The Use of Serum Albumin as a Prognostic or Nutritional Marker and The Pros and Cons of IV Albumin Therapy

The effects of adjunctive treatment with L-carnitine on monitoring laboratory variables in ICU patients: a double-blinded randomized controlled clinical trial

BACKGROUND

Critically ill patients must be monitored constantly in intensive care units (ICUs). Among many laboratory variables, nutritional status indicators are a key role in the prognosis of diseases. We investigated the effects of L-carnitine adjunctive therapy on monitoring variables in critical illness.

METHOD

A prospective, double-blind, randomized controlled trial was implemented in a medical ICU. Participants were 54 patients, aged > 18 years, with multiple conditions, randomly assigned to receive 3 g L-carnitine per day or placebo, along with enteral feeding, for 1 week. Primary outcomes included monitoring variables related to nutritional status.

RESULT

Of 54 patients randomly assigned, 51 completed the trial. Serum albumin (Alb) (P-value: 0.001), total protein (P-value: 0.003), and calcium (Ca) (0.044) significantly increased in the intervention vs. control group. Alanine transaminase (ALT) (0.022), lactate (<0.001), creatinine (Cr) (0.005), and international normalized ratio (INR) (0.049) decreased meaningfully in the intervention vs. control group.

CONCLUSION

L-Carnitine supplementation in critically ill patients can improve several parameters including INR, Cr, ALT, lactate, Ca, Alb, and total protein.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials IRCT 20151108024938N2. This trial was approved by the Research Ethics Committee of Mashhad University of Medical Sciences (registration code: IR.MUMS.fm.REC.1396.671) (available at https://en.irct.ir/trial/30748 , May 2018).

Use of Albumin in the NICU: An Evidence-based Review

Albumin is the most abundant protein in human blood with distinctive functions throughout the human body. Low albumin levels are a predictor of mortality as well as disease outcome in children and adults. However, the clinical significance of hypoalbuminemia and the role of albumin infusions in NICUs remain unclear and controversial.

Hypoalbuminemia Predicts Adverse Events following Unicompartmental Knee Arthroplasty

Hypoalbuminemia is a potentially modifiable risk factor associated with adverse events following total knee arthroplasty. The present study aimed to evaluate whether hypoalbuminemia similarly predisposes to adverse events following unicompartmental knee arthroplasty (UKA). Patients who underwent UKA during 2006-2018 were identified through the American College of Surgeons National Surgical Quality Improvement Program. Only patients with preoperative serum albumin concentration were included. Outcomes were compared between patients with and without hypoalbuminemia (serum albumin concentration < 3.5 g/dL). All associations were adjusted for demographic, comorbidity, and laboratory differences between populations. A total of 11,342 patients were identified, of whom 6,049 (53.3%) had preoperative serum albumin laboratory values available for analysis. After adjustment for potential confounders, patients with hypoalbuminemia had a greater than 2-fold increased probability for occurrence of any complication (7.02% vs. 2.23%, p = 0.009) and a 4-fold increased probability of receiving a blood transfusion (1.81% vs. 0.25%, p = 0.045). Among procedures performed as inpatients, mean postoperative length of stay (LOS) was longer in patients with hypoalbuminemia (2.2 vs. 1.8 days; p = 0.031). Hypoalbuminemia is independently associated with complications and increased LOS following UKA and a marker for patients at higher risk of postoperative complications. Patients should be screened for hypoalbuminemia and nutritional deficiencies addressed prior to UKA.

Incidence and risk factors for surgical site infection following elective foot and ankle surgery: a retrospective study

Background

This study aimed to investigate the incidence of surgical site infection (SSI) in elective foot and ankle surgeries and identify the associated risk factors.

Methods

This was designed as a retrospective study, including patients who underwent elective surgery of foot and ankle between July 2015 and June 2018. Data on demographics, comorbidities, and perioperative parameters were collected from the medical records, the laboratory report, the operation report, and the outpatient follow-up registration database. SSI was defined in accordance with the Center for Disease Control criteria. Univariate and multivariate logistic regression analyses were used to identify the independent risk factors for SSI.

