The role of albumin in human physiology and pathophysiology, Part III: Albumin and disease states

Correlation between lung injury score and serum albumin levels in patients at risk for developing acute lung injury

This is a prospective observational study of 100 consecutive patients who were at risk for developing acute lung injury and were admitted into the surgical intensive care unit. We found a highly significant correlation between an increase in serum albumin levels and a fall in lung injury score and vice versa (r = -0.51, P = 0.000). A highly significant association was also found between mortality, fall in serum albumin levels, rise in lung injury score, and a higher simplified acute physiology score at admission (P = 0.000).

Four-year experience with a unit for long-term ventilation (respiratory special care unit) at the Cleveland Clinic Foundation

BACKGROUND

In the context that special weaning units have been advocated as effective alternatives to the ICU for weaning selected patients, we initiated a Respiratory Special Care Unit (ReSCU) at the Cleveland Clinic Hospital in August 1993. The goals of the ReSCU were the following: (1) to wean ventilator-dependent patients when possible; and (2) when weaning was not possible, to optimize patient and family instruction for patients going home with ventilatory support. This study presents our 4-year experience with 212 patients managed in the ReSCU and analyzes clinical features associated with favorable clinical outcomes.

METHODS

The features of the ReSCU include six private beds in a pulmonary inpatient ward staffed by nurses with special pulmonary expertise; 24-h respiratory therapy supervision; bedside and central noninvasive monitoring (i.e., continuous pulse oximetry, end tidal capnometry, and ventilator alarms); and a multidisciplinary approach involving dietitians, physical therapists, occupational therapists, social workers, and speech pathologists. All ReSCU patients were cared for primarily by a pulmonary/critical care attending physician and fellow, with consultative input solicited as deemed necessary. The criteria for admission to the ReSCU included hemodynamic stability; absence of an arrhythmia requiring telemetry; and in the attending physician's judgment, the ability to benefit from the ReSCU.

RESULTS

Between August 23, 1993, and August 31, 1997, 212 patients were admitted to the ReSCU. The median age was 68 years old; 55% were women; 86% were white; and 55% were transferred from the medical ICU. Underlying reasons for ventilator dependence were ARDS from a nonsurgical cause (33%), ARDS following surgery (18%), status post-cardiothoracic surgery (13%), status post-thoracic surgery (12%), and COPD (12%). The median length of ReSCU stay was 17 days (interquartile range, 10 to 29 days). Eighteen percent (n = 38) died during the hospitalization. Among the 174 survivors, complete ventilator independence was achieved in 127 patients (60% of the 212 patient cohort), 28 patients were ventilator dependent (13% of 212 patients), and the remaining 19 patients (9%) required partial ventilatory support. Univariate analysis regarding the association of baseline characteristics with death identified lower albumin and transferrin levels, increasing age, and the physician's estimate of lower weaning likelihood as significant correlates of death. In contrast, achieving complete ventilator independence was associated with a higher serum albumin level, a nonmedical ICU referral source, a cause of respiratory failure other than COPD, and a physician's estimate of higher weaning likelihood. To analyze the financial impact of the ReSCU, we assumed that ReSCU patients would have otherwise stayed in the medical ICU and compared the charges (ICU vs ReSCU) with, for a subset of patients, the true costs of ReSCU vs. ICU care. Analyses of both charges and cost differences showed similar savings associated with ReSCU care ($13,339 per patient [charges] and $10,694 per patient [costs]).

CONCLUSIONS

We conclude the following: (1) the rate of achieving complete ventilator independence in the ReSCU was high; and (2) based on our achieving clinical outcomes, which are comparable to the most favorable rates reported in other series from ventilator units, we conclude that the ReSCU can be an effective and cost-saving alternative to the ICU for carefully selected patients.

