Evidence that albumin is not a suitable marker of body composition-related nutritional status in elderly patients

THE VALUE OF PREOPERATIVE PROGNOSTIC NUTRITIONAL INDEX IN GASTRIC CANCER AFTER CURATIVE RESECTION

BACKGROUND

Predicting short- and long-term outcomes of oncological therapies is crucial for developing effective treatment strategies. Malnutrition and the host immune status significantly affect outcomes in major surgeries.

AIMS

To assess the value of preoperative prognostic nutritional index (PNI) in predicting outcomes in gastric cancer patients.

METHODS

A retrospective cohort analysis was conducted on patients undergoing curative-intent surgery for gastric adenocarcinoma between 2009 and 2020. PNI was calculated as follows: PNI=(10 x albumin [g/dL])+(0.005 x lymphocytes [nº/mm3]). The optimal cutoff value was determined by the receiver operating characteristic curve (PNI cutoff=52), and patients were grouped into low and high PNI.

RESULTS

Of the 529 patients included, 315 (59.5%) were classified as a low-PNI group (PNI<52) and 214 (40.5%) as a high-PNI group (PNI≥52). Older age (p=0.050), male sex (p=0.003), American Society of Anesthesiologists score (ASA) III/IV (p=0.001), lower hemoglobin level (p<0.001), lower body mass index (p=0.001), higher neutrophil-lymphocyte ratio (p<0.001), D1 lymphadenectomy, advanced pT stage, pN+ and more advanced pTNM stage were related to low-PNI patient. Furthermore, 30-day (1.4 vs. 4.8%; p=0.036) and 90-day (3.3 vs. 10.5%; p=0.002) mortality rates were higher in low-PNI compared to high-PNI group. Disease-free and overall survival were worse in low-PNI patients compared to high-PNI (p<0.001 for both). ASA III/IV score, low-PNI, pT3/T4, and pN+ were independent risk factors for worse survival.

CONCLUSIONS

Preoperative PNI can predict short- and long-term outcomes of patients with gastric cancer after curative gastrectomy. Low PNI is an independent factor related to worse disease-free and overall survival.

Effect of Body Composition on Graft Function and Cardiovascular Outcomes in Normotensive Renal Transplant Recipients

OBJECTIVES

We evaluated the effects of body composition on graft function and cardiovascular outcomes in normotensive renal transplant recipients.

MATERIALS AND METHODS

In this cross-sectional study, we analyzed ambulatory blood pressure monitoring data from 136 renal transplant recipients with stable allograft function after living related donor transplant. We enrolled 87 normotensive recipients. We analyzed left ventricular mass index, renal resistive index, and body composition of recipients. We divided recipients into 2 groups according to mean lean body mass, defined by bioimpedance analysis, with 38 in group 1 (lean body mass <47 kg) and 49 in group 2 (lean body mass ≥47 kg).

RESULTS

Mean time posttransplant was 35.0 ± 23.3 months. Mean renal resistive index, left ventricular mass index, lean body mass, body mass index, and fat mass were 0.67 ± 0.1, 195.0 ± 118.5 g/m2, 47.3 ± 9.1 kg, 25.9 ± 5.0 kg, and 44.6±10.5 kg,respectively. Lean body mass was positively correlated to sex (r = 0.36, P = .03), body mass index (r = 0.04, P = .416),renalresistive index (r = 0.495, P = .01), and left ventricular mass index (r = 0.713, P = .02) but negatively correlated to serum albumin levels (r=-0.343, P=0.04). Lean body mass was significantly higher in males than in females (P = .03). Patients in group 2 had significantly higher left ventricular mass index (P = .01) and renal resistive index (P = .03). In multiple regression analysis, lean body mass (P = .01) and left ventricular mass index (P = .01) were predictors of renal resistive index.

CONCLUSIONS

Lean body mass significantly influences left ventricular mass index and renal resistive index. Hence, body composition analysis could be an early predictor of graft function and cardiovascular outcomes in normotensive renal transplant recipients.

Factors Associated with Low Albumin in Community-Dwelling Older Adults Aged 75 Years and Above

This study aimed to clarify the factors associated with low albumin in Japanese older adults aged ≥75 years. The data utilized were the health checkup data of older adults aged ≥75 years from 42 municipalities in Gifu Prefecture, which were provided by the National Health Insurance database system. After excluding the data of individuals with incomplete information on serum albumin, BMI, lifestyle habits, or weight at previous year, the data from 18,674 individuals' health checkup were analyzed. A logistic regression showed that low albumin was associated with smoking, not walking at least 1 h/day, slow walking speed, difficulty in chewing, slow eating speed, weight loss in the previous year, and underweight. Furthermore, an analysis conducted for older adults aged ≥85 years showed that low albumin was associated with not walking at least 1 h/day, difficulty in chewing, slow eating speed, weight loss in the previous year, and underweight. In the future, the number of older adults will increase in Japan; therefore, a strategic approach to promote the health of these aged individuals will become even more necessary. An early approach to maintaining an active physical life, an appropriate weight, and good oral function will lead to improved health in older adults.

Amputation-free survival in the long-term follow-up and gender-related characteristics in patients revascularized for critical limb ischemia

OBJECTIVE

Patients with Critical Limb Ischemia (CLI) present a high risk of cardiovascular events and death. Revascularization is the cornerstone of therapy to relieve ischemic pain and prevent limb loss. Literature data suggest that women tend to present with worse outcomes after revascularization. The aim of the present study is to determine amputation-free survival in a long-term follow-up in women and men following endovascular revascularization procedure for CLI.