Results

A total of 1201 patients undergoing 1259 elective foot/ankle surgeries were included, of whom 26 (2.1%) had an SSI, representing an incidence rate of 1.3% for superficial SSI and 0.8% for deep SSI, respectively. The results for organism culture showed Pseudomonas aeruginosa in 7 cases, methicillin-resistant Staphylococcus aureus (MRSA) in 6, methicillin-susceptible Staphylococcus aureus (MSSA) in 5, methicillin-resistant coagulase-negative Staphylococci (MRCNS) in 2, Escherichia coli in 2, and Proteus mirabilis in 1 case. Five factors were identified to be independently associated with SSI, including prolonged preoperative stay (OR, 1.21; 95% CI, 1.09 to 1.30), allograft or bone substitute (OR, 3.76; 95% CI, 1.51 to 5.30), elevated FBG level (OR, 1.17; 95% CI, 1.04 to 1.26), lower ALB level (OR, 2.33; 95% CI, 1.19 to 3.05), and abnormal NEUT count (OR, 1.72; 95% CI, 1.27 to 2.12).

Conclusions

SSI following elective foot and ankle surgeries is low, but relatively high in forefoot surgeries, requiring particular attention in clinical practice. Although most not modifiable, these identified factors aid in risk assessment of SSI and accordingly stratifying patients and therefore should be kept in mind.

Recurrence of spontaneous bacterial peritonitis in cirrhosis: novel predictors

BACKGROUND AND AIMS

Recurrence of spontaneous bacterial peritonitis (SBP) is still a matter of debate. We conducted this study to evaluate the probable factors that predict the recurrence of SBP in patients who recovered from the first episode of SBP and the long-term outcomes of SBP recurrence.

METHODS

One hundred twenty-four patients diagnosed with liver cirrhosis, SBP and did not receive secondary prophylaxis either with norfloxacin or other antibiotics were included in this prospective cohort pilot study. Clinical, biochemical and ascitic fluid analysis parameters were evaluated. Ascitic fluid interferon-γ-induced protein (IP-10), calprotectin, interleukin-6 and tumor necrosis factor-α were measured by ELISA.

RESULTS

Of these, 76 patients survived with an in-hospital mortality rate of 38.7%. The survivors were classified into two groups according to recurrence and nonrecurrence of SBP and survival time, clinical parameters and cause of death were investigated. Thirty-one participants had one or more attacks of SBP, with a recurrence rate of 40.8% within one-year follow-up. Before discharge, multivariate analysis showed that ascitic IP-10 (≥1220 pg/ml), ascitic calprotectin (≥550 ng/ml), serum albumin (≤2.5 g/dl), nonuse of prophylactic β-blockers and use of proton-pump inhibitors (PPIs) were the independent variables in predicting recurrent SBP. Sepsis-related organ failure was the most common etiology of mortality in the recurrent SBP group within 3 and 6 months.

CONCLUSION

Increased ascitic calprotectin and IP-10, hypoalbuminemia, nonuse of prophylactic β-blockers and use of PPI were independently associated with increased SBP recurrence rate. Sepsis-related organ failure was the most common etiology of mortality.

Effect of postoperative hypoalbuminemia and supplement of human serum albumin on the development of surgical site infection following spinal fusion surgery: a retrospective study

PURPOSE

To determine the association between postoperative hypoalbuminemia and the development of surgical site infection (SSI) and evaluate whether the supplement of exogenous human serum albumin (HSA) in patients following spinal surgery would decrease the rate of postoperative SSI.

METHODS

We performed a retrospective review of all patients who underwent lumbar spinal fusion surgery in our institution between January 2014 and December 2018. Patients with postoperative SSI were identified. We reviewed the demographic and clinical records of the patients and performed multiple logistic regression models to clarify the relevance between postoperative hypoalbuminemia, the supplement of HSA and SSI. Statistical adjustment for the potential confounders was also performed to exclude possible variation.

