Post-operative hypoalbuminaemia and procalcitonin elevation for prediction of outcome in cardiopulmonary bypass surgery

BACKGROUND

Because few studies have addressed postoperative hypoalbuminaemia in relation to hospital mortality, we evaluated this association and the prognostic value of increased procalcitonin (PCT) after cardiopulmonary bypass (CPB) surgery.

METHODS

In 454 consecutive patients undergoing CPB, minimal serum albumin, colloid osmotic pressure (COP) and maximal PCT were retrospectively obtained from the 2nd to 10th postoperative day. Receiver operating characteristic (ROC) and multiple regression analyses determined independent predictive strength for 28-day mortality from preoperative albumin, Euroscore, postoperative minimal albumin and COP, and maximal PCT. Cut-off points for the four strongest predictors were calculated by the area under the curve (AUC) in the ROC for the 28-day mortality.

RESULTS

Maximal PCT showed the largest AUC (0.85; 95% CI 0.79-0.90) and the highest relative risk (RR 12.17; 95%CI 5.26-28.16; P < 0.001), compared with postoperative albumin (AUC 0.72; 95% CI 0.62-0.81; RR 5.35; 95%CI 2.99-9.56; P < 0.001) and EuroSCORE (AUC 0.73; 95%CI 0.63-0.83; RR 4.48; 95%CI: 1.78-11.28; P < 0.01). By logistic regression, postoperative albumin was the strongest predictor of mortality (odds ratio 0.86; 95% CI 0.84-0.89). Cut-off values for predicting 28-day mortality were found for postoperative albumin and PCT at 17.8 g l(-1) and 2.5 ng l(-1), respectively. A slight but significant inverse correlation between PCT and albumin was found. Patients with albumin less than the cut-off showed significantly higher median values for PCT levels (2.5 vs. 1.0 g l-1), a higher 28-day mortality rate (20.8% vs. 4.5%), and a longer ICU stay (6 vs. 3 days) in comparison with patients with minimal albumin greater than 18 g l(-1).

CONCLUSIONS

Post-operative serum albumin <18 g l(-1) and PCT >2.5 ng l(-1) are predictive for a higher 28-day mortality rate in cardiosurgical patients. Both peak PCT and minimal albumin were better outcome predictors than the Euroscore, which better represents the preoperative condition of the patient.

Acute nontraumatic hemoabdomen in the dog: a retrospective analysis of 39 cases (1987-2001)

The medical records of 39 dogs with acute nontraumatic hemoabdomen were identified and reviewed. Anemia and hypoalbuminemia were identified in 36/37 (97%) and 25/33 (76%) dogs, respectively. Coagulopathies were identified in 26/31 (84%) dogs. When a definitive diagnosis was obtained, malignant neoplasia was diagnosed most frequently and occurred in 24/30 (80%) dogs. Hemangiosarcoma accounted for 21/30 (70%) diagnoses. Sixteen dogs underwent exploratory laparotomy, of which seven (44%) survived the perioperative period. Of the dogs that did not undergo surgery, 9/23 (39%) survived to be discharged from the hospital.

Increased albumin and fibrinogen synthesis rate in patients with chronic renal failure

BACKGROUND

Hypoalbuminemia and hyperfibrinogenemia are frequently observed in patients with chronic renal failure (CRF) and are both associated with cardiovascular diseases. The mechanisms responsible for hypoalbuminemia and hyperfibrinogenemia in CRF are unknown.

METHODS

In the present study, both albumin and fibrinogen kinetics were measured in vivo in predialysis patients (N = 6), patients on peritoneal dialysis (N = 7) and control subjects (N = 8) using l-[1-13C]-valine.