Incidence, prognosis, and etiology of end-stage liver disease in patients receiving home total parenteral nutrition

BACKGROUND

Elevations in liver function tests have been reported in patients receiving total parenteral nutrition (TPN). The clinical aspects of end-stage liver disease (ESLD) associated with the prolonged use of home TPN have not been fully clarified. In previous series patients with duodenocolostomies appeared to be at higher risk than persons with some jejunum or ileum remaining in situ.

METHODS

The records of 42 patients treated with home TPN for more than 1 year were examined. This constituted 283 person-years of home TPN. Patients with duodenocolostomies were examined as a separate group on the basis of the literature experience.

RESULTS

Six of 42 patients who received chronic home TPN had ESLD with 100% subsequent mortality, at an average of 10.8 +/- 7.1 months after the initial bilirubin elevation. Thirteen of 42 patients had superior mesenteric artery or vein thrombosis (SMT) leading to duodenocolostomy. In 8 of these 13 patients with SMT and underlying inflammatory or malignant disorder, 2 had ESLD. The remaining 5 SMT patients who had only minimal liver enzyme elevation over 13.6 +/- 6.7 (range 3 to 19) years of home TPN were significantly younger (36 +/- 7 years vs 64 +/- 13 years) and did not have underlying inflammation either by clinical diagnosis or as reflected in the high normal serum albumin level (> or = 4.0 g/dL). Despite their extreme short bowel syndrome and long exposure to home TPN, ESLD did not develop.

CONCLUSIONS

Approximately 15% of patients who receive prolonged TPN have ESLD with a high rate of morbidity and mortality. The combination of chronic inflammation and the short bowel syndrome appears to be necessary for the development of ESLD with prolonged home TPN.

The relationship between clinical assessments of nutritional status and adverse outcomes in older hospitalized medical patients

BACKGROUND

Malnutrition is common in hospitalized older people and may predict adverse outcomes. Previous studies of the relationship between nutritional status and hospital outcomes are limited by inadequate accounting for other potential predictors of adverse outcomes, the failure to consider functional outcomes, and the omission of clinical assessments of nutritional status.

OBJECTIVE

To measure the relationship between a clinical assessment of nutritional status on hospital admission and subsequent mortality, functional dependence, and nursing home use.

DESIGN

Prospective cohort study

SETTING

A tertiary care hospital

PATIENTS

A total of 369 patients at least 70 years old (mean age 80.3, 62% women) admitted to a general medical service

MEASUREMENTS

Nutritional status was measured with the Subjective Global Assessment, a validated measure of nutritional status based on historical and physical exam findings. Patients were classified as severely malnourished (generally at least a 10% weight loss over the previous 6 months and marked physical signs of malnutrition), moderately malnourished (generally a 5 to 10% weight loss and moderate physical signs), or well nourished. Vital status, independence in activities of daily living, and nursing home use were determined through patient or surrogate interview at admission and 90 days and 1 year after discharge. Indices of comorbidity and illness severity were determined from chart review.

RESULTS

219 patients (59.3%) were well nourished, 90 (24.4%) were moderately malnourished, and 60 (16.3%) were severely malnourished. Severely malnourished patients were more likely than moderately malnourished or well nourished patients to die by 90 days (31.7%, 23.3%, and 12.3%, respectively, P < .001) and 1 year (55.0%, 35.6%, and 27.9%, P < .001) after discharge. In logistic regression models controlling for acute illness severity, comorbidity, and functional status on admission, severely malnourished patients were more likely than well nourished patients to die within 1 year of discharge (OR = 2.83, 95% CI, 1.47-5.45), to be dependent in activities of daily living 3 months after discharge (OR = 2.81, 1.06-7.46), and to spend time in a nursing home during the year after discharge (OR = 3.22, 1.05-9.87).

CONCLUSION

Malnutrition was common in hospitalized patients with medical illness and was associated with greater mortality, delayed functional recovery, and higher rates of nursing home use. These adverse outcomes were not explained by greater acute illness severity, comorbidity, or functional dependence in malnourished patients on hospital admission.

