Y90 Radioembolization Significantly Prolongs Time to Progression Compared With Chemoembolization in Patients With Hepatocellular Carcinoma

BACKGROUND & AIMS

Conventional transarterial chemoembolization (cTACE) is used to treat patients with hepatocellular carcinoma (HCC). Radioembolization is a minimally invasive procedure that involves implantation of radioactive micron-sized particles loaded with yttrium-90 (Y90) inside the blood vessels that supply a tumor. We performed a randomized, phase 2 study to compare the effects of cTACE and Y90 radioembolization in patients with HCC.

METHODS

From October 2009 through October 2015, we reviewed patients with HCC of all Barcelona Clinic Liver Cancer (BCLC) stages for eligibility. Of these, 179 patients with BCLC stages A or B met our enrollment criteria and were candidates for cTACE or Y90 therapy. Patients were assigned randomly to groups that received Y90 therapy (n = 24; 50% Child-Pugh A) or cTACE (n = 21; 71% Child-Pugh A). The primary outcome was time to progression (TTP), evaluated by intention-to-treat analysis. Secondary outcomes included safety, rate of response (based on tumor size and necrosis criteria), and Kaplan-Meier survival time. We performed inverse probability of censoring weighting and competing risk analyses.

RESULTS

Patients in the Y90 radioembolization group had significant longer median TTP (>26 mo) than patients in the cTACE group (6.8 mo; P = .0012) (hazard ratio, 0.122; 95% confidence interval [CI], 0.027-0.557; P = .007). This was confirmed by competing risk and inverse probability of censoring weighting analyses accounting for transplantation or death. A significantly greater proportion of patients in the cTACE group developed diarrhea (21%) than in the Y90 group (0%; P = .031) or hypoalbuminemia (58% in the cTACE group vs 4% in the Y90 group; P < .001). Similar proportions of patients in each group had a response to therapy, marked by necrosis (74% in the cTACE group vs 87% in the Y90 group) (P = .433). The median survival time, censored to liver transplantation, was 17.7 months for the cTACE group (95% CI, 8.3-not calculable) vs 18.6 months for the Y90 group (95% CI, 7.4-32.5) (P = .99).

CONCLUSIONS

In a randomized phase 2 study of patients with HCC of BCLC stages A or B, we found Y90 radioembolization to provide significantly longer TTP than cTACE. Y90 radioembolization provides better tumor control and could reduce drop-out from transplant waitlists. ClinicalTrials.gov no. NCT00956930.

Human serum albumin in cardiovascular diseases

Cardiovascular diseases are the leading cause of death worldwide. Endothelial dysfunction, inflammation and oxidative stress are at the forefront in the onset and development of atherosclerosis and many cardiovascular diseases. Epidemiological evidence is that low serum albumin levels are linked to incident ischemic heart disease, heart failure, atrial fibrillation, stroke and venous thromboembolism, independent of risk factors, body mass index and inflammation. Hypoalbuminemia has also emerged as an independent prognosticator in many cardiovascular diseases, such as coronary artery disease, heart failure, congenital heart disease, infective endocarditis and stroke, even after adjusting for usual causal factors and prognostic markers. Given physiological properties of serum albumin that include anti-inflammatory, antioxidant, anticoagulant and antiplatelet aggregation activity as well as colloid osmotic effect, hypoalbuminemia could act as an unrecognized modifiable risk factor. The purpose of this review is to provide an overview of the physiological properties of serum albumin, as well as prevalence, causes, prognostic value and potential contribution to the disease emergence and progression of hypoalbuminemia, and the resulting clinical implications.

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.