RESULTS

Plasma albumin concentration was significantly lower in patients on peritoneal dialysis compared to control subjects (P < 0.05). Plasma fibrinogen was significantly increased in both predialysis patients (P < 0.01) as well as patients on peritoneal dialysis (P < 0.001) in comparison to control subjects. In contrast to albumin, fibrinogen is only lost in peritoneal dialysate and not in urine. The absolute synthesis rates (ASR) of albumin and fibrinogen were increased in patients on peritoneal dialysis (ASR albumin, 125 +/- 9 mg/kg/day versus 93 +/- 9 mg/kg/day, P < 0.05; ASR fibrinogen, 45 +/- 4 mg/kg/day versus 29 +/- 3 mg/kg/day, P < 0.01) compared to control subjects. Albumin synthesis is strongly correlated with fibrinogen synthesis (r2 = 0.665, P < 0.0001, N = 21). In this study, the observed hypoalbuminemia in patients on peritoneal dialysis is likely not explained by malnutrition, inadequate dialysis, inflammation, metabolic acidosis, or insulin resistance. We speculate that peritoneal albumin loss is of relevance.

CONCLUSION

Synthesis rate of albumin and fibrinogen are coordinately up-regulated. Both albumin and fibrinogen are lost in peritoneal dialysis fluid. To compensate protein loss, albumin synthesis is up-regulated, but the response, in contrast to predialysis patients, does not fully correct plasma albumin concentrations in peritoneal dialysis patients. The increase in fibrinogen synthesis introduces an independent risk factor for atherosclerosis, since plasma fibrinogen pool is enlarged.

[Clinical observation of recombinant growth hormone therapy for liver cirrhosis with hypoproteinemia]

OBJECTIVE

To assess the effect of recombinant growth hormone (rhGH) therapy for liver cirrhosis patients with hypoproteinemia.

METHODS

Fifteen patients with liver cirrhosis were treated with rhGH (4 U per day) for 7 days and 15 controls were given human albumin (10 g) for every other day (altogether 3 times). Albumin was measured one day before the treatment, and on day 1, 10, 14, and 28 after the treatment.

RESULTS

After 7 days of rhGH administration, the albumin level of the patients was significantly higher and the function lasted longer than those of patients treated with human albumin (P < 0.05).

CONCLUSION

Exogenous rhGH in treating hypoproteinemia in patients with liver cirrhosis is more effective than human albumin.

Intestinal protein loss and hypoalbuminemia in children with pneumonia

BACKGROUND

Intestinal protein loss has been reported mainly in diseases affecting the gastrointestinal tract. Intestinal protein loss during pneumonia with effusion has not been reported to date. The authors attempted to assess the associations between pneumonia with effusion and intestinal protein loss and hypoalbuminemia in children.

METHODS

This was a prospective consecutive case series study of in children hospitalized with pneumonia and effusion during a period of 4(1/2) years. Serum albumin, C-reactive protein (CRP), and fecal alpha-1 antitrypsin (alpha-1-AT) were measured in the first 72 hours of hospitalization. Two control groups were studied: one consisted of 50 febrile children hospitalized because of viral or mild bacterial infections, and the other consisted of 20 afebrile children hospitalized because of convulsive disorders.

RESULTS

Sixty-seven children ages 4 months to 14 years hospitalized with pneumonia and effusion were enrolled in the study. Fifty-nine percent (40 children) were found to have elevated fecal alpha-1-AT excretion (range, 2-10 mg/g) compared with none in the two control groups (P < 0.000).Fifty-two percent (35 children) of the children with pneumonia and effusion had mild to moderate hypoalbuminemia (range, 22-34 g/L). Only one child (2%) in the febrile control group had a low albumin of 34 g/L; none were found in the afebrile control group. The level of fecal alpha-1-AT was inversely correlated with serum albumin level.

CONCLUSIONS

Pneumonia with effusion in children is often associated with an intestinal protein loss that can be monitored by measuring gastrointestinal loss of protein, namely fecal alpha-1-AT. In most cases the development of hypoalbuminemia correlates with the development of intestinal protein loss.