RESULTS

Twenty-four of 602 patients developed SSI after lumbar spinal fusion surgery. No statistical significance was found between postoperative hypoalbuminemia and SSI rate (OR 0.74; 95% CI 0.22-2.48; P = 0.6199). However, the supplement of exogenous HSA was significantly associated with increased postoperative SSI rate (OR 1.21; 95% CI 1.05-1.41; P = 0.0094). Interestingly, stratified analyses showed supplement of HSA in patients without postoperative hypoalbuminemia increased the risk of SSI (OR 2.55; 95% CI 1.01-6.45; P = 0.0475), compared with patients with postoperative hypoalbuminemia (OR 1.17; 95% CI 1.00-1.36; P = 0.0434).

CONCLUSIONS

The present study suggests that postoperative hypoalbuminemia is not associated with the development of SSI after spinal surgery. However, the supplement of HSA following spinal surgery will increase the rate of SSI. These slides can be retrieved under Electronic Supplementary Material.

Albumin supplementation may have limited effects on prolonged hypoalbuminemia in major burn patients: An outcome and prognostic factor analysis

BACKGROUND

Burns that affect ≥20% of the total body surface area (TBSA) trigger a major inflammatory response in addition to capillary leakage and loss of serum proteins including albumin. Persistent hypoalbuminemia is therefore common in major burn patients. The purpose of this study was to determine whether human albumin solutions can benefit major burn patients with persistent hypoalbuminemia.

METHODS

We conducted a retrospective review of major burn patients with ≥20% of TBSA involved at Taipei Veterans General Hospital between January 2007 and December 2018. Thirty-eight patients were enrolled. Patient demographics, burn characteristics, fluid balance, laboratory results, and outcomes were recorded through chart review.

RESULT

No significant differences were found in the baseline characteristics of patients who received <25 mg/kg/%TBSA/day of human albumin solutions and those who received more than this amount. Renal replacement therapy, duration of mechanical ventilation, length of stay in the burn unit, and in-hospital mortality rate were not statistically different between the two groups. The serum C-reactive protein/albumin ratio was associated with in-hospital mortality (p = 0.036).

CONCLUSION

The administration of large amounts of albumin supplements for the correction of prolonged hypoalbuminemia in major burn patients had no significant benefits on mortality.

Hypoalbuminemia remains an independent predictor of complications following total joint arthroplasty

Introduction

Hypoalbuminemia (<3.5 mg/dL) is an accepted marker of malnutrition, but it was unknown if low albumin remained an independent predictor of post-operative complications following primary total hip (THA) and knee (TKA) arthroplasty.

Methods

The National Surgical Quality Improvement Program (NSQIP) database was queried for patients undergoing primary THA and TKA. Propensity score-matched analysis was used to control for co-morbid conditions.

Results

Patients with low albumin demonstrated greater odds of death (by 2-21x), morbidity (by 25-51%), re-admission (by 45-54%), and increased length of stay.

Conclusion

Low albumin remains an independent predictor of adverse outcomes following primary total joint arthroplasty.

Serum albumin levels correlate with inflammation rather than nutrition supply in burns patients: a retrospective study

The aim of this retrospective study was to examine whether serum albumin levels offer a good marker of nutritional status in patients with burns. Serum albumin levels have been used to evaluate nutritional status in burns patients, even though these levels are affected by various factors and are not specific to malnutrition. To clarify whether provision of nutrition or presence of inflammation affects serum albumin levels, we studied serum albumin levels, C-reactive protein (CRP) levels and caloric intake over time in 30 patients with burns. Serum albumin levels did not respond to provision of nutrition, but correlated negatively with CRP levels, suggesting that serum albumin levels are more closely associated with inflammation than nutrition. This study also suggests that hypoalbuminemia is a good indicator of the severity of burns or associated complications. We conclude that serum albumin levels do not offer a good nutritional marker in burns patients.

Relation between the serum albumin level and nutrition supply in patients with pressure ulcers: retrospective study in an acute care setting

This retrospective study examined the validity of the commonly used serum albumin level as an indicator of nutrition status of patients with pressure ulcer(s), particularly because the serum albumin level is affected by various factors and may not be specific to malnutrition. Specifically, we investigated whether nutrition supply or inflammation affects the serum albumin level in 82 patients with pressure ulcers(s) (29 in whom pressure ulcer was present upon admission and 53 in whom pressure ulcer developed after hospital admission). Serum albumin levels, blood test including C-reactive protein (CRP) levels and blood count, caloric intake, and depth and healing of pressure ulcers were compared between various subgroups of patients. Serum albumin levels correlated with red blood cell counts and hemoglobin and CRP levels but not with caloric intake. The correlation with CRP before and after several weeks of pressure ulcer treatment was negative. The serum albumin level upon admission was higher in patients in whom the ulcer healed than in those in whom it did not heal as well as in patients who were discharged than in those who died in the hospital. The serum albumin level appears to reflect inflammation, wound healing, and disease severity rather than nutrition supply in patients with pressure ulcer. J. Med. Invest. 61: 15-21, February, 2014.