Metabolic Acidosis of CKD: Diagnosis, Clinical Characteristics, and Treatment

Metabolic acidosis is noted in the majority of patients with chronic kidney disease (CKD) when glomerular filtration rate (GFR) decreases to less than 20% to 25% of normal, although as many as 20% of individuals can have acid-base parameters close to or within the normal range. Acidosis generally is mild to moderate in degree, with plasma bicarbonate concentrations ranging from 12 to 22 mEq/L (mmol/L), and it is rare to see values less than 12 mEq/L (mmol/L) in the absence of an increased acid load. Degree of acidosis approximately correlates with severity of renal failure and usually is more severe at a lower GFR. The metabolic acidosis can be of the high-anion-gap variety, although anion gap can be normal or only moderately increased even with stage 4 to 5 CKD. Several adverse consequences have been associated with metabolic acidosis, including muscle wasting, bone disease, impaired growth, abnormalities in growth hormone and thyroid hormone secretion, impaired insulin sensitivity, progression of renal failure, and exacerbation of beta 2 -microglobulin accumulation. Administration of base aimed at normalization of plasma bicarbonate concentration might be associated with certain complications, such as volume overload, exacerbation of hypertension, and facilitation of vascular calcifications. Whether normalization of plasma bicarbonate concentrations in all patients is desirable therefore requires additional study. In the present review, we describe clinical and laboratory characteristics of metabolic acidosis, discuss potential adverse effects, and address benefits and complications of therapy.

Effects of Albumin Treatment on Systemic and Portal Hemodynamics and Systemic Inflammation in Patients With Decompensated Cirrhosis

BACKGROUND & AIMS

We investigated the effect of albumin treatment (20% solution) on hypoalbuminemia, cardiocirculatory dysfunction, portal hypertension, and systemic inflammation in patients with decompensated cirrhosis with and without bacterial infections.

METHODS

We performed a prospective study to assess the effects of long-term (12 weeks) treatment with low doses (1 g/kg body weight every 2 weeks) and high doses (1.5 g/kg every week) of albumin on serum albumin, plasma renin, cardiocirculatory function, portal pressure, and plasma levels of cytokines, collecting data from 18 patients without bacterial infections (the Pilot-PRECIOSA study). We also assessed the effect of short-term (1 week) treatment with antibiotics alone vs the combination of albumin plus antibiotics (1.5 g/kg on day 1 and 1 g/kg on day 3) on plasma levels of cytokines in biobanked samples from 78 patients with bacterial infections included in a randomized controlled trial (INFECIR-2 study).

RESULTS

Circulatory dysfunction and systemic inflammation were extremely unstable in many patients included in the Pilot-PRECIOSA study; these patients had intense and reversible peaks in plasma levels of renin and interleukin 6. Long-term high-dose albumin, but not low-dose albumin, was associated with normalization of serum level of albumin, improved stability of the circulation and left ventricular function, and reduced plasma levels of cytokines (interleukin 6, granulocyte colony-stimulating factor, interleukin 1 receptor antagonist, and vascular endothelial growth factor) without significant changes in portal pressure. The immune-modulatory effects of albumin observed in the Pilot-PRECIOSA study were confirmed in the INFECIR-2 study. In this study, patients given albumin had significant reductions in plasma levels of cytokines.

CONCLUSIONS

In an analysis of data from 2 trials (Pilot-PRECIOSA study and INFECIR-2 study), we found that albumin treatment reduced systemic inflammation and cardiocirculatory dysfunction in patients with decompensated cirrhosis. These effects might be responsible for the beneficial effects of albumin therapy on outcomes of patients with decompensated cirrhosis. ClinicalTrials.gov, Numbers: NCT00968695 and NCT03451292.

Hypoalbuminemia and Clinical Outcomes: What is the Mechanism behind the Relationship?