METHODS

From November 2013 to December 2020, 357 consecutive patients were retrospectively included. Clinical and biological parameters were recorded at baseline before endovascular revascularization. During follow-up until February 2023, overall survival and amputation-free survival (freedom from major amputation) were analysed using the Kaplan-Meier method. Univariate and multivariate analyses were performed to study the parameters associated with amputation-free survival. A P<0.05 was considered as statistically significant.

RESULTS

A total of 357 consecutive patients were included, 189 men and 168 women with CLI, with a mean age of 78.6±12 years. Treated hypertension (79%), diabetes mellitus (48%), coronary artery disease (39%) and protein malnutrition (61%) were the most prevalent comorbidities. Women were older than men with a mean age of 82.4±11.4 years (versus 75.4±11 years in men) and presented more frequently with protein malnutrition (70% of women). Prevalence of diabetes, tobacco use and history of coronary heart disease were significantly higher in men. During the 10-year follow-up period, 241 patients had died (68%) and 38 (11%) underwent major amputation, of whom 22 patients were still alive on February 2023. Median survival was 35.5 months [IQR: 29.5; 43] in the overall population, 38.5 [32; 50.4] months in women and 33.5 months [24.7; 43.5] in men. No gender-related differences were noted according to peri-procedural complications, survival probability and amputation-free survival. In multivariate analysis for amputation-free survival, age, previous coronary heart disease, C-reactive protein level, left ventricular ejection fraction (LVEF)<60% and albumin level<35g/L were correlated with poor outcome. In particular, protein malnutrition, as a treatable risk factor, appears significantly correlated with poor outcome in both men and women (HR=2.50 [1.16;5.38], P=0.0196 in men; HR=1.77 [1.00;3.13], P=0.049 in women).

CONCLUSION

The present results highlight that mortality in patients after endovascular revascularization remains high with a mortality rate of 28% at 1 year, 40% at 2 years and 51% at 3 years. Women represented a distinct population, almost 10-year older than their male counterparts, with more prevalent protein malnutrition. However, no gender-related difference was noted according to amputation-free survival on the long-term follow-up. Associated risk factors are mainly age, a history of coronary heart disease, pre-procedural inflammatory syndrome and protein malnutrition. Correction of malnutrition could have the potential to improve functional and general long-term prognosis in patients with CLI together with optimal medical and interventional management.

Patients with cardiac amyloidosis are at a greater risk of mortality and hospital readmission after acute heart failure

AIMS

Cardiac amyloidosis (CA) is an under-diagnosed cause of heart failure (HF) and has a worse prognosis than other forms of HF. The frequency of death or rehospitalization following discharge for acute heart failure (AHF) in CA (relative to other causes) has not been documented. The study aims to compare hospital readmission and death rates 90 days after discharge for AHF in patients with vs. without CA and to identify risk factors associated with these events in each group.

METHODS AND RESULTS

Patients with HF and CA (HF + CA+) were recruited from the ICREX cohort, after screening of their medical records. The cases were matched 1:5 by sex and age with control HF patients without CA (HF + CA-). There were 27 HF + CA + and 135 HF + CA- patients from the ICREX cohort included in the study. Relative to the HF + CA- group, HF + CA+ patients had a higher heart rate (P = 0.002) and N-terminal prohormone of brain natriuretic peptide levels (P < 0.001) and lower blood pressure (P < 0.001), weight, and body mass index values (P < 0.001) on discharge. Ninety days after discharge, the HF + CA+ group displayed a higher death rate, a higher all-cause hospital readmission rate, and a higher hospital readmission rate for AHF. Death and hospital readmissions occurred sooner after discharge in the HF + CA+ group than in the HF + CA- group.

CONCLUSIONS

The presence of CA in patients with HF was associated with a three-fold greater risk of death and a two-fold greater risk of all-cause hospital readmission 90 days after discharge. These findings emphasize the importance of close, active management of patients with CA and AHF.

Development and validation of a cancer cachexia risk score for digestive tract cancer patients before abdominal surgery

BACKGROUND

Cancer cachexia is prevalent in digestive tract cancer patients and has significant impacts on prognosis; it is vital to identify individuals who are at risk of cancer cachexia to allow for appropriate evaluation and treatment. This study evaluated whether digestive tract cancer patients with a risk of cancer cachexia and who had a risk of adverse survival could be identified before abdominal surgery.

METHODS

This large-scale cohort study involved patients who underwent abdominal surgery between January 2015 and December 2020 to treat digestive tract cancer. Participants were allocated to the development cohort, the validation cohort, or the application cohort. Univariate and multivariate analyses of the development cohort were performed to detect distinct risk variables for cancer cachexia to create a cancer cachexia risk score. The performance of the risk score across all the three cohorts was assessed through calculating the area under the receiver operating characteristic curve (AUC), as well as calibration and decision curves. We tested how well the score predicted survival outcomes in the application cohort.

RESULTS

A total of 16 264 patients (median 64 years of age; 65.9% male) were included, with 8743 in the development cohort, 5828 in the validation cohort, and 1693 in the application cohort. Seven variables were identified as independent predictive factors and were included in the cancer cachexia risk score: cancer site, cancer stage, time from symptom onset to hospitalization, appetite loss, body mass index, skeletal muscle index, and neutrophil-lymphocyte ratio. The risk score predicting cancer cachexia owns a good discrimination, with the mean AUC of 0.760 (P < 0.001) in the development cohort, 0.743 (P < 0.001) in the validation cohort, and 0.751 (P < 0.001) in the application cohort, respectively, and had an excellent calibration (all P > 0.05). The decision curve analysis revealed net benefits of the risk score across a range of risk thresholds in the three cohorts. In the application cohort, compared with the high-risk group, the low-risk group experienced significantly longer overall survival [hazard ratio (HR) 2.887, P < 0.001] as well as relapse-free survival (HR 1.482, P = 0.01).