The soluble interleukin-2 receptor predicts mortality in older hospitalized men

BACKGROUND

There is an inverse relationship between the soluble interleukin-2 receptor (sIL-2R) and serum albumin, cholesterol, transferrin, prealbumin, and hemoglobin. Inasmuch as low serum albumin and cholesterol have been associated with excess mortality, we hypothesized that elevated sIL-2R would predict mortality in older adults.

OBJECTIVE

To determine if elevated sIL-2R predicts mortality in patients on a geriatric rehabilitation unit.

DESIGN

Prospective cohort.

SETTING

University-affiliated VA medical center.

PARTICIPANTS

Seventy-two male patients aged greater than 60 years admitted to a geriatric rehabilitation unit. Patients with severe hepatic or renal disease were excluded.

MEASUREMENTS

We measured serum albumin, prealbumin, cholesterol, transferrin, hemoglobin, body mass index (BMI), C-reactive protein (CRP), and sIL-2R upon admission. Subjects were followed for 1 year.

RESULTS

Low serum albumin, prealbumin, and hemoglobin and high sIL-2R and CRP predicted 1-year mortality on univariate analysis. When these predictors were included as covariates in a Cox regression model, only sIL-2R was a significant independent predictor of mortality (P = .043). Multiple linear regression with the above covariates revealed that only sIL-2R predicted time to death at (P = .003).

CONCLUSIONS

High sIL-2R and CRP and low albumin, prealbumin, and hemoglobin predicted mortality using univariate analysis on a rehabilitation unit. However, with multivariate analysis, sIL-2R was the sole predictor of mortality.

Hepatic protein synthesis in the regenerating rat liver after hepatopancreatectomy

To evaluate the effects of hepatopancreatectomy on the regenerative process of the liver, the serum protein changes, hepatic protein synthesis (HPS), and bromodeoxyuridine (BrdU) labeling index were measured in rats. Sprague-Dawley rats were divided into four groups according to the type of resection: A simple laparotomy was performed in the sham group; 68% of the liver was excised in the Hx group; 45% of the pancreas was excised in the Px group; and 45% of the pancreas and 68% of the liver were excised simultaneously in the HPx group. Serum total protein and albumin levels were significantly lower in the HPx group compared to the other three groups on postoperative day (POD) 3 (P < 0.05). HPS was markedly increased in the Hx and HPx groups. In the Hx group, it was significantly higher, peaking on POD 2, compared to the HPx group (P < 0.05), while in the HPx group, it was significantly higher compared to the Hx group (P < 0.05), peaking on POD 3. The BrdU labeling index, as a marker of DNA synthesis, was significantly suppressed in the HPx group on POD 1 compared to the Hx group (P < 0.05). Thus, compared to hepatectomy alone, hepatopancreatectomy suppresses DNA synthesis, causing a delay in the increase of protein synthesis in the regenerating liver, resulting in a more marked decrease in the serum protein level.

Gene expression of albumin and liver-specific nuclear transcription factors in liver of protein-deprived rats

Protein-energy malnutrition causes hypoalbuminemia. Recent work has suggested that this may be partly due to decreased transcription of the albumin gene. This study examined the role of cis-acting and transacting elements of the albumin gene during protein deprivation. Male 7-wk-old Donryu rats were fed a protein-free diet (0% casein diet) for 10 d or given restricted (pair-fed control) or free access (freely fed control) to a 25% casein diet. Serum albumin concentrations were significantly lower in the protein-deprived rats (29 +/- 1 g/L) than in the pair-fed controls (42 +/- 3 g/L) or the freely fed controls (45 +/- 3 g/L). The albumin mRNA level was also significantly lower in livers of protein-deprived rats (36% of pair-fed control). However, gel mobility shift analysis using liver nuclear extracts did not show any significant difference between the protein-deprived rats and the pair-fed controls in the binding activity to the B and D sites of the albumin promoter. Furthermore, gel mobility shift-Western blot analysis showed no significant difference between the two groups in the protein levels of nuclear transcription factors binding to the D sites. The amounts of mRNA of hepatocyte nuclear factor-1 binding to the B site were not significantly different between these two groups. These results suggest that the proximal promoter region may not play a major role in the down-regulation of the albumin gene during protein deprivation.