Albumin has a number of important physiologic functions, which include maintaining oncotic pressure, transporting various agents (fatty acids, bile acids, cholesterol, metal ions, and drugs), scavenging free oxygen radicals, acting as an antioxidant, and exerting an antiplatelet effect. Hypoalbuminemia in adults, defined by an intravascular albumin level of <3.5 g/dL, is associated with poor postoperative outcomes in patients undergoing surgical intervention. Although the relationship of hypoalbuminemia and poor surgical outcome has been known for many years, the pathophysiology behind the relationship is unclear. Three theoretical constructs might explain this relationship. First, albumin might serve as a nutritional marker, such that hypoalbuminemia represents poor nutritional status in patients who go on to experience poor postoperative outcomes. Second, albumin has its own pharmacologic characteristics as an antioxidant or transporter, and therefore, the lack of albumin might result in a deficiency of those functions, resulting in poor postoperative outcomes. Or third, albumin is known to be a negative acute phase protein, and as such hypoalbuminemia might represent an increased inflammatory status of the patient, potentially leading to poor outcomes. A thorough review of the literature reveals the fallacy of these arguments and fails to show a direct cause and effect between low albumin levels per se and adverse outcomes. Interventions designed solely to correct preoperative hypoalbuminemia, in particular intravenous albumin infusion, do little to change the patient's course of hospitalization. While surgeons may use albumin levels on admission for their prognostic value, they should avoid therapeutic strategies whose main endpoint is correction of this abnormality.

Hypoalbuminemia as Surrogate and Culprit of Infections

Hypoalbuminemia is associated with the acquisition and severity of infectious diseases, and intact innate and adaptive immune responses depend on albumin. Albumin oxidation and breakdown affect interactions with bioactive lipid mediators that play important roles in antimicrobial defense and repair. There is bio-mechanistic plausibility for a causal link between hypoalbuminemia and increased risks of primary and secondary infections. Serum albumin levels have prognostic value for complications in viral, bacterial and fungal infections, and for infectious complications of non-infective chronic conditions. Hypoalbuminemia predicts the development of healthcare-associated infections, particularly with Clostridium difficile. In coronavirus disease 2019, hypoalbuminemia correlates with viral load and degree of acute lung injury and organ dysfunction. Non-oncotic properties of albumin affect the pharmacokinetics and pharmacodynamics of antimicrobials. Low serum albumin is associated with inadequate antimicrobial treatment. Infusion of human albumin solution (HAS) supplements endogenous albumin in patients with cirrhosis of the liver and effectively supported antimicrobial therapy in randomized controlled trials (RCTs). Evidence of the beneficial effects of HAS on infections in hypoalbuminemic patients without cirrhosis is largely observational. Prospective RCTs are underway and, if hypotheses are confirmed, could lead to changes in clinical practice for the management of hypoalbuminemic patients with infections or at risk of infectious complications.

Why is protein-energy wasting associated with mortality in chronic kidney disease?

Observational studies in chronic kidney disease (CKD) populations consistently have shown the strong mortality-predictability of such markers of protein-energy wasting (PEW) as hypoalbuminemia, low serum cholesterol levels, low body mass index, and reduced dietary protein intake. Even though the PEW-mortality association data traditionally are reported mostly in maintenance dialysis patients, emerging studies extend the existence of these associations to predialysis stages of CKD. Paradoxic risk factor patterns (reverse epidemiology) for both obesity and cholesterol recently have been reported in predialysis CKD, underscoring the overwhelming impact of PEW, a short-term killer, on reversing the long-term effect of conventional cardiovascular risk factors. Multiple pathophysiologic mechanisms have been suggested to explain the link between PEW and mortality in CKD, including derangements in muscle, adipose tissue, and the gastrointestinal, hematopoietic, and immune systems; complications related to deficiencies of multiple micronutrients; and the maladaptive activation of the inflammatory cascade. In addition to well-described pathophysiologic mechanisms involved in the higher mortality seen with PEW, we also discuss the potential role of novel factors such as circulating actin, gelsolin, and proinflammatory high-density lipoprotein. Whether PEW is causally related to adverse outcomes in CKD needs to be verified in randomized controlled trials of nutritional interventions. The initiation of major clinical trials targeting nutritional interventions with the goal of improving survival in CKD offer the promise of extending the survival of this vulnerable patient population.

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.