Factors determining the post-operative hypo-albuminaemia in cancer patients--stepwise regression analysis

AIM

To investigate factors influencing post-operative hypo-albuminaemia in cancer patients, with special reference to low dose albumin and/or immunoglobulins administration.

PATIENTS AND METHODS

In 270 patients with malignant neoplasms, who underwent extensive chest and/or abdominal surgery, albumin concentrations on the first four postoperative days were examined. One hundred and three high-risk patients received human immunoglobulins intravenously; 44 were given albumin. Univariate and multivariate regression analyses were used to determine the factors influencing albuminaemia on the first four postoperative days.

RESULTS

Mean nadir of hypo-albuminaemia occurred on the third postoperative day. In the multivariate analysis, a positive correlation was found between postoperative albuminaemia and pre-operative albuminaemia (b = 0.4919; p = 0.0000) as well as male gender (b = 2.0939; p = 0.0025). A negative correlation was found with the duration of surgery (b = -0.0416; p = 0.0212), pre-operative plasma protein (b = -0.2118, p = 0.0130) and postoperative immunoglobulin administration (b = -1.8858, p = 0.0074).

CONCLUSIONS

Postoperative albuminaemia is positively correlated with pre-operative albuminaemia and male gender and negatively correlated with the duration of surgery, pre-operative proteinaemia and postoperative Ig administration.

Hypoalbuminemia is a marker of overhydration in chronic maintenance patients on dialysis

Hypoalbuminemia is an important risk factor for increased morbidity and mortality in patients on dialysis. Hypoalbuminemia is usually attributed to malnutrition or a state of chronic inflammation. However, hypoalbuminemia could result from hemodilution caused by chronic volume expansion. We prospectively evaluated 142 patients on chronic dialysis for 12 consecutive months (mean age: 62 +/- 14 years; 41% women, 37% African American, 43% diabetic, 27% peritoneal dialysis). Intracellular (ICW) and extracellular (ECW) water content was estimated using single frequency bioelectrical impedance. Values in each albumin grouping (group 1, < 3.5 g/dl; group 2, 3.5-4.0 g/dl; group 3, > 4.1 g/dl) are expressed as annual mean +/- SEM. Group 1 patients had lower body weight, body mass index, blood urea nitrogen, serum creatinine, dietary protein intake, and ICW content than those in groups 2 and 3. ECW was significantly increased in group 1 when compared with groups 2 and 3 (p < 0.001). A significant correlation was found between ECW and serum albumin concentration (R = 0.2230; p < 0.0001). Resistance and reactance were decreased in group 1 when compared with groups 2 and 3 (p < 0.05 and 0.001, respectively), causing the resultant bioimpedance vector to move away from the normal population range into the overhydration boundaries. We conclude that, in addition to malnutrition and chronic inflammation, overhydration is a contributor to hypoalbuminemia in patients on chronic dialysis.

Pleural effusion caused by prostaglandin E1 preparation

We encountered a case of bilateral pleural effusion associated with prostaglandin E(1) (PGE(1)) preparation. A 75-year-old man underwent replacement surgery for an amputated hand. PGE(1) was administered at 120 micro g/d to maintain circulation after vascularization. From day 7 of administration, respiratory distress developed. On day 12, pleural effusion was observed bilaterally. By discontinuing PGE(1) and improving hypoalbuminemia, pleural effusion resolved rapidly. This is the first case report of PGE(1)-induced pleural effusion; like other drug-induced pleural effusions, discontinuing the drug resulted in rapid improvement. Although a rare complication, pleural effusion has to be suspected when a patient receiving PGE(1) experiences difficulty with breathing.