Post-ICU mechanical ventilation: treatment of 1,123 patients at a regional weaning center

STUDY OBJECTIVES

To update our database, reporting changes in the results of weaning attempts and profile of patients transferred to us after prolonged mechanical ventilation (PMV) in the ICU.

DESIGN

Retrospective record review, with prospective recording of physiologic measurements on admission from mid-1994.

SETTING

Regional weaning center (RWC).

PATIENTS

We studied 1,123 consecutive ventilator-dependent patients transferred for attempted weaning over an 8-year period.

MEASUREMENTS AND RESULTS

Median (range) time of mechanical ventilation prior to transfer to the RWC declined from 37 (1 to 249) days in 1988 to 29 (1 to 120) days in 1996 (p<0.05). Acute physiology score of acute physiology and chronic health evaluation (APACHE) III was 32 (6 to 123) on RWC admission, equaling reported scores soon after ICU admission. Comparing other data on admission from 1988 to 1996, mean (+/-SD) serum albumin level declined from 2.92+/-0.58 to 2.43+/-0.50 g/dL, and alveolar-arterial oxygen pressure difference widened from 106+/-50 to 139+/-99 mm Hg. Prevalence of stage II or worse pressure ulceration on admission increased from 34% in 1988 to 46% in 1995. Despite these trends, there has been no significant change in patient outcome (55.9% weaned, 15.6% failed to wean, 28.8% died) or in median time to wean (29 [1 to 226] days). Overall survival at 1 year after discharge for the 8-year period is 37.9%, improving from 29% in 1988-1991 to 45% since 1992; survival in weaned patients discharged to home has improved from 45 to 59% during the respective time periods.

CONCLUSIONS

Patients are being transferred from the ICU to our RWC for attempted weaning sooner in their course of PMV. Although more severely ill on arrival than in past years, mortality is unchanged, more than half of the patients continue to be successfully weaned, and survival after RWC discharge is improved.

Association of serum albumin and mortality risk

Reduced levels of serum albumin concentration, a routine blood test, within the "normal" range have been reported to be associated with mortality risk. The literature is reviewed, with a focus on cohort studies meeting specified criteria, and findings are summarized. In studies of many populations, comprising healthy subjects and patients with acute or chronic illness, serum albumin concentration is inversely related to mortality risk in a graded manner over its entire range; the estimated increase in the odds of death ranges from 24% to 56% for each 2.5 g/l decrement in serum albumin concentration. The association predicts overall and cause-specific mortality including cardiovascular mortality. It is likely that albumin concentration is a highly sensitive indicator of preclinical disease and disease severity. A direct protective effect of the albumin molecule is suggested by the persistence of the association after adjustment for other known risk factors and preexisting illness, and after exclusion of early mortality. Although biologically plausible, there is no direct evidence for this hypothesis. Serum albumin concentration is an independent predictor of mortality risk and could be useful in the quantification of risk in a broad range of clinical and research settings.

Impact of disease on markers of macronutrient status

It is apparent that illness, particularly acute illness, affects most tests which are used to assess macronutrient status. In acutely-ill patients, the best tests in terms of specificity for nutritional status are in vivo neutron-activation analysis for body composition and N balance as an assessment of recent intake. Changes in plasma protein concentration must be interpreted with great care, and this is best done in conjunction with changes in the acute-phase-protein response. Measurement of plasma IGF-1 may be helpful in the presence of an acute-phase response, but this requires further validation. In many such patients, the most important part of the assessment continues to be the clinical and dietary history, together with a careful physical examination. However, the need for accurate measurement remains, so that nutritional status and its progress can be accurately quantified. This was best expressed many years ago by William Thompson, Lord Kelvin, when he stated '... when you can measure what you are speaking about and express it in numbers you know something about it... when you cannot express it in numbers your knowledge is of a meagre and unsatisfactory kind; it may be the beginning of knowledge, but you have scarcely, in your thoughts, advanced to the stage of science...'.