Recurrence of spontaneous bacterial peritonitis in cirrhotic patients non-prophylactically treated with norfloxacin: serum albumin as an easy but reliable predictive factor

BACKGROUND

Several large studies revealed that selective intestinal decontamination (SID) prevented recurrence of spontaneous bacterial peritonitis (SBP) in cirrhotic patients. Nonetheless, there are no definitive patient selection parameters identifying who would benefit from SID.

AIMS

To investigate long-term outcomes in cirrhosis patients with recurrence of SBP and to identify predictive factors for SBP recurrence.

METHODS

We retrospectively studied 146 cirrhosis patients diagnosed with a first episode of SBP from 2005 to 2006. Of these, 89 patients survived; the survivors were divided into two groups based on recurrence and non-recurrence of SBP, and clinical parameters, survival time and cause of death were analysed.

RESULTS

The in-hospital mortality was 39% (57/146). The SBP recurrence rate was 42.7% (38/89). The survival rate between patients with recurrent SBP and those without recurrence did not differ (P=0.092). Sepsis was the major cause of death in the recurrent SBP group, but not in the non-recurrent group. Serum albumin level before discharge and β-blocker use between the two groups differed significantly (P<0.0001). Using the cut-off point for serum albumin level before discharge of 2.85 g/dl as a predictor for recurrence of SBP, the sensitivity was 70.2% and the specificity was 76.3%. Furthermore, long-term survival of the group with high albumin before discharge was better than that of the corresponding group with low albumin (P=0.007).

CONCLUSION

Spontaneous bacterial peritonitis was associated with high sepsis-related mortality in cirrhotic patients. Serum albumin before discharge was a useful single parameter to predict the recurrence of SBP and long-term survival.

Hepatic proteins and nutrition assessment

Serum hepatic protein (albumin, transferrin, and prealbumin) levels have historically been linked in clinical practice to nutritional status. This paradigm can be traced to two conventional categories of malnutrition: kwashiorkor and marasmus. Explanations for both of these conditions evolved before knowledge of the inflammatory processes of acute and chronic illness were known. Substantial literature on the inflammatory process and its effects on hepatic protein metabolism has replaced previous reports suggesting that nutritional status and protein intake are the significant correlates with serum hepatic protein levels. Compelling evidence suggests that serum hepatic protein levels correlate with morbidity and mortality. Thus, serum hepatic protein levels are useful indicators of severity of illness. They help identify those who are the most likely to develop malnutrition, even if well nourished prior to trauma or the onset of illness. Furthermore, hepatic protein levels do not accurately measure nutritional repletion. Low serum levels indicate that a patient is very ill and probably requires aggressive and closely monitored medical nutrition therapy.

Albumin infusion for low serum albumin in preterm newborn infants

BACKGROUND

Intravenous albumin infusion to treat hypoalbuminaemia is used in intensive care nurseries. Hypoalbuminaemia occurs in a number of clinical situations including prematurity, the acutely unwell infant, respiratory distress syndrome (RDS), chronic lung disease (CLD), necrotising enterocolitis (NEC), intracranial haemorrhage, hydrops fetalis and oedema. Fluid overload is a potential side effect of albumin administration. Albumin is a blood product and therefore carries the potential risk of infection and adverse reactions. Albumin is also a scarce and expensive resource.

OBJECTIVES

The primary objective was to assess whether albumin infusions, in preterm neonates with low serum albumin, reduces mortality and morbidity. A secondary objective was to assess whether albumin infusion is associated with significant side effects.