CONCLUSIONS

The cancer cachexia risk score constructed and validated demonstrated good performance in identifying those digestive tract cancer patients before abdominal surgery at a higher risk of cancer cachexia and unfavourable survival. This risk score can help clinicians to enhance their capabilities to screen for cancer cachexia, assess patient prognosis, and strengthen early decision-making on targeted approaches to attune cancer cachexia for digestive tract cancer patients before abdominal surgery.

Serum transthyretin and aminotransferases are associated with lean mass in people with coronary heart disease: Further insights from the CARE-CR study

Background

Low muscle mass disproportionately affects people with coronary heart disease compared to healthy controls but is under-researched and insufficiently treated. Inflammation, poor nutrition, and neural decline might contribute to low muscle mass. This study aimed to assess circulatory biomarkers related to these mechanisms [albumin, transthyretin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), and C-terminal agrin fragment] and their relationship with muscle mass in people with coronary heart disease. Our findings could be beneficial to indicate mechanisms of sarcopenia, detect sarcopenia, and evaluate treatment.

Methods

Serum blood samples from people with coronary heart disease were analysed for biomarker concentrations using enzyme-linked immunosorbent assays. Skeletal muscle mass was estimated using dual X-ray absorptiometry derived appendicular lean mass and reported as skeletal muscle index (SMI; kg m^-2), and as a proportion of total body mass [appendicular skeletal mass (ASM%)]. Low muscle mass was defined as a SMI <7.0 and <6.0 kg m^-2, or ASM% <25.72 and <19.43% for men and women, respectively. Associations between biomarkers and lean mass were adjusted for age and inflammation.

Results

Sixty-four people were assessed; 14 (21.9%) had low muscle mass. People with low muscle mass had lower transthyretin (effect size 0.34, p = 0.007), ALT (effect size 0.34, p = 0.008), and AST (effect size 0.26, p = 0.037) concentrations, compared to those with normal muscle mass. SMI was associated with inflammation-corrected ALT (r = 0.261, p = 0.039) and with inflammation- and age-adjusted AST/ALT ratio (r = -0.257, p = 0.044). Albumin and C-terminal agrin fragment were not associated with muscle mass indices.

Conclusion

Circulatory transthyretin, ALT and AST were associated with low muscle mass in people with coronary heart disease. Low concentrations of these biomarkers might indicate that low muscle mass is partially explained by poor nutrition and high inflammation in this cohort. Targeted treatments to address these factors could be considered for people with coronary heart disease.

Practical parameters that can be used for nutritional assessment in patients hospitalized in the intensive care unit with the diagnosis of chronic obstructive pulmonary disease: Prognostic nutritional index, neutrophil-to-lymphocyte, platelet-to-lymphocyte, and lymphocyte-to-monocyte ratio

Malnutrition is an important condition in patients diagnosed with chronic obstructive pulmonary disease (COPD). There is a need for practical and objective nutritional assessment methods in patients hospitalized in the intensive care unit with the diagnosis of COPD. In this study, it was aimed to determine the parameters that can practically evaluate the nutritional status of these patients. It was aimed to determine the relationship between prognostic nutritional index (PNI), and nutritional risk screening (NRS)-2002, nutrition risk in the critical ill (Nutric) Score and to determine a cut-off value for PNI, neutrophil-to-lymphocyte (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), and other complete blood count parameters.Hemogram values, albumin values, NLR, PLR, LMR, NRS-2002, PNI and modified Nutric Score calculations of the patients hospitalized in the intensive care unit due to COPD were recorded. The relationship between PNI and NRS-2002 and modified Nutric Score, as well as the relationship between NLR, PLR, LMR, hemogram parameters and PNI were analyzed using statistical methods.The PNI cut-off value for nutritional assessment in patients hospitalized in the intensive care unit due to COPD was determined as 38.5 (area under curve = 0.891, sensitivity 80.8%, specificity 88.1%, positive predictive value 92.9%, negative predictive value 88%). High-risk group according to PNI compared to low-risk group, lymphocyte count (P < .001), basophil count (P = .004), red blood cell (P < .001), hemoglobin (P < .001), hematocrit (P < .001), and LMR (P = .001) were statistically significantly lower, while NLR (P < .001) and PLR (P = .001) were statistically significantly higher. Cut-off values for lymphocyte count, basophil count, NLR, PLR, and LMR were found to be 1.18, 0.035, 7.97, 291.10, and 2.606, respectively.Nutritional risk assessment can be made in a practical way by using PNI in patients hospitalized in intensive care unit due to COPD. For this, the PNI cut-off value was determined as 38.5 in our study. In addition, NLR, PLR, LMR, basophil and lymphocyte values, which can be calculated using complete blood count parameters, may also be useful in the evaluation of nutritional status in these patients. In our study, the cut-off values determined for NLR, PLR, LMR, basophil and lymphocyte were 7.97, 291.10 and 2.606, 0.035 and 1.18, respectively. We think that the results we have obtained can provide preliminary information for future research.

