+/-0.2. More than 70% of subjects had at least one site with LA 6+ mm, while 91 exhibited 10% or more sites with LA 6+ mm. Using a multiple regression analysis, we found that sites of LA 6+ mm had a significant effect on serum albumin level (correlation coefficient=-0.14; p<0.05), which was independent of the other covariates.

CONCLUSIONS

The findings of the present study indicated that there might be an inverse relationship between periodontal disease and serum albumin concentration in these elderly subjects.

Intravenous immunoglobulin for the treatment of severe, refractory, and recurrent Clostridium difficile diarrhea

PURPOSE

Clostridium difficile diarrhea is common in elderly patients and leads to prolonged hospitalization. Patients with severe or recurrent Clostridium difficile diarrhea have poor antitoxin antibody responses. Intravenous immunoglobulin has been advocated in these patients. This study was designed to assess the response of patients with refractory, recurrent, or severe Clostridium difficile diarrhea to intravenous immunoglobulin.

METHODS

Retrospective review (November 2003-January 2005) of 14 patients with severe, refractory, recurrent Clostridium difficile diarrhea treated with intravenous immunoglobulin (Flebogamma, 150-400 mg/kg) from 264 Clostridium difficile toxin-positive patients.

RESULTS

Median age was 79 (range, 54-91) years. Median length of symptoms before intravenous immunoglobulin was 29 (range, 3-90) days. Patients received a median of three (range, 1-5) courses of vancomycin or metronidazole before intravenous immunoglobulin. All had hypoalbuminemia (median, 22 g/l; range, 18-33) and raised C-reactive protein (median, 47 mg/l; range, 25-255) at time of infusion. The median white cell count was 15.3 x 10(9)/liters (range, 4-24). Eight patients had evidence of pancolitis on abdominal imaging, suggesting severe Clostridium difficile diarrhea. All patients tolerated intravenous immunoglobulin without side effects. Nine (64 percent) responded with bowels normalizing in a median of ten (range, 2-26) days; one patient received two doses. One patient had a partial response from two doses but died two months later after a recurrence. The other four patients died of other causes within three weeks of infusion.

CONCLUSIONS

Intravenous immunoglobulin may be effective for severe, refractory, or recurrent Clostridium difficile diarrhea after failed conventional treatment.

Hypoalbuminemia: a cause of fetal hydrops?

OBJECTIVE

The pathophysiology of fetal hydrops is still unclear. One factor that is believed to contribute to hydrops is hypoalbuminemia. Our research question was whether hypoalbuminemia in immune hydrops is causative or a secondary effect.

STUDY DESIGN

Between 1987 and 2005, fetal blood samples were taken at the first fetal blood transfusion in 224 Rh-D alloimmunized pregnancies. We measured hemoglobin concentration and albumin concentration and assessed the severity of hydrops.

RESULTS

A decrease in albumin concentration occurred only below a hemoglobin deficit of >8 SDs in 27 fetuses. In 161 nonhydropic, 44 mildly hydropic, and 19 severely hydropic fetuses, albumin concentrations were >2 SDs below the mean for gestational age in 6%, 14%, and 63%, respectively.

CONCLUSION

Our finding that most fetuses with immune hydrops have an albumin concentration within the normal range (71%) suggests that hypoalbuminemia is unlikely to cause the initial development of immune hydrops.

Digital clubbing in tuberculosis--relationship to HIV infection, extent of disease and hypoalbuminemia

Background

Digital clubbing is a sign of chest disease known since the time of Hippocrates. Its association with tuberculosis (TB) has not been well studied, particularly in Africa where TB is common. The prevalence of clubbing in patients with pulmonary TB and its association with Human Immunodeficiency Virus (HIV), severity of disease, and nutritional status was assessed.

Methods

A cross-sectional study was carried out among patients with smear-positive TB recruited consecutively from the medical and TB wards and outpatient clinics at a public hospital in Uganda. The presence of clubbing was assessed by clinical signs and measurement of the ratio of the distal and inter-phalangeal diameters (DPD/IPD) of both index fingers. Clubbing was defined as a ratio > 1.0. Chest radiograph, serum albumin and HIV testing were done.

Results

Two hundred patients (82% HIV-infected) participated; 34% had clubbing by clinical criteria whilst 30% had clubbing based on DPD/IPD ratio. Smear grade, extensive or cavitary disease, early versus late HIV disease, and hypoalbuminemia were not associated with clubbing. Clubbing was more common among patients with a lower Karnofsky performance scale score or with prior TB.

Conclusion

Clubbing occurs in up to one-third of Ugandan patients with pulmonary TB. Clubbing was not associated with stage of HIV infection, extensive disease or hypoalbuminemia.