The relationship between hypoalbuminaemia, tumour volume and the systemic inflammatory response in patients with colorectal liver metastases

The relationship between hypoalbuminaemia, tumour volume and C-reactive protein was examined in patients with colorectal liver metastases (n=57). On multiple regression analysis, albumin concentrations were independently associated with C-reactive protein (r=0.56, P<0.001) but not percentage hepatic replacement (P=0.34). These results show that hypoalbuminaemia is associated with the presence of a systemic inflammatory response rather than tumour volume in patients with colorectal liver metastases.

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.

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.

Longitudinal and cross-sectional effects of C-reactive protein, equilibrated normalized protein catabolic rate, and serum bicarbonate on creatinine and albumin levels in dialysis patients

BACKGROUND

Loss of muscle mass and hypoalbuminemia each may result in part from either malnutrition, inflammation, or a combination of both. Short-term acidosis increases muscle protein catabolism and inhibits albumin synthesis.

METHODS

We analyzed albumin and creatinine levels as outcome variables and their association with C-reactive protein (CRP) level, equilibrated normalized protein catabolic rate (enPCR), and serum bicarbonate level as independent variables from laboratory data obtained from patients in the Hemodialysis Study. Analyses controlled for race, sex, age, body mass index, and randomized treatment group.

RESULTS

Albumin level correlated with both enPCR and CRP level, but not serum bicarbonate level, in both cross-sectional and longitudinal analyses. Effects of CRP level and enPCR were not linear. Albumin level correlated positively with enPCR for an enPCR less than 1.0 g/kg/d, but not for a greater enPCR, and correlated inversely with CRP level for a CRP level greater than 13 mg/L. Similarly, creatinine level correlated with both enPCR and CRP level. As in the case of albumin level, effects were not linear. Creatinine level correlated positively with enPCR for values less than 1.0 g/kg/d, but not for greater enPCR values. In contrast to albumin level, creatinine level correlated negatively with serum bicarbonate level, even when adjusted for enPCR.

CONCLUSION

Albumin and creatinine levels are independently associated with nutrition (enPCR) and inflammation (CRP level). The cross-sectional relationship with enPCR is apparent only at values less than 1.0 g/kg/d. CRP level is associated with reduced albumin and creatinine values when increased to values greater than 5.6 mg/dL. CRP may be increased to levels associated with increased cardiovascular risk with little or no effect on either serum albumin or creatinine level. Thus, a normal albumin level does not exclude elevated CRP levels.

Serum albumin and clinical outcome in pediatric cardiac surgery

OBJECTIVE

We evaluated the behavior of serum albumin concentrations in response to metabolic stress that is associated with cardiac surgery and the role of this protein as a predictor of clinical outcome in children at high surgical risk who undergo operative correction of congenital heart defects.

METHODS

Serum albumin concentrations were measured in 30 children who had heart disease and were at high surgical risk. Analyses were performed before surgery, on the second postoperative day, and on discharge from the intensive care unit. Preoperative serum concentrations of albumin were compared with those of a control group that consisted of 20 healthy and well-nourished children.

RESULTS

Preoperative albumin concentrations of patients were lower than those of the control group (3.4+/-0.25 g/dL versus 4.0+/-0.18 g/dL, P<0.05). Serum levels decreased on the second postoperative day and at discharge from the intensive care unit (3.1+/-0.65 g/dL and 3.2+/-0.44 g/dL, P<0.05) compared with preoperative concentrations. Preoperative concentrations lower than 3.0 g/dL were associated with increased postsurgical infection (P=0.0026) and with increased mortality (P=0.0138). Patients whose postoperative levels were lower than 3.0 g/dL had longer hospital stays compared with those whose concentrations were higher than 3.0 g/dL (14.5+/-1.3 d versus 10+/-2.2 d, P<0.05).

CONCLUSION

The results suggest that hypoalbuminemia is common among children who have heart disease and are at high surgical risk, and serum albumin concentrations lower than 3 g/dL may be related to outcome in the period after cardiac surgery.