Evaluation of Nutritional Status in Hospitalized Chronic Obstructive Pulmonary Disease Patients and Can C-reactive Protein-to-Albumin Ratio Be Used in the Nutritional Risk Assessment in These Patients

Background Malnutrition is common in patients diagnosed with chronic obstructive pulmonary disease (COPD). CRP/albumin ratio (CAR) can be used as a parameter to evaluate the inflammatory process and nutritional status together. The aim of this study was to make a general evaluation of the nutritional status of hospitalized patients with COPD and to investigate whether CAR can predict nutritional status in these patients. Methods Patients who were hospitalized with COPD who were consulted to the nutrition department were included in the study. The patients' Nutritional Risk Score-2002 (NRS), demographic data, diagnoses, body mass indexes (BMI), nutritional support applied to the patients were recorded. CRP, Albumin, and CAR values of the patients were determined. Patients recommended nutritional follow-up, total parenteral nutrition (TPN) or enteral nutrition (EN) initiated, and oral nutritional supplement (ONS) support were identified. Results A total of 393 patients with COPD were analyzed. 88.55% of the patients were in the NRS ≥ 3 risk group. TPN treatment was started in 10.2% of the patients, EN in 10.9%, ONS in 76.3%, and nutritional follow-up was recommended in 2.5% of the patients. While albumin level was lower in patients with NRS ≥ 3, CRP and CAR were higher in patients with NRS ≥ 3 (p < 0.05). There was a negative correlation between NRS-2002 and albumin (p < 0.001). A positive correlation was observed between NRS-2002 and CRP and CAR (p < 0.001). Age and CAR were found to be effective in predicting those with NRS-2002 ≥ 3. The cut-off value for CAR was accepted as 3.26. Conclusions The need for nutritional support is high in patients hospitalized with COPD. It is important to evaluate nutritional support needs in these patients, regardless of NRS-2002 and BMI. In this respect, the clinician's observation and the decision are as valuable as the scoring that determines malnutrition. We think that the cut-off value of 3.26 determined for CAR can be used in the nutritional risk assessment in patients with COPD.

The Relationship Between Prognostic Nutritional Index and All-Cause Mortality in Critically Ill Patients: A Retrospective Study

Purpose

The effectiveness and prognostic value of the prognostic nutritional index (PNI) in critically ill patients are unknown. Hence, this study aimed to analyze the relationship between the PNI and all-cause mortality in critically ill patients.

Patients and Methods

Patient data were obtained from the Multiparameter Intelligent Monitoring in Intensive Care III database. The relationship between the PNI and in-hospital mortality was analyzed using receiver operating characteristic curve analysis and a logistic regression model. Propensity score matching (PSM) was used to eliminate the bias caused by confounding factors. The Kaplan-Meier curve and Cox regression model were used to test the effect of the PNI on 30-, 90-, 180-, and 365-day mortality.

Results

A low PNI score is an independent risk factor for in-hospital mortality in critically ill patients. A total of 3644 cases were successfully matched using PSM. The PSM group with balanced covariates obtained similar results in the three models, which were statistically significant. The Kaplan-Meier curve and Cox regression model showed that the PNI was negatively correlated with 30-, 90-, 180-, and 365-day all-cause mortality.

Conclusion

The PNI score is an independent risk factor for all-cause mortality in critically ill patients, where a low PNI score is associated with increased mortality.

Albumin and the fibrinogen-to-albumin ratio: Biomarkers for the acute phase response following total knee arthroplasty

PURPOSE

Complications following total knee arthroplasty (TKA) lead to patient morbidity and cost. While acute phase reactants, such as c-reactive protein (CRP) and fibrinogen, have been used to predict complications following TKA, the extent and duration of changes in albumin levels following TKA are unknown. It is hypothesized that like CRP and fibrinogen, albumin, and the fibrinogen/albumin ratio (FAR) represent useful measures of the acute phase response (APR) following TKA. The purpose of this study was to describe the longitudinal course of albumin and FAR in healthy patients following TKA, relative to established biomarkers, and examine if the variance in albumin or FAR correlates with patient comorbidities.

METHODS

This retrospective cohort study of patients undergoing TKA at a tertiary medical center. CRP, fibrinogen, and albumin values were collected pre- and post-operatively. An age-adjusted Charlson comorbidity index (CCI) was utilized as a measure of patient comorbidity status.

RESULTS

The median preoperative albumin value was 4.3 g/dL, which dropped to 3.6 g/dL on postoperative day 1 following TKA. The albumin value returned to 93% of the baseline by postoperative week 2. The course of albumin inversely mirrored the course of CRP (r = -0.41). Median preoperative FAR was 0.087 g/L, which rose to 0.130 g/L by postoperative week 2 and returned to baseline by postoperative week 6. While preoperative FAR strongly correlated with postoperative week 2 values (r = 0.74), there was a weak positive correlation between age-adjusted CCI and pre-operative FAR (r = 0.24) in patients undergoing primary TKA.

CONCLUSION

Albumin levels follow a predictable postoperative decline that inversely correlates with CRP in healthy patients following TKA. Given the low cost and abundance of laboratories offering albumin levels, direct albumin levels and/or albumin ratios such as FAR may be underutilized biomarkers for monitoring the APR following TKA.

Reduced Albumin Concentration Predicts Weight Gain and Higher Ad Libitum Energy Intake in Humans

OBJECTIVE

Circulating albumin is negatively associated with adiposity but whether it is associated with increased energy intake, lower energy expenditure or weight gain has not been examined.

METHODS

In study 1 (n=238; 146 men), we evaluated whether fasting albumin concentration was associated with 24-h energy expenditure and ad libitum energy intake. In study 2 (n=325;167 men), we evaluated the association between plasma albumin and change in weight and body composition.

RESULTS

After adjustment for known determinants of energy intake lower plasma albumin concentration was associated with greater total daily energy intake (β= 89.8 kcal/day per 0.1 g/dl difference in plasma albumin, p=0.0047). No associations were observed between plasma albumin concentrations and 24-h energy expenditure or 24-h respiratory quotient (p>0.2). Over 6 years, volunteers gained on average 7.5 ± 11.7 kg (p<0.0001). Lower albumin concentrations were associated with greater weight [β=3.53 kg, p=0.039 (adjusted for age, sex, follow up time), CI 0.16 to 6.21 per 1 g/dl difference albumin concentration] and fat mass (β=2.3 kg, p=0.022), respectively, but not with changes in fat free mass (p=0.06).