International Federation of Clinical Chemistry. Laboratory assessment of protein-energy status

Laboratory and non-laboratory methods for assessing protein-energy nutritional status are reviewed. These are classified into methods for assessing adequacy of recent nutritional intake, methods for assessing whole body status, and tests which assist in the interpretation of these assessments. Each measurement is critically discussed in terms of the rationale for its use, the method of analysis, reference values, technical interference and limitations of methods, the effects of nutritional status and of other factors on the results, its overall usefulness in nutritional assessment, and its value relative to other methods. Non-laboratory tests such as dietary assessment, indirect calorimetry, functional tests and the many methods available for assessment of body composition, including anthropometry, bioelectrical impedance and isotope and imaging techniques, are compared with the clinical chemistry tests in common use, such as nitrogen balance, plasma protein measurements and urinary markers of muscle metabolism. This review provides comprehensive and practical advice on the use and limitations of these tests in the assessment of protein-energy nutritional status of a group, or of an individual patient.

The change in serum protein concentration in response to the stress of total joint surgery: a comparison of older versus younger patients

OBJECTIVE

To investigate whether the physiological response to surgery-induced stress, as measured by changes in serum secretory proteins, is more profound on older than in younger total joint arthroplasty patients.

DESIGN

Retrospective study.

SETTING

A 267-bed teaching hospital.

PARTICIPANTS

A total of 220 ambulatory patients with normal admission serum albumin levels, of whom 106 were 65 years of age or older (mean age 73.3 +/- 6.2 years) and 114 less than age 65 (mean age 48.8 +/- 12.2 years).

METHODS

Serum albumin and transferrin levels obtained at admission an on the fifth and tenth postoperative days were compared in the two age groups.

RESULTS

In both age groups, admission serum albumins were significantly higher than on the corresponding postoperative Day 5 levels (40.4 +/- 3.7 g/L vs 25.0 +/- 3.3 g/L, P < .0001 and 39.5 +/- 2.5 g/L vs 23.9 +/- 3.1 g/L, P < .001 in older and younger patients, respectively). The drop in the serum concentration of albumin by postoperative Day 5 in the older patients was not significantly different from that of the younger patients (a drop of 15.6 +/- 3.3 g/L in older vs 15.4 +/- 4.4 g/L for the younger, P = .740). Among the 64 patients who remained in the hospital 10 days subsequent to surgery, the average postoperative Day 10 serum albumin concentration was significantly lower in the older patients when compared with the younger (26.2 vs 29.1 g/L P = .016). Similar results were obtained for serum transferrin.

CONCLUSIONS

Subsequent to elective arthroplasty, the magnitude of change in serum albumin and transferrin concentrations is similar in older compared with younger, patients, suggesting that this stress response to surgery is nor age dependent. In contrast, the rate of recovery of the serum protein concentrations to preoperative levels may be slower in the older patients. However, this issue needs to be investigated further.

Nonrespiratory predictor of mechanical ventilation dependency in intensive care unit patients

OBJECTIVE

To determine the role of serum albumin concentration as a predictor of mechanical ventilation dependency.

DESIGN

Prospective, observation trial.

SETTING

Multidisciplinary intensive care unit (ICU) in a university hospital.

PATIENTS

One hundred forty-five consecutive patients who required mechanical ventilation for > 72 hrs.

INTERVENTIONS

Patients were classified into five different groups based on the cause of respiratory failure. The following parameters were recorded daily: serum albumin concentration; Acute Physiology and Chronic Health Evaluation II (APACHE II) score; and fluid balance. Using multiple regression, multiple logistic regression analysis, and the Anderson-Gill proportional hazards model, we determined the metabolic factors that could help predict weaning success.