Corticosteroid-responsive enteropathy of infancy

Nineteen American infants aged less than three months developed persistent diarrhoea, acidosis, hypoalbuminaemia, and malnutrition, without evidence of enteric pathogens. Symptoms began 11-59 days before admission to the University of North Carolina Children's Hospital, and infants were fed semielemental formula. Despite further treatment with amino acid-based formula by continuous nasogastric infusion, diarrhoea persisted. Endoscopic biopsies showed inflammation in the stomach, duodenum, and/or colon. A trial of intravenous corticosteroids was initiated in 14 infants. Corticosteroids were associated with rapid resolution of diarrhoea (duration after corticosteroids = 3.8 +/- 1.7 days [mean +/- SD]). In contrast, five infants with identical history were not treated with corticosteroids. In three infants, diarrhoea lasted for 92-147 days versus 31 +/- 3 total days in the treated group. In the other two infants, diarrhoea worsened after discharge, but were treated later with corticosteroids, with rapid resolution. Corticosteroids were uneventfully weaned over a four-month period. The results suggest that a trial of corticosteroids in infants with unresponsive persistent diarrhoea of unknown origin is beneficial and deserves prospective evaluation.

Vacuum-Assisted Closure Treatment Complicatedby Anasarca

The vacuum-assisted closure system has proven to be effective and safe in the treatment of a variety of wound types. In this case report, we present a rare complication of anasarca due to hypoalbuminemia, which developed during vacuum-assisted closure treatment. The patient was known to suffer from clinically stable congestive heart failure and had not had previous hypoalbuminemia. We emphasize the need for careful monitoring of electrolytes and proteins in compromised patients that have marked wound drainage when they are treated with a negative-pressure apparatus.

Megestrol Acetate in a Moderate Dose for the Treatment of Malnutrition-Inflammation Complex in Maintenance Dialysis Patients

BACKGROUND

Malnutrition-inflammation complex syndrome and anorexia, common conditions in maintenance dialysis patients, are strongly associated with higher mortality and hospitalization and lower quality of life (QoL) in this population. Megestrol acetate, 800 mg/day, has been shown to increase appetite and food intake and to mitigate inflammation in cachectic AIDS and cancer patients, leading to weight gain, but it is also associated with side effects at this dose.

METHODS

We evaluated the efficacy of the oral solution of megestrol acetate in half of its conventional dose in improving the nutritional state and inflammation in 10 hypoalbuminemic dialysis patients (albumin < 3.7 g/dL). Six women and 4 men, ages 60.2 years, took 400 mg of megestrol acetate solution daily for 16 weeks. Anthropometry, dual energy x-ray absorptiometry, 24-hour diet recalls, and biochemical measurements of nutrition and inflammation, including serum C-reactive protein and leptin, were performed.

RESULTS

At the end of the 16 weeks of intervention, weight and body mass index increased by 9%, body fat proportion by 31%, and triceps skinfold by 40% (P < .01). Serum albumin increased from 3.0 to 3.3 g/dL and continued to increase significantly to 3.6 g/dL after 3 months postintervention (P = .03). Serum leptin increased from 5.2 to 10.7 ng/mL (P = .09). Daily protein and energy intake increased progressively up to 27% to 42% by the end of the trial (P < or = .01). In 8 patients without acute infection, serum C-reactive protein declined from 1.24 to 0.78 mg/L (P = .06). QoL and appetite were reported to be improved. No major side effects were observed, and all 10 patients completed the 16 weeks of daily intake of megestrol acetate without interruption.

CONCLUSIONS

Megestrol acetate oral solution in half of its conventional dose is safe and improves the nutritional state, inflammation, and anorexia in maintenance dialysis patients. Larger-scale placebo-controlled randomized studies are needed to confirm the beneficial effects of 400 mg/day of megestrol acetate in dialysis patients.

Is portal hypertension associated with protein-losing enteropathy?

BACKGROUND AND AIM

Hypoalbuminemia in patients with decompensated cirrhosis has traditionally been assumed to be a result of to impaired liver synthesis; however, protein-losing enteropathy (PLE) may also contribute. The aim of this study was to assess whether hypoalbuminemic cirrhotic patients with portal hypertension had evidence of PLE.

METHODS

Sixteen patients with alcoholic cirrhosis, hypoalbuminemia and portal hypertension underwent whole gut lavage with polyethylene glycol solution. The effluent obtained was analyzed for albumin, immunoglobulin (Ig)G and alpha1-antitrypsin (alpha1-AT). Serum C-reactive protein (CRP) was also measured to assess the systemic inflammatory response.

RESULTS

Twelve of the 16 enrolled patients had a persistently low albumin concentration at the time of lavage. Only one patient (who was subsequently found to have celiac disease) had elevated concentrations of lavage albumin, alpha1-AT and IgG levels. There was a significant correlation between lavage albumin and alpha1-AT (r = 0.671, P = 0.024), and between lavage albumin and IgG (r = 0.614, P = 0.045). There was no correlation between serum albumin and lavage proteins. Six patients had elevated serum CRP levels, but serum albumin or lavage protein concentrations did not correlate with serum CRP.

CONCLUSION

There is no evidence of a significant PLE in patients with alcoholic cirrhosis, hypoalbuminemia and portal hypertension.