CONCLUSIONS

Lower albumin concentrations were associated with increased ad libitum food intake and weight gain, indicating albumin as a marker of energy intake regulation.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, identifiers NCT00340132, NCT00342732.

The Use of Visceral Proteins as Nutrition Markers: An ASPEN Position Paper

Serum albumin and prealbumin, well-known visceral proteins, have traditionally been considered useful biochemical laboratory values in a nutrition assessment. However, recent literature disputes this contention. The aim of this document is to clarify that these proteins characterize inflammation rather than describe nutrition status or protein-energy malnutrition. Both critical illness and chronic illness are characterized by inflammation and, as such, hepatic reprioritization of protein synthesis occurs, resulting in lower serum concentrations of albumin and prealbumin. In addition, the redistribution of serum proteins occurs because of an increase in capillary permeability. There is an association between inflammation and malnutrition, however, not between malnutrition and visceral-protein levels. These proteins correlate well with patients' risk for adverse outcomes rather than with protein-energy malnutrition. Therefore, serum albumin and prealbumin should not serve as proxy measures of total body protein or total muscle mass and should not be used as nutrition markers. This paper has been approved by the American Society for Parenteral and Enteral Nutrition Board of Directors.

Melatonin supplementation in the management of obesity and obesity-associated disorders: A review of physiological mechanisms and clinical applications

Despite the evolving advances in clinical approaches to obesity and its inherent comorbidities, the therapeutic challenge persists. Among several pharmacological tools already investigated, recent studies suggest that melatonin supplementation could be an efficient therapeutic approach in the context of obesity. In the present review, we have amalgamated the evidence so far available on physiological effects of melatonin supplementation in obesity therapies, addressing its effects upon neuroendocrine systems, cardiometabolic biomarkers and body composition. Most studies herein appraised employed melatonin supplementation at dosages ranging from 1 to 20 mg/day, and most studies followed up participants for periods from 3 weeks to 12 months. Overall, it was observed that melatonin plays an important role in glycaemic homeostasis, in addition to modulation of white adipose tissue activity and lipid metabolism, and mitochondrial activity. Additionally, melatonin increases brown adipose tissue volume and activity, and its antioxidant and anti-inflammatory properties have also been demonstrated. There appears to be a role for melatonin in adiposity reduction; however, several questions remain unanswered, for example melatonin baseline levels in obesity, and whether any seeming hypomelatonaemia or melatonin irresponsiveness could be clarifying factors. Supplementation dosage studies and more thorough clinical trials are needed to ascertain not only the relevance of such findings but also the efficacy of melatonin supplementation.

Role of Albumin as a Nutritional and Prognostic Marker in Elective Intestinal Surgery

BACKGROUND

The aim of this study was to investigate albumin, nutritional status, and inflammation in the perioperative course of patients undergoing elective intestinal surgery.

METHODS

A retrospective analysis of patients with preoperative measurements of nutritional parameters who underwent intestinal surgery between April 2017 and August 2018 at our institution was performed. Preoperatively, the correlation of albumin levels with markers for inflammation and nutritional status was investigated. Postoperatively, albumin levels were assessed with regard to high-grade morbidity and inflammation.

RESULTS

A total of 105 patients were included. Preoperatively, albumin levels were correlated with both markers for nutritional status and inflammation, with phase angle (PA) (p=0.004) and C-reactive protein (CRP) (p < 0.001) as independent factors predicting the albumin levels in multivariable analysis. Postoperatively, the reduction in serum albumin (∆-albumin) on postoperative day (POD) 1/2 (p=0.025) and POD 4/5 (p=0.003) was significantly associated with Clavien-Dindo complications ≥grade III. A cut-off value of 27.3% for ∆-albumin on POD 1/2 predicted postoperative high-grade morbidity (sensitivity 75% and specificity 69%). The product of ∆-albumin and CRP on POD 4/5 identified patients with major complications more reliably than ∆-albumin or CRP alone (sensitivity 91% and specificity 72%).

CONCLUSION

Preoperatively, albumin was a marker for nutritional status even if an inflammatory component was present. Postoperatively, ∆-albumin on POD 1/2 predicted high-grade morbidity. A new marker to identify patients with major complications on POD 4/5 is presented.

Nutritional status and functionality in geriatric rehabilitation patients: a systematic review and meta-analysis

PURPOSE

Since there is only limited evidence available for geriatric rehabilitation patients, this systematic review and meta-analysis aims to characterize the nutritional status in this population and its relationship with functionality.

METHODS

Eight databases were searched for full-text articles reporting baseline nutritional intake and status of adults ≥ 60 years in rehabilitation settings. Pooled estimates were calculated for prevalence of malnutrition and risk of malnutrition based on the Mini Nutritional Assessment (MNA) and for mean body mass index (BMI). Associations between nutritional status (MNA, MNA short form and BMI) and functional status (Barthel Index and Functional Independence Measure) and prevalence of sarcopenia were reviewed.

RESULTS

62 out of 1717 references were eligible for inclusion. Pooled prevalence [95% confidence interval (CI)] of malnutrition and risk of malnutrition were 13 (5-20) % and 47 (40-54) %. Pooled estimate (95% CI) for BMI was 23.8 (23.2-24.5) kg/m². Existing data suggest a risk for low protein and energy intake and vitamin D deficiency. Functional status differed widely. Seven out of ten studies reported significant associations between reduced nutritional status and reduced functionality, whilst two out of seven studies reported significant associations between higher BMI and functionality. Prevalence of sarcopenia was high with 40-76% in this population.