[Hypoalbuminemia and invalidating edema in an elderly subject: treatment with parenteral albumin infusion]

Many factors can lead to edema. Hypoalbuminemia and the inability of the renal distal tubule to excrete salt are a common cause of edema, that can be due to a defect of albumin synthesis or malnutrition, kidney disease, protein-losing enteropathy, or increased protein catabolism. Hypoalbuminemia is frequent amongst elderly people. Its prevalence ranges from 4% to 50% depending on whether they live at home or in hospice. In normal circumstances, albumin has a double function to maintain oncotic pressure and to transport endogenous or exogenous substances. Lack of albumin is thus responsible for numerous pathological states. In this article, we report two clinical observations in patients aged over 65, suffering from generalized, highly invalidating edema, with low albumin states due to malnutrition. A rapid long-term recovery was observed after administrating albumin, and produced a far better quality of life for the patients. The clinical results obtained following this specific indication warrant further research work to verify their scientific validity on a larger scale.

[Albumin and its use]

Although albumin (A) may be considered an ideal natural colloid, the clinical importance efficacy of A administration in the treatment of critical illness have changed considerably of late years. This article reviews data about the use of A at present. It is obvious that, routine administration of A on the basis of reduced plasma albumin levels cannot be recommended. There are at the present time no clear indications for A administration. Albumin can be used only as a second-choice infusion solution when other products are not indicated, are contraindicated or have been used up their maximum dose.

[Study of non-invasive hemodynamic parameters in pulmonary edema: hypoalbuminemia is a factor frequently associated with acute diastolic cardiac insufficiency]

SUBJECT

A critical diminution of the gradient between plasma oncotic pressure (PO) and pulmonary capillary pressure (PCP) is the origin of the formation of haemodynamic pulmonary oedema (OAP), but the respective contribution of these two haemodynamic forces as a function of the type of cardiac insufficiency is not known.

METHOD

74 cases of OAP were included (78 +/- 15 years old, 43 diastolic defined by an ejection fraction greater than 45%, and 31 systolic), and 33 control subjects. PO and PCP were calculated respectively from total protein and albumin serum levels, and from transthoracic echocardiography with the new Doppler indices using refilling flow propagation speed in colour TM or the study of pulmonary venous flow, at the start of treatment.

RESULTS

The gradient was very significantly diminished in those with diastolic and systolic cardiac insufficiency compared to the control group (p < 0.001), with no difference between the two types of OAP. An elevation of PCP > or = 18 mm Hg was the principal haemodynamic factor in the critical diminution of the gradient in the systolic group and in the diastolic group with ischaemic or valvular cardiopathy. In parallel with the elevation in PCP was a state of plasma hypo-oncocity < or = 18 mm Hg, consecutive with a significant diminution of albuminaemia, contributing to the critical diminution of the gradient in 41% of diastolic cases versus 3% of systolic cases.

CONCLUSION

Hypo-albuminaemia is a factor frequently favouring acute diastolic cardiac insufficiency in elderly subjects and must be sought systematically.

[Protein losing enteropathy (PLE) detected by Tc99m-labelled human serum albumin abdominal scintigraphy--case report]