MEASUREMENTS AND MAIN RESULTS

The mean length of ICU stay was 12.3 +/- 1.0 days. The duration of mechanical ventilation dependency was 10.5 +/- 1.0 days. The initial mean serum albumin concentration was 25.2 +/- 0.6 g/L. The APACHE II score on the first day of ICU stay was 19.1 +/- 0.6. Although albumin concentration was significantly lower and the APACHE II score was significantly higher in ICU nonsurvivors than in ICU survivors, albumin concentration on ICU admission was not a predictor of the length of time spent receiving mechanical ventilation. The profile of albumin concentration changes was different between weaned and mechanical ventilation-dependent patients. At the time of weaning patients from the ventilator, the median albumin concentration was higher than in those patients who continued to be supported by mechanical ventilation. This effect of albumin could not be attributed to patient fluid balance or to the severity of illness since each factor had an independent influence in predicting weaning, using the Anderson-Gill proportional hazards models.

CONCLUSIONS

Initial serum albumin concentration did not necessarily predict weaning success. However, when serum albumin concentration was assessed on a daily basis, its trend was important in determining the relative chance of being successfully weaned from the ventilator. This finding suggests that albumin may be an index of the metabolic status of the patient, which could be important in determining the weanability of the patients who are mechanically ventilated for prolonged periods of time.

[Role of albumins in burnt patients: its efficacy during intensive care. Addendum to the expert guidelines of the Consensus Conference, Paris December 15th 1995]

In the burned patient, the critical threshold over which a correction of hypoalbuminemia is required has not yet been clearly defined. The level of 30 g.L-1 of albumin is usually admitted. According to the extent of the burn, albumin is not indicated in patients with a burn size below 15% of the total body surface. It is essential, from the very beginning of management in patients with a burn size over 50%. Its administration can be postponed to the 8th, 12th or even 24th hour in case of a burn size between 15 and 50%.

Improving malnutrition documentation enhances reimbursement

Diagnosis coding for malnutrition can positively affect hospital reimbursements. Our goal was to quantify the possible increase in reimbursements when the diagnosis of malnutrition was identified and appropriately coded. A sample of 234 cases representing 14% of Medicare patients seen from March 1991 through February 1992 at Allenmore Hospital in Tacoma, Wash, was retrospectively reviewed. Malnutrition diagnoses (using ICD-9-CM codes) were assessed according to established criteria. Ninety-four cases (39.7%) met the criteria for malnutrition. Seven demonstrated increased reimbursement, totaling $12,326 for the sample. Length of hospital stay was significantly longer in the malnourished group (P = .001). The results indicated a need for an improved system of documenting and coding malnutrition diagnoses for improved identification and reimbursement enhancement purposes. An example of criteria used for each malnutrition ICD-9-CM diagnosis code and a policy defining the criteria usage are shown. A nutrition assessment form, which includes each malnutrition ICD-9-CM code title for enhanced interdisciplinary communication leading to improved coding of malnutrition diagnoses, is also shown. We conclude that effective identification of malnutrition leading to enhanced reimbursement strengthens the leadership potential of hospital dietitians and improves hospital revenues. Additionally, we suggest that such a system initiates a process that may lead to improved, cost-effective treatment of persons identified as being malnourished and provide a foundation for surviving within the future health care reform environment.

The effect of glycosylated albumin on platelet aggregation

BACKGROUND

Albumin has a role in the complicated process of platelet aggregation. Although it is known that quantitative changes in plasma albumin alter platelet aggregation, less is known about the interaction between qualitative changes in plasma albumin and platelets. One common qualitative change in plasma albumin is nonenzymatic glycosylation, which occurs during states of prolonged hyperglycemia.

METHODS

Albumin was selectively removed from normal plasma by means of an affinity column. Glycosylated albumin was added to this albumin-poor plasma, and it was used to study platelet aggregation induced by low concentrations of arachidonic acid. Platelet aggregation was determined by light transmittance.