CONCLUSIONS

Although geriatric rehabilitation populations and settings were heterogeneous, a relevant percentage of geriatric rehabilitation patients were affected by a reduced nutritional status. Nutritional status was associated with decreased functionality. This emphasizes the need for screening for malnutrition and targeted nutritional intervention.

A Low Geriatric Nutritional Risk Index is Associated with Aggressive Pathologic Characteristics and Poor Survival after Nephrectomy in Clear Renal Cell Carcinoma: A Multicenter Retrospective Study

Purpose: To investigated the prognostic significance of the geriatric nutritional risk index (GNRI) in patients with surgically treated clear cell renal cell carcinoma (ccRCC).Patients and methods: We retrospectively selected 4,591 consecutive patients with surgically treated ccRCC from a multi-institutional Korean collaboration between 1988 and 2015. The clinical significance of the GNRI as a continuous and categorical variable was determined.Results: Preoperative low GNRI was significantly associated with older age, low body mass index, presence of diabetes, poor performance status, and presence of symptoms at diagnosis, as well as pathologic features such as aggressive tumor characteristics including large tumor size, advanced stage, high nuclear grade, lymphovascular invasion, sarcomatous differentiation, and tumor necrosis. A low GNRI was significantly associated with a short recurrence-free survival (RFS) in localized (pT1-2N0M0) ccRCC and cancer-specific survival (CSS) in the entire cohort, and with short RFS and CSS in the subgroup analysis according to age categories (≤65 and >65 years). Multivariate Cox regression analysis showed that preoperative GNRI, as a continuous or categorical variable, was an independent predictor of RFS and CSS.Conclusion: Malnutrition as assessed by the preoperative GNRI is associated with aggressive tumor characteristics and poor survival in patients with surgically treated ccRCC.

[Undernutrition of the elderly]

Malnutrition remains a particularly important issue in elderly. Physiological ageing induces many changes but ageing cannot entirely explain a Protein-Energy Malnutrition (PEM). Nutritionnal screening is indicated once a year in community medicine or in the first 48hours in case of an acute disease or of hospitalization. The Mini Nutritional Assessment is recommended for screening and for the diagnostic of malnutrition. Possible aetiologies are large and must be investigated in order to be careful not to dismiss curable disease and to be able to take corrective actions. PEM is associated to functional decline, length of stay in hospital and to morbi-mortality. Recommendations for dietary intakes in healthy old subjects are about 30 kcal/kg/day and 1 g/kg/day of protein and are strongly enhanced in case of acute or chronic diseases. The nutritional strategy depends on spontaneous food intake, medical situation, patient profile and opinion. Appropriate nutritional care could reduce morbidity-mortality and prevent functional decline in various disease contexts.

Clinical outcomes and prognostic factors in patients directly transferred to the intensive care unit from long-term care beds in institutions and hospitals: a retrospective clinical study

Background

There has been a steady increase in the aging population and an increase in the need for long-term care beds in institutions and hospitals (LTCHs) in Korea. The aim of this study was to investigate prognosis and to identify factors contributing to mortality of critically ill patients with respiratory problems who were directly transferred to intensive care units (ICU) from LTCHs.

Methods

Following a retrospective review of clinical data and radiographic findings between July 2009 and September 2016, we included 111 patients with respiratory problems who had visited the emergency room (ER) transferred from LTCHs due to respiratory symptoms and who were then admitted to the ICU.

Results

The mean age of the 111 patients was 79 years, and 71 patients (64%) were male. Pneumonia developed in 98 patients (88.3%), pulmonary thromboembolism in 4 (3.6%) and pulmonary tuberculosis in 3 (2.7%). Overall mortality was 19.8% (22/111). Multiple-drug-resistant (MDR) pathogens (odds ratio [OR], 17.43; 95% confidence interval [CI], 1.96–155.40) and serum albumin levels < 2.15 g/dL, which were derived through ROC (sensitivity, 72.7%; specificity, 85.4%) (OR, 28.05; 95% CI, 5.47–143.75), were independent predictors for mortality. The need for invasive ventilation (OR, 2.74; 95% CI, 1.02–7.32) and history of antibiotic use within the 3 months (OR, 3.23; 95% CI, 1.32–7.90) were risk factors for harboring MDR pathogens.

Conclusions

The presence of MDR pathogens and having low serum albumin levels may be poor prognostic factors in patients with respiratory problems who are admitted to the ICU from LTCHs. A history of antibiotic use within the 3 months and the need for invasive ventilation can be helpful in choosing the appropriate antibiotics to combat MDR pathogens at the time of admission.

Relation between hypermetabolism, cachexia, and survival in cancer patients: a prospective study in 390 cancer patients before initiation of anticancer therapy