Protein losing enteropathy (PLE) is a gastrointestinal disorder that is associated with excessive loss of plasma protein into the gut resulting from abnormal mucosal permeability. The disease is usually caused by inflammation. The loss of protein in PLE is a nonselective process affecting albumin, globulin and transferrin. Abdominal scintigraphy with human serum albumin marked by Tc99m seems to be an easy and sensitive method for diagnosing PLE. An 4-year-old girl was presented to an outside Pediatric Department due to hypoproteinemia and recurrent pneumonia which had caused several prior hospitalizations. The laboratory tests revealed hypoproteinemia, hypoalbuminemia, low level of IgG, sideropenia, and a decreased level of T lymphocytes. The loss of protein into the gut was confirmed by fecal clearance of alfa-1 antitrypsin. Only nonspecific inflammation was detected by biopsy of the small intestine. These clinical and laboratory findings, quickly decreasing IgG and albumin levels in spite of i.v. supplementation and the lack of proteinuria permitted PLE diagnosis. The abdominal scintigraphy was planned to assess and localise protein losing through GIT and for strategy of possible surgical treatment. Abdominal dynamic scintigraphy was performed immediately after the injection of 300 MBq Tc99m human albumin. 90 images were taken within 180 minutes. Delayed abdominal images were obtained 6 and 24 hours after the tracer injection. Anterior abdominal scintigraphy showed pathological activity of Tc99m-albumin in small bowel in the upper left segment of the abdomen in the 40th minute after injection. Extensive accumulation of albumin was seen in the 160th minute. Delayed images, after 3 and 6 hours, revealed translocation of the tracer into the lower right abdominal segment. The further passage and tracer concentration was detected in ascendant and transverse colon. Based on the laboratory tests and scintigraphic images the girl was suspected to have segmental lymphangiectasia of small intestine and was qualified for laparatomy and, possibly, for surgical resection of the pathologically changed bowel. However, diffuse pathological changes revealed in the guts during the operation, rendered the operation impossible. Tc99m-labelled human serum albumin scintigraphy may be considered the method-of-choice in the diagnosis of protein-losing enteropathy. However, in this test the assessment of the enteropathy dimension is difficult and surgical treatment should be planned with caution.

A Patient with Severe Hypertriglyceridemia Associated with Anemia and Hypoalbuminemia

We report a patient with severe hypertriglyceridemia associated with anemia and hypoalbuminemia, in which the former may have caused the latter two conditions. This is the first reported case of abrupt onset of severe hypertriglyceridemia resulting in suppression of bone marrow and liver function.

[Trichobezoars, a little known clinical entity]

A voluminous trichobezoar was discovered in an 11-year-old girl without major clinical implications. The diagnosis was made by endoscopy and surgery was performed without complications.

High peritoneal transport: a blessing or curse?

High transporters are defined based on the peritoneal equilibration test. Peritoneal transport rate changes over time, inflammation and angiogenesis affecting the total pore area. Factors influencing the neovascularization process are described. High transporters have distinctive clinical and laboratory features. The incidence of high transporters varies among different populations. Unfortunately, high transporters have the worst clinical outcomes. Mechanisms proposed to explain the adverse prognosis--including hypoalbuminemia, chronic fluid overload, malnutrition, and chronic inflammation--are discussed. We suggest dividing baseline high transporters into two groups: "sick" and "healthy" high transporters. The two types of high transporters have different baseline characteristics and different clinical outcomes. Hopefully, further studies will better define the appearance of the two groups of high transporters.

A new approach to classifying malnutrition in the hemodialysis patient

BACKGROUND

Novel classification nomenclature defining the type of malnutrition by the root cause of the hypoalbuminenia has been developing in the literature since 1999. As the classification of malnutrition became more definite in the literature, the need to assess the type of malnutrition, thereby the root cause(s) and initiate appropriate intervention(s), has become apparent.

METHODS

In September 1999, San Diego Dialysis began a continuous quality improvement (CQI) project to assess the root causes of hypoalbuminemia for patients with serum albumin level <3.5 g/dL. An extensive review of the literature was conducted on the subject of malnutrition, inflammation, and the acute-phase reaction.

FINDINGS

Two major groups of patients emerged: those consuming adequate protein and calories, yet presenting with hypoalbuminemia, and those suffering from a protein calorie deficit. Observation of the second group showed that although the monthly percentage of patients with hypoalbuminemia remained fairly constant, the names on the list changed from month to month.

CONCLUSIONS

The CQI team developed a protocol and a unique nomenclature to classify the types of malnutrition, type I, type IIa, type IIb, or mixed, by adapting the definitions in the literature through clinical practice. Interventions were developed to address each classification of malnutrition.

The relationship between serum albumin and hydration status in hemodialysis patients

OBJECTIVE

A decreased serum albumin level predicts poor survival in end-stage renal failure. Hypoalbuminemia is multifactorial and related to poor nutrition, inflammation, and comorbid disease. Overhydration is also common in renal replacement therapy patients, and hemodilution may also contribute to a low serum albumin level.