SEARCH STRATEGY

Searches were made of MEDLINE from 1966 to April 2004, CINAHL from 1982 to April 2004 and the current Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library issue 1, 2004). Previous reviews (including cross references) and abstracts were also searched.

SELECTION CRITERIA

All randomised controlled trials in which individual patients were allocated to albumin infusion versus control were included. Cross-over studies were excluded. Quasi randomised trials were excluded. Participants were preterm infants who had hypoalbuminaemia. Types of interventions included albumin infusion versus placebo (e.g. crystalloid) or no treatment.

DATA COLLECTION AND ANALYSIS

The reviewers worked independently to search for trials for inclusion and to assess methodological quality. Studies were assessed using the following key criteria: blinding of randomisation, blinding of intervention, completeness of follow up and blinding of outcome measurement.

MAIN RESULTS

Only two small studies were found for inclusion in this review and only one reported clinically relevant outcomes - it found no significant differences for our primary outcome measure of death (RR 1.5 [95% confidence interval 0.3 - 7.43]) or secondary outcome measures of intraventricular haemorrhage, patent ductus arteriosus, necrotising enterocolitis, bronchopulmonary dysplasia, duration of mechanical ventilation and duration of oxygen therapy.

REVIEWERS' CONCLUSIONS

There is a lack of evidence from randomised trials to determine whether the routine use of albumin infusion, in preterm neonates with low serum albumin, reduces mortality or morbidity, and no evidence to assess whether albumin infusion is associated with significant side effects. There is a need for good quality, double-blind randomised controlled trials to assess the safety and efficacy of albumin infusions in preterm neonates with low serum albumin.

Total parenteral nutrition vs oral diet in autologous hematopoietic cell transplant recipients

Autologous HCT patients often have poor oral intake for 2-4 weeks post transplant. To compare outcomes between patients provided prophylactic total parenteral nutrition (TPN) or an oral diet (OD), 55 well nourished breast cancer/ hematopoietic cell transplantation (HCT) patients were randomized to TPN (n=27), beginning day -1, or OD (n=28). Parameters studied include length of stay (LOS), engraftment, infections, survival, weight, anthropometrics, handgrip strength, and quality of life (QOL) In all, 50% of OD patients were given TPN due to poor oral intake for 10 consecutive days. No significant differences were found between the groups for any of the above parameters except weight and anthropometrics, which were better maintained in the TPN group than the OD group. Trends were seen for increased infections, more stable handgrip strength, and improved QOL in the TPN group vs the OD group. Prophylactic TPN did result in a more intact nutritional status and preservation of lean body mass post transplant but did not impact LOS or survival when compared to OD. For this reason, TPN should be reserved for autologous HCT patients with pretransplant nutritional depletion, complications post transplant, or prolonged poor oral intake. These results should not be extrapolated to allogeneic HCT patients but are likely applicable to other well nourished autologous HCT patients.

Protein-energy undernutrition in hospital in-patients

Impaired nutritional status has been frequently reported in surveys estimating its prevalence amongst patients in hospital. While there is no doubt that protein-energy undernutrition has serious implications for health, recovery from illness or surgery and hospital costs, lack of nationally or internationally accepted cut-off points and guidelines for most nutrition-related variables make nutritional assessment difficult and proper comparisons between studies impossible. In reviewing published work in which the prevalence of undernutrition has been assessed, it can be seen that each study defined undernutrition, or nutritional risk, using different methodology. This present review aims to highlight the problems which arise when deciphering these studies, and the resulting difficulty in determining the true prevalence of undernutrition and nutritional risk, amongst both general and specific groups of hospital in-patients. It is widely agreed that routine hospital practices can further adversely affect the nutritional status of sick patients in hospital. How this occurs, and the potential effects of impaired nutritional status on clinical outcome are examined. The methods currently available to assess nutritional status are evaluated in the knowledge that such assessments are difficult in clinical practice. The review concludes by proposing that if we want the medical and nursing professions to consider the nutritional status of hospital patients seriously, definitions of undernutrition and nutritional risk, and cut-off values for the nutritional variables measured must be agreed to allow evidence-based practice. Outcome measures which allow clear comparisons between groups and treatments must be used in studies assessing the effects of nutritional interventions.