Background: Cachexia is a major cause of death in cancer patients. The role of hypermetabolism in cancer cachexia remains unclear.Objective: We studied the relation between resting energy expenditure (REE), the estimated energy balance, clinical and biological markers of cachexia, and survival.Design: REE was measured with the use of indirect calorimetry in cancer patients before the initiation of anticancer therapies. Hypermetabolic, normometabolic, and hypometabolic patients were identified with the use of Boothby's standard. Weight loss, performance status (PS), C-reactive protein (CRP), albumin, the nutritional risk index, daily energy intake, energy balance (equal to daily energy intakes minus the REE), and survival were recorded.Results: Of 390 enrolled patients, 49% of subjects were hypermetabolic, 30% of subjects were normometabolic, and 21% of subjects were hypometabolic. Mean daily energy intakes did not differ significantly between the 3 groups. Hypermetabolic patients, compared with normometabolic patients, were more likely to have a negative energy balance [45% compared with 32%, respectively; OR: 1.74 (95% CI: 1.05, 2.91); P = 0.024], weight loss >5% [48% compared with 34%, respectively; OR: 1.83 (95% CI: 1.11, 3.04); P = 0.013], PS ≥2 [40% compared with 29%, respectively; OR: 1.70 (95% CI: 1.01, 2.88); P = 0.038], and CRP concentrations ≥10 mg/L [52% compared with 33%, respectively; OR: 2.2 (95% CI: 1.33, 3.66); P = 0.001]. In metastatic patients, compared with normometabolism, hypermetabolism was associated with a reduced median survival [14.6 compared with 21.4 mo, respectively; OR: 1.48 (95% CI: 1.01, 2.17); P = 0.044].Conclusions: Hypermetabolism is correlated with clinical and biological markers of cancer cachexia and is associated with a shorter survival in metastatic cancer patients. The development of therapeutic strategies that aim to blunt hypermetabolism appears warranted. This trial was registered at www.controlled-trials.com as ISRCTN46152275.

Serum albumin and health in older people: Review and meta analysis

Albumin is the most abundant plasmatic protein. It is only produced by the liver and the full extent of its metabolic functions is not known in detail. One of the main roles assigned to albumin is as an indicator of malnutrition. There are many factors, in addition to nutrition, that influence levels of albumin in plasma. The main aim of this review is to assess the clinical significance of albumin in elderly people in the community, in hospital and in care homes. Following the review, it can be stated that age is not a cause of hypoalbuminemia. Albumin is a good marker of nutritional status in clinically stable people. Significant loss of muscle mass has been observed in elderly people with low albumin levels. Hypoalbuminemia is a mortality prognostic factor in elderly people, whether they live in the community or they are in hospital or institutionalized. Low levels of albumin are associated to worse recovery following acute pathologies. Inflammatory state and, particularly, high concentrations of IL-6 and TNF-alpha, are two of the main influencing factors of hypoalbuminemia. In elderly patients with a hip fracture, albumin levels below 38 g/L are associated to a higher risk of post-surgery complications, especially infections. Further research is needed on the impact of nutritional intervention upon albumin levels and on the outcomes in elderly people in the community, in hospital and in care.

Nutrition and hydration in older adults in critical care

Nutrition and hydration are vital components of critical care nursing. However, meeting the nutrition and hydration needs of the critically ill older adult is often complex, because of preexisting risk factors (malnutrition, unintentional weight loss, frailty, and dehydration); as well as intensive care unit-related challenges (catabolism, eating and feeding, end-of-life care). This article highlights the challenges of managing nutrition and hydration in the critically ill older adult, reviews assessment principles, and offers strategies for optimizing nutrition and hydration.

Impact of protein pulse feeding on lean mass in malnourished and at-risk hospitalized elderly patients: a randomized controlled trial

BACKGROUND & AIMS

Aging is associated with a blunted anabolic response to dietary intake, possibly related to a decrease in systemically available amino acids (AAs), which in turn may stem from increased splanchnic AA metabolism. This splanchnic sequestration can be saturated by pulse feeding (80% of daily protein intake in a single meal), enabling increased protein synthesis. This study aimed to evaluate the efficacy of a new nutritional strategy, termed protein pulse feeding.

METHODS

This prospective randomized study (ClinicalTrials.gov registration number NCT00135590) enrolled 66 elderly malnourished or at-risk patients in an inpatient rehabilitation unit. All were given a controlled diet for 6 weeks. In a spread diet (SD) group (n = 36), dietary protein was spread over the four daily meals. In a pulse diet (PD) group (n = 30), 72% of dietary protein (1.31 g/kg weight/d on average) was consumed in one meal at noon. The patients were evaluated at admission and at 6 weeks for body composition [lean mass (LM), appendicular skeletal muscle mass (ASMM), and body cell mass (BCM) indices, measured by X-ray absorptiometry combined with bioelectrical impedance analysis] (primary outcome), hand grip strength, and activities of daily living (ADL) score.

RESULTS

Protein pulse feeding was significantly more efficacious than protein spread feeding in improving LM index (mean changes from baseline for PD group: +0.38 kg/m(2); 95% confidence interval (CI), [0; 0.60]; for SD group: -0.21 kg/m(2); 95% CI, [-0.61; 0.20]; p = 0.005 between the two groups), ASMM index (+0.21 kg/m(2); 95% CI, [0; 0.34] and -0.11 kg/m(2); 95% CI, [-0.20; 0.09]; p = 0.022), BCM index (+0.44 kg/m(2); 95% CI, [0.08; 0.52] and -0.04 kg/m(2); 95% CI, [-0.09; 0.10]; p = 0.004). There was no significant effect for hand-grip strength or ADL score.

CONCLUSIONS

This study demonstrates for the first time that protein pulse feeding has a positive, clinically relevant effect on lean mass in malnourished and at-risk hospitalized elderly patients.

Risk factors for 90-day and 180-day mortality in hospitalised patients with pressure ulcers

An understanding of risk factors associated with mortality among pressure ulcer patients can inform prognostic counselling and treatment plans. This retrospective cohort study examined associations of comorbid illness, demographic characteristics and laboratory values with 90-day and 90- to 180-day mortality in adult hospitalised patients with pressure ulcers. Data were extracted from hospital databases at two academic urban hospitals. Covariates included mortality risk factors identified in other populations, including demographic and laboratory variables, DRG weight, 'systemic infection or fever' and comorbidity categories from the Charlson comorbidity index. In adjusted Cox proportional hazards models, diabetes, chronic renal failure, congestive heart failure and metastatic cancer were significantly associated with mortality in both time frames. There was no significant effect on mortality from dementia, hemiplegia/paraplegia, rheumatic disease, chronic pulmonary disease or peripheral vascular disease. Myocardial infarction, cerebrovascular disease, liver disease and human immunodeficiency virus/AIDS were associated with mortality in the 90-day time frame only. 'Systemic infection or fever' was associated with mortality in the 90-day time frame but did not show a confounding effect on other variables, and the only significant interaction term was with metastatic cancer. Albumin was the only studied laboratory value that was strongly associated with mortality. Understanding the context of comorbid illness in pressure ulcer patients sets the groundwork for more robust studies of patient- and population-level outcomes, as well as study of heterogeneity within this group.