Hypoalbuminemia in renal failure: pathogenesis and therapeutic considerations

Hypoalbuminemia is common in patients with end-stage renal disease (ESRD). It is caused by a combination of a reduced synthesis and an increased degradation of albumin. The altered albumin homeostasis in ESRD patients is caused by a systemic inflammatory state which correlates closely with mortality. Hypoalbuminemia is a strong predictor of an adverse prognosis, but it is not a pathogenic factor in itself. In critically ill patients in intensive care units, the intravenous administration of human serum albumin generally does not improve prognosis. In contrast, in hypoalbuminemic dialysis patients with volume overload and a reduced effective arterial volume the administration of albumin is based on the pathophysiological concept of increasing intravascular oncotic pressure to transfer extravascular fluid into the intravascular compartment for ultrafiltration in order to mobilize edema fluid.

Improving Albumin Levels Among Hemodialysis Patients: A Community-Based Randomized Controlled Trial

BACKGROUND

Low albumin level is a strong predictor of mortality and morbidity among hemodialysis patients, yet few interventions are available to improve albumin levels. Moreover, the relative importance of nutritional barriers versus inflammation in contributing to hypoalbuminemia is unclear. We sought to determine whether targeting specific nutritional barriers will improve albumin levels.

METHODS

We conducted a randomized controlled trial involving 180 patients with baseline albumin levels less than 3.7 g/dL (<37 g/L) at 44 long-term hemodialysis facilities. Study coordinators identified and intervened on specific barriers present among intervention patients, whereas control patients continued to receive the usual care. Barriers targeted included poor nutritional knowledge, poor appetite, help needed with shopping or cooking, low fluid intake, inadequate dialysis dose, depression, difficulty chewing, difficulty swallowing, gastrointestinal symptoms, and acidosis.

RESULTS

At baseline, intervention and control patients had similar albumin levels, dietary intakes, levels of inflammatory markers, and numbers of nutritional barriers. After 12 months, intervention patients had greater increases in albumin levels compared with control patients (+0.21 versus +0.06 g/dL [+2.1 versus +0.6 g/L]; P < 0.01), as well as greater increases in energy intake (+4.1 versus -0.6 Kcal/d/kg; P < 0.001) and protein intake (+0.13 versus -0.06 g/d/kg; P < 0.001). The intervention appeared most effective for barriers related to poor nutritional knowledge, help needed with shopping or cooking, and difficulty swallowing. About half the subjects had elevated levels of inflammatory markers, but there was no relationship between change in levels of albumin and inflammatory markers.

CONCLUSION

A nutrition intervention tailored to patient-specific barriers resulted in modest improvements in albumin levels regardless of levels of inflammatory markers.

Diagnostic discordance for hepatitis C virus infection in hemodialysis patients

BACKGROUND

Hepatitis C virus (HCV) infection is associated with an increase in proinflammatory cytokine levels. Similar changes are seen in maintenance hemodialysis patients with malnutrition-inflammation-cachexia syndrome (MICS), which is associated with poor clinical outcomes in this population. We hypothesized that HCV transcription-mediated amplification (TMA), a sensitive qualitative molecular test for HCV RNA, may identify maintenance hemodialysis patients with HCV infection not detected by means of antibody enzyme immunoassay (EIA), particularly in those with MICS.

METHODS

We evaluated HCV status in 314 maintenance hemodialysis patients by using HCV antibody EIA (version 2.0; Abbott Laboratories, Abbott Park, IL) and HCV TMA (Bayer Diagnostics Laboratories, Berkeley, CA).