Admission serum albumin is predicitve of outcome in critically ill trauma patients

There is a paucity of data evaluating serum albumin on admission as a predictor of outcome in adult trauma patients. Our objectives were to evaluate whether or not hypoalbuminemia on admission is a predictor of adverse outcome in trauma patients. Prospective data was collected daily on 1023 patients over a 2-year period. Patients were stratified by serum albumin level on admission, age, gender, injury severity, and comorbid conditions. Outcome was measured by ICU and hospital length of stay, ventilator days, incidence of infection, and mortality. Student t test, chi2, and multilinear regression analysis were used to determine level of significance. Blunt injuries accounted for the majority (78%) of the admissions. The mean age of the study population was 43+/-21 years with a mean Injury Severity Score (ISS) of 21.4+/-12. The majority of patients were male (74.5%). The mean albumin level on admission was 2.9+/-1.8. Five hundred ninety-three (58%) patients were admitted with a serum albumin level of > or =2.6 as compared to 430 patients (42%) with an admission albumin level of <2.6. Patients with a lower serum albumin level were found to have a significantly greater ICU (17.1 vs 14.2 days) and hospital length of stay (17.3 vs 20.1 days, P'< 0.05), ventilator days (11.1 vs 13.5 days, P < 0.05), and mortality (P = 0.008) when matched for age and injury severity. The relative risk of infection and mortality increased greater than 2.5-fold in patients with increased age and low serum albumin when analyzed by multilinear regression analysis, P < 0.001. An admission serum albumin level of <2.6 g/dL is a significant independent predictor of morbidity and mortality in trauma patients. The combination of increased age and low albumin level was most predictive of infection and mortality. Early nutrition should be considered in these high-risk patients.

Improving perioperative outcome expands the role of hepatectomy in management of benign and malignant hepatobiliary diseases: analysis of 1222 consecutive patients from a prospective database

OBJECTIVE

To assess the trends in perioperative outcome of hepatectomy for hepatobiliary diseases.

METHODS

Data of 1222 consecutive patients who underwent hepatectomy for hepatobiliary diseases from July 1989 to June 2003 in a tertiary institution were collected prospectively. Perioperative outcome of patients in the first (group I) and second (group II) halves of this period was compared. Factors associated with morbidity and mortality were analyzed.

RESULTS

Diagnoses included hepatocellular carcinoma (n = 734), other liver cancers (n = 257), extrahepatic biliary malignancies (n = 43), hepatolithiasis (n = 101), benign liver tumors (n = 61), and other diseases (n = 26). The majority of patients (61.8%) underwent major hepatectomy of > or = 3 segments. The overall hospital mortality and morbidity were 4.9% and 32.4%, respectively. The number of hepatectomies increased from 402 in group I to 820 in group II, partly as a result of more liberal patient selection. Group II had more elderly patients (P = 0.006), more patients with comorbid illnesses (P = 0.001), and significantly worse liver function. Nonetheless, group II had lower blood loss (median 750 versus 1450 mL, P < 0.001), perioperative transfusion (17.3% versus 67.7%, P < 0.001), morbidity (30.0% versus 37.3%, P = 0.012), and hospital mortality (3.7% versus 7.5%, P = 0.004). On multivariate analysis, hypoalbuminemia, thrombocytopenia, elevated serum creatinine, major hepatic resection, and transfusion were the significant predictors of hospital mortality, whereas concomitant extrahepatic procedure, thrombocytopenia, and transfusion were the predictors of morbidity.

CONCLUSIONS

Perioperative outcome has improved despite extending the indication of hepatectomy to more high-risk patients. The role of hepatectomy in the management of hepatobiliary diseases can be expanded. Reduced perioperative transfusion is the main contributory factor for improved outcome.

[Nephrotic syndrome: pathophysiology, classification and diagnostic criteria]

The nephrotic syndrome is defined by heavy proteinuria due to abnormal increase of glomerular permeability and following hypoalbuminemia, hyperlipidemia and edema. Disorders of size selective barrier, charge selective barrier, slit diaphragm and circulating permeability factors are thought to be the causes of proteinuria. Most patients with nephrotic edema have primary salt retention. Overproduction and impaired catabolism of lipoproteins are the causes of hyperlipidemia. Abnormality of coagulation factors is also associated with nephrotic syndrome. Nephrotic syndrome may be primary or secondary to systemic disorders. Once diagnosed, the cause for the nephrotic syndrome must be examined.

Novel splice variants increase molecular diversity of aprataxin, the gene responsible for early-onset ataxia with ocular motor apraxia and hypoalbuminemia

Early-onset ataxia with ocular motor apraxia and hypoalbuminemia (EAOH) is one of the most common forms of autosomal recessive cerebellar ataxia. We identified six new alternative transcripts produced by the aprataxin gene responsible for EAOH. Total eight transcripts encoded truncated proteins that were located within the nucleus or cytoplasm and showed different binding abilities to wild-type (WT) aprataxin. Thus, the alternative splicing increases the molecular diversity of aprataxin and the expression profiles of these transcripts in various tissues may be related to the tissue-specific phenotypes.