DESIGN

Crosssectional observational study.

SETTING

Outpatient hemodialysis unit of a district general hospital.

SUBJECTS

We investigated the relationship of serum albumin to C-reactive protein (CRP) and hydration state in 49 unselected hemodialysis patients (28 men).

METHODS

Patients were assessed predialysis and postdialysis at their clinical dry weight. Extracellular fluid volume (Vecf) and total body water (Vtbw) were estimated by whole-body bioelectric impedance. Vecf was expressed as a percentage of Vtbw (Vecf%Vtbw). Predialysis CRP, predialysis and postdialysis serum albumin, and body weight were measured. Normalized protein catabolic rate (nPCR) and KT/V urea were calculated.

RESULTS

Predialysis and postdialysis serum albumin levels were 36.9 g/L (95% CI, 35.7 and 38.1) and 41.4 g/L (95% CI, 39.7 and 43.3), respectively (P <.0001). Mean weight change was 2.0 +/- 1.2 kg. Predialysis and postdialysis serum albumin levels were negatively correlated with CRP (before: r = -0.393, P <.005; after: r = -0.445, P =.001) and positively with nPCR (before: r = 0.336, P =.018; after: r = 0.353, P =.013). Predialysis serum albumin level correlated with predialysis Vecf%Vtbw (r = -0.384, P =.006) and postdialysis serum albumin level with postdialysis Vecf%Vtbw (r = -0.654, P <.0001). In multivariate analysis, predialysis albumin was dependent on nPCR (P =.04), CRP (P <.0001), and predialysis Vecf%Vtbw (P =.002), and postdialysis albumin was dependent on nPCR (P =.01), CRP (P =.002), and postdialysis Vecf%Vtbw (both P <.0001). The increase in albumin was strongly correlated with both change in actual weight (r = -0.651, P <.0001) and change in Vecf%Vtbw (r = -0.684, P <.0001).

CONCLUSION

In unselected hemodialysis patients, serum albumin level is dependent on nPCR, CRP, and extracellular fluid volume. This relationship persists after dialysis, suggesting that many patients remain fluid overloaded at their postdialysis dry weight.

Biochemical changes and liver tissue pathology in weanling Wistar albino rats with protein-energy malnutrition (PEM)

Kwashiorkor remains a significant cause of childhood morbidity and mortality in tropical regions. However, there are relatively few reproducible animal models to elucidate the aetiopathogenesis, biochemical derangements, and morphological changes of this condition. In the present study, 64 weanling male Wistar albino rats were divided into high protein chow, high protein maize starch, and low protein maize starch groups. After 4 weeks on these respective diets, animals on the low protein diet were commenced on the high protein maize starch diet, while those in the other groups were continued on their original diets for a further period of 5 weeks each The low protein group of animals initially showed growth failure, hair loss, oedoma, fatty liver, metabolic acidosis, hypoalbuminaemia, and anaemia, which are characteristic features of human kwashiorkor. These changes were all reversed by dietary rehabilitation with the high protein diet. The reduced plasma retinol, increased plasma alanine and aspartate aminotransferases and fatty liver observed in the low protein group of animals probably suggest an important role for free radicals in the aetiopathogenesis of kwashiorkor.

[Electrophoretic behaviour of serum and liver proteins and of some isoenzymes in rats receiving a steatogenous, hyperlipidic, hypoprotein diet, with and without choline]

Albino rats were kept for long periods on a steatogenous, hypoproteic, hyperlipidic diets, either with or without choline. Serum protein and liver soluble protein and enzyme values showed changes that were only partly similar to those observed in human and experimental cirrhosis. The main features, in fact, were an absolute and percent decrease in albumins, an increase in serum alpha1-globulins and alpha proteins generally, and, more particularly, a constant fall in gamma-globulins and enzymes migrating to this site.