RESULTS

Twenty-five patients (8%) were EIA positive (EIA+)/TMA+; 4 patients (1%), EIA+/TMA negative (TMA-), and 22 patients (7%), EIA-/TMA+. In the 47 TMA+ patients, the sensitivity of EIA for HCV infection was only 53%. TMA+ patients had lower albumin levels and higher tumor necrosis factor alpha and serum glutamic oxaloacetic transaminase levels than TMA- patients. EIA+/TMA+ patients were more likely than EIA-/TMA+ or EIA-/TMA- patients to have hypoalbuminemia and higher iron and transaminase levels. Of all TMA+ patients, EIA- patients were more likely to have diabetes, be on dialysis therapy longer, and have lower liver enzyme levels and higher proinflammatory cytokine levels, including tumor necrosis factor alpha and interleukin 6.

CONCLUSION

Maintenance hemodialysis patients infected with HCV according to TMA have clinical features suggestive of MICS. In this population, HCV EIA appears to have a low sensitivity for the identification of HCV infection, which may be caused by the confounding effect of MICS or other demographic or clinical factors. These apparently false-negative HCV antibody test results are seen in persons with a longer time on hemodialysis therapy, mirroring observations in other populations with serious progressive conditions, such as human immunodeficiency virus infection.

A high peritoneal large pore fluid flux causes hypoalbuminaemia and is a risk factor for death in peritoneal dialysis patients

BACKGROUND

Hypoalbuminaemia is common in peritoneal dialysis (PD) patients and has an associated high mortality. An excess morbidity and mortality has previously been found in patients with high peritoneal transport. A high peritoneal large pore fluid flux (Jv(L)) results in increased peritoneal loss of protein that possibly contributes to patient morbidity. Alternatively, hypoalbuminaemia and high transport status could be just a marker of capillary pathology associated with atherosclerotic comorbidity.

METHODS

Peritoneal dialysis capacity computer modelling of peritoneal transport, based on Rippe's three-pore model, was performed to measure Jv(L) in 155 incident PD patients 2-4 weeks after PD initiation. Patient clinical and biochemical status was determined -6, -3, -1, 1 and 6 months after PD initiation, and every 6 months thereafter. Jv(L) was redetermined in prevalent patients 2 and 4 years after PD initiation.

RESULTS

Jv(L) was 0.106+/-0.056 ml/min/1.73 m(2) (median 0.094, interquartile range 0.068-0.128). It was correlated to age*** (*P<0.05; **P<0.01; ***P<0.001) (20-30 years 0.079+/-0.04; 70 years 0.121+/-0.071), but not to gender. No correlation to diabetic or preexisting renal replacement therapy was seen, but patients with atherosclerosis had higher Jv(L) (0.123+/-0.06 vs 0.100+/-0.056*) as had patients with other systemic disease (0.121+/-0.68 vs 0.100+/-0.051*). Jv(L) was positively correlated to area parameter (r = 0.41***), and negatively correlated to plasma albumin (-0.36***). Patients were divided into three equal groups: group 1, Jv(L) <0.075 ml/min/1.73 m(2); group 2, 0.075-0.11; group 3: >0.11. There was no difference between the groups in p-albumin prior to PD. Immediately after PD start, differences between the three groups appeared (1 month p-albumin: (micromol/l) group 1, 548+/-83; group 2, 533+/-86; group 3, 497+/-78**), and persisted for up to 6 years. No significant change in Jv(L) was seen at 2 and 4 years. Patients with significant albuminuria also had hypoalbuminaemia (<1 g/day: 546+/-81 mumol/l; >2 g/day: 503+/-54 micromol/l). Intermittent PD ameliorated the effect of Jv(L) on albumin losses and clearance. Mortality was increased significantly with raised Jv(L), independently of age (2 year mortality: group 1, 10%, group 3, 32%*). There was no overall effect on technique survival, but hypoalbuminaemic group 3 patients had a higher failure rate.

CONCLUSION

Jv(L) is related to hypoalbuminaemia and mortality after PD initiation. A high Jv(L) seems to be a marker of preexisting vascular pathology, and to cause hypoalbuminaemia after PD initiation. It is suggested that peritoneal albumin loss can have an identical pathogenic effect as urinary albumin loss, by causing an iatrogenic "nephrotic" syndrome.