RESULTS

As the concentration of glucose in which albumin was incubated was increased, there was progressive augmentation of platelet aggregation. At a plasma glucose of 150 mg/dL, average light transmittance was 9.4%, and at 200 mg/dL, it was 24.6%. These values were significantly different at a p value < .01. At glucose levels of 300 mg/dL and 400 mg/dL, mean light transmittance was 40.6% and 74.4%, respectively, and these values were significantly different with p values of < .01.

CONCLUSIONS

Platelet aggregation in response to a relatively low concentration of arachidonic acid is enhanced in the presence of albumin that has been incubated in a medium containing levels of glucose that are higher than would be seen in normal patients but are consistent with those seen in diabetics with less than optimal control. This augmentation of platelet aggregation is statistically significant.

Observations on the prevalence of protein-calorie undernutrition in VA nursing homes

OBJECTIVE

To determine the prevalence of underweight and hypoalbuminemia in Veterans Affairs nursing home residents and the frequency with which physicians, nurses, and dietitians documented their awareness of the presence of underweight and hypoalbuminemia.

DESIGN

Retrospective survey of medical records.

SETTING

Twenty-six Department of Veterans Affairs nursing homes located in the Department's Central Region.

PATIENTS

2811 residents.

MAIN OUTCOME MEASURES

(1) Prevalence of underweight (defined as body weight less than 80% of standard) and hypoalbuminemia (defined as serum albumin less than 3.5 g/dl); (2) frequency with which physicians, nurses, and dietitians documented the prevalence of underweight and hypoalbuminemia in the records.

RESULTS

Three hundred thirty-two (11.8%) of the patients were underweight and 772 (27.5%) were hypoalbuminemic. The prevalence of the two conditions varied widely across nursing homes. The prevalence of low serum albumin ranged from 5% to 58% in the 26 institutions, and the prevalence of body weight less than 80% of standard ranged from 2% to 20%. In the Region as a whole, the dietician's notes in the medical charts mentioned underweight in an average of 95% of affected cases but mentioned the suboptimal albumin level in only 82% of the hypoalbuminemic individuals. In the nurses's notes, these figures were only 80% and 45%, respectively, and in the physician's notes, only 62% and 46%, respectively. The frequency of documented awareness of underweight and hypoalbuminemia by nurses and physicians varied tremendously across the 26 facilities (as few as 7% of the undernourished cases in one nursing home, 100% of the affected individuals in another).

CONCLUSIONS

This study showed a high prevalence of calorie and protein undernutrition in the nursing home residents of VA nursing homes, wide variation in the prevalence across nursing homes, and frequent lack of documentation of these nutritional deficiencies by physicians and nurses.

Serum albumin concentrations: who needs them?

OBJECTIVE

To examine the multiple factors that influence serum albumin concentrations and to discuss settings in which the monitoring of such concentrations provides clinically useful information.

DATA SOURCES

Original investigations, review articles, books, and abstracts published in English.

STUDY SELECTION

Studies pertaining to factors affecting serum albumin concentration were chosen based on general applicability. Recommendations related to the appropriate monitoring of albumin concentrations were based on studies performed in the clinical setting with direct applicability to patient care.

DATA EXTRACTION

Data on factors affecting serum albumin concentration were extracted from studies that resulted in similar conclusions regardless of assay technique. Appropriate indications for albumin monitoring were derived from studies demonstrating direct clinical relevance.

DATA SYNTHESIS

A number of factors may influence serum albumin concentration and ultimately affect interpretation of the concentration. Serum albumin concentrations generally are useful in the institutional setting shortly after admission or preoperatively to determine patient prognosis. Albumin concentrations have limited merit for predicting the free fractions of various hormones, electrolytes, and drugs. When used as an indicator of nutritional support, albumin concentrations are most helpful when measured over longer periods in relatively stable patients.

CONCLUSIONS

Serum albumin determinations should be limited to those situations in which the concentrations are likely to provide clinically useful information. Such situations are limited.