Routinely assessed biochemical markers tested on admission as predictors of adverse outcomes in hospitalized elderly patients

AIM

To explore whether routinely assessed biochemical markers tested on admission will predict 3 predefined adverse outcomes for hospitalized elderly patients: discharge to a long-term care facility, in-hospital mortality, and prolonged hospital length of stay (> 14 days).

METHODS

A prospective observational study of elderly patients (aged ≥ 75 years) admitted to an acute-care geriatric ward over a 6-month period. Patients were assessed on admission and baseline characteristics were collected. Activities of daily living were assessed by the Barthel Index and cognitive function by the abbreviated mental test. Results from biochemical markers tested on admission were downloaded from the pathology laboratory database using patient details. Patients were followed-up with until discharge or in-hospital mortality.

RESULTS

A total of 392 patients formed the study population. Mean (standard deviation) age was 83.2 (± 5.5) years and 283 (72%) patients were men. Thirty-eight (10%) patients were discharged to a long-term care facility, 134 (34%) had a prolonged hospital length of stay, and 33 (8%) died in the hospital. Results from testing 5 biochemical markers independently predicted in-hospital mortality: hypoalbuminemia (adjusted odds ratio [OR], 2.5; 95% CI, 0.9-6.7; P = 0.04), low total cholesterol level (adjusted OR, 2.9; 95% CI, 1.3-6.3; P = 0.01), hyperglycemia (adjusted OR, 2.9; 95% CI, 1.2-7.4; P = 0.02), high C-reactive protein level (adjusted OR, 4.2; 95% CI, 1.3-13.4; P = 0.01), and renal impairment (adjusted OR, 3.8; 95% CI, 1.7-8.7; P = 0.002). High C-reactive protein level independently predicted prolonged hospital length of stay (OR, 1.7; 95% CI, 1.1-2.9; P = 0.03). Hypoalbuminemia predicted discharge to a long-term care facility independent of confounding factors except for physical dysfunction (OR, 2.4; 95% CI, 1.1-5.1; P = 0.03). Significance was reduced after adjustment for Barthel Index score (OR, 1.9; 95% CI, 0.9-4.1; P = 0.08).

CONCLUSION

Testing of routinely assessed biochemical markers on admission predicted adverse hospital outcomes for elderly patients. Their inclusion in a standardized prediction tool may help to create interventions to improve such outcomes.

Leptin is better than any other biological parameter for monitoring the efficacy of renutrition in hospitalized malnourished elderly patients

OBJECTIVE

Despite malnutrition being a major problem in hospitalized elderly patients, there is a lack of studies focusing on the comparative value of biological parameters for monitoring renutrition. The aim of this study was to determine which biological parameter(s) could best monitor successful renutrition in hospitalized malnourished elderly patients.

DESIGN

The objective of the study was to explore the impact of a 6-week renutrition process on anthropometric and biological parameters in elderly patients and to define the biological parameters associated with weight regain.

PATIENTS

A total of 72 hospitalized malnourished elderly patients admitted to a hospital-based geriatric rehabilitation unit.

MEASUREMENTS

Patients were evaluated at admission and at 6 weeks for anthropometric measurements of weight, sum of the four subcutaneous skinfold thicknesses, calf circumference and biological serum parameters including albumin, transthyretin, leptin, IGF-1, IGFBP-1 and IGFBP-3. Renutrition was considered successful if a patient gained at least 5% of body weight over 6 weeks.

RESULTS

Leptin was the only biological parameter that increased at 6 weeks in successful renutrition. Leptin variations were not influenced by C-reactive protein variations, in contrast to transthyretin which can be modified by the inflammatory states frequently encountered in geriatric patients.

CONCLUSIONS

Serum leptin is a more appropriate parameter than transthyretin for monitoring renutrition.

Serum albumin level is a limited nutritional marker for predicting wound healing in patients with pressure ulcer: two multicenter prospective cohort studies

BACKGROUND & AIMS

We aimed to investigate the predictive validity of serum albumin for pressure ulcer healing, according to patient condition and wound characteristics.

METHODS

This study was a secondary analysis of pooled data from two multicentre cohort studies undertaken in 2005 and 2007. All adult patients with pressure ulcer were included and were tracked until wound healing or discharge from care. Baseline serum albumin data were obtained from medical charts.

RESULTS

A total of 2530 patients were analyzed. By multivariate Cox proportional hazards analysis, higher serum albumin level was associated with wound healing of only superficial pressure ulcers for patients in acute/postoperative conditions (hazard ratio 1.29, 95% confidence interval 1.13-1.46) and the cutoff point was 24/25 g/L. However, the addition of serum albumin level to other factors resulted in little increase in the ability to predict wound healing as measured by the overall C-statistics. For patients in chronic/palliative conditions, serum albumin level as the continuous variable was not significantly associated with ulcer healing.

CONCLUSIONS

The addition of serum albumin marker may not have much advantage to predict pressure ulcer healing although its level can be associated with ulcer healing, depending on patient condition and wound depth.