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.

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.

Cytomegalovirus-associated protein-losing gastropathy in childhood

Menetrier's disease is an uncommon disease in childhood, characterized by gastric hypertrophy and hypoalbuminemia secondary to protein loss through the gastric mucosa. This paper describes a series report of protein-losing gastropathy associated with cytomegalovirus (CMV) infection in children and reviews the literature. We reviewed the medical records of eight children with diagnosis of Menetrier's disease or protein-losing gastropathy with evidence of acute CMV infection. During a five-year period there were eight children that were diagnosed with CMV-associated protein-losing gastropathy, all in one medium-sized pediatric ward in a general hospital. The mean age was 32 months and there was no gender predominance. The most common presenting symptoms were vomiting and edema. Average symptoms' duration prior to admission was 3.2 weeks and mean albumin at presentation was 1.8 g/dl (range, 1.5-2.5 g/dl; normal values, 3.5-5 g/dl). All eight children fully recovered. In conclusion, CMV infection should be suspected in every child who presents with protein-losing gastropathy. The availability of newer, rapid diagnostic techniques such as polymerase chain reaction (PCR) may facilitate diagnosis, as serology studies may be misleading. Usually, only supportive care is required, but treatment with ganciclovir may be considered for severe or prolonged cases.

A pilot study on tacrolimus treatment in membranous or quiescent lupus nephritis with proteinuria resistant to angiotensin inhibition or blockade

Persistent proteinuria in patients with quiescent lupus can result from membranous lupus nephritis and/or glomerular scarring following previous flares. This pilot study examined the effects of tacrolimus over two years in six patients with membranous/inactive lupus nephritis and persistent proteinuria despite angiotensin inhibition/blockade. Tacrolimus treatment reduced proteinuria and increased serum albumin (time effect, P = 0.047 and 0.032 respectively). Compared with baseline levels, proteinuria improved by more than 50% in five patients (83.3%) and hypoalbuminaemia was corrected in four patients. The efficacy was most prominent in four patients with biopsy-proven membranous lupus nephritis, whose protienuria improved by over 80%. One patient developed biopsy-proven chronic nephrotoxicity after 10 months of tacrolimus treatment, despite non-excessive blood levels. These data suggest that tacrolimus is an effective treatment for proteinuria due to membranous lupus nephritis, but should probably be reserved for patients who are refractory to other non-nephrotoxic treatments, in view of the potential risk of subclinical nephrotoxicity.

Zinc and protein metabolism in chronic liver diseases

The capacity to metabolize proteins is closely related to the hepatic functional reserve in patients with chronic liver disease, and hypoalbuminemia and hyperammonemia develop along with hepatic disease progression. Zinc deficiency, which is frequently observed in patients with chronic liver disease, significantly affects protein metabolism. Ornithine transcarbamylase is a zinc enzyme involved in the urea cycle. Its activity decreases because of zinc deficiency, thereby reducing hepatic capacity to metabolize ammonia. Because the glutamine-synthesizing system in skeletal muscles compensates for the decrease in ammonia metabolism, hyperammonemia does not develop in the early stages of chronic liver disease. However, branched-chain amino acids (BCAAs) are consumed with the increase in glutamine-synthesizing system reactions, leading to a decreased capacity to synthesize proteins, including albumin, due to amino acid imbalance. Upon further disease progression, skeletal muscle mass decreases because of nutritional deficiency, as well as the further decreased capacity to metabolize ammonia in the liver, whereby the capacity to detoxify ammonia reduces as a whole, resulting in hyperammonemia. BCAA supplementation therapy for nutritional deficiency in liver cirrhosis improves survival by correcting amino acid imbalance via recovery of the capacity to synthesize albumin, while zinc supplementation therapy improves the capacity to metabolize ammonia in the liver. Here, the efficacy of a combination of BCAA and zinc preparation for nutritional deficiency in liver cirrhosis, as well as its theoretical background, was reviewed.

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.

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.