The treatment of hypoalbuminaemia

The clinical significance of hypoalbuminaemia

Albumin is a relatively small molecule with a radius of 7.5 nm and a molecular weight of 65 kDa. It is the most abundant protein in plasma, accounting for 60-75% of its oncotic pressure. Its concentration in plasma is merely one static measurement reflecting a dynamic and complex system of albumin physiology, and is the net result of several different processes, one or more of which may become deranged by disease or its treatment. It is also unsurprising that hypoalbuminaemia has proved to be an indicator of morbidity and mortality risk since the underlying conditions which cause it, including protein energy malnutrition, crystalloid overload, inflammation, and liver dysfunction are themselves risk factors. In some cases, its underlying cause may require treatment but mostly it is just a parameter to be monitored and used as one measure of clinical progress or deterioration. While malnutrition, associated with a low protein intake, may be a contributory cause of hypoalbuminaemia, in the absence of inflammation and/or dilution with crystalloid its development in response to malnutrition alone is slow compared with the rapid change caused by inflammatory redistribution or dilution with crystalloids. Other significant causes include liver dysfunction and serous losses. These causal factors may occur singly or in combination in any particular case. Treatment is that of the underlying causes and associated conditions such as a low plasma volume, not of hypoalbuminaemia per se.

Association of hemoglobin, albumin, lymphocyte, and platelet score with risk of cerebrovascular, cardiovascular, and all-cause mortality in the general population: results from the NHANES 1999-2018

Background and aims

Cardiovascular and cerebrovascular disease (CCDs) contribute to leading causes of morbidity and mortality in the United States of America (USA). Hemoglobin, albumin, lymphocyte, and platelet (HALP) score, a simple and convenient indicator, could reflect the combination of inflammation and nutritional status. This study was undertaken to evaluate the associations between HALP score and risk of cardiovascular, cerebrovascular, and all-cause mortality in the general population from the National Health and Nutrition Examination Survey (NHANES) 1999-2018.

Methods

We identified 21,578 participants during the 1999-2018 cycles of the NHANES in this research. HALP score was calculated as hemoglobin (g/L) × albumin (g/L) × lymphocytes (/L)/platelets (/L). Outcomes were cerebrovascular, cardiovascular, and all-cause mortality determined by the NHANES-linked National Death Index record and followed until 31 December 2019. Survey-weighted Cox regression, restricted cubic spline analysis, and subgroup analysis were applied to investigate relationships between HALP score and risk of mortality.

Results

This cohort study comprised 49.2% male and 50.8% female, of which the median age was 47 years old. In multivariate survey-weighted Cox regression adjusting for all confounders, compared with participants with low HALP scores, participants with highest HALP score had a lower risk of all-cause mortality (adjusted HR:0.80, 95% CI: 0.73, 0.89, P < 0.0001) and cardiovascular mortality (adjusted HR:0.61, 95% CI: 0.50, 0.75, P < 0.0001), and mediate HALP score had the lowest risk of all-cause mortality (adjusted HR:0.68, 95% CI: 0.62, 0.75, P < 0.0001) and cardiovascular mortality (adjusted HR:0.60, 95% CI: 0.48, 0.75, P < 0.0001). Restricted cubic spline analysis showed a non-linear relationship between HALP score and cardiovascular and all-cause mortality (all P values <0.001).

Conclusion

HALP score was independently associated with risk of cardiovascular and all-cause mortality, but not cerebrovascular mortality.

Low serum albumin may predict poor efficacy in patients with perforated peptic ulcer treated nonoperatively

BACKGROUND

Nonoperative management (NOM) is a promising therapeutic modality for patients with perforated peptic ulcer (PPU). However, the risk factors for poor efficacy and adverse events of NOM are a concern.

AIM

To investigate the factors predictive of poor efficacy and adverse events in patients with PPU treated by NOM.

METHODS

This retrospective case-control study enrolled 272 patients who were diagnosed with PPU and initially managed nonoperatively from January 2014 to December 2018. Of these 272 patients, 50 converted to emergency surgery due to a lack of improvement (surgical group) and 222 patients were included in the NOM group. The clinical data of these patients were collected. Baseline patient characteristics and adverse outcomes were compared between the two groups. Logistic regression analysis and receiver operating characteristic curve analyses were conducted to investigate the factors predictive of poor efficacy of NOM and adverse outcomes in patients with PPU.

RESULTS

Adverse outcomes were observed in 71 patients (32.0%). Multivariate analyses revealed that low serum albumin level was an independent predictor for poor efficacy of NOM and adverse outcomes in patients with PPU.

CONCLUSION

Low serum albumin level may be used as an indicator to help predict the poor efficacy of NOM and adverse outcomes, and can be used for risk stratification in patients with PPU.

Hypoalbuminemia - An Indicator of the Severity and Prognosis of COVID-19 Patients: A Multicentre Retrospective Analysis

BACKGROUND

Hypoalbuminemia has been reported in COVID-19 patients. Exploring the influencing factors and possible adverse consequences of albumin reduction may provide some guidance for the treatment of COVID-19 patients.

METHODS

In this multicentre retrospective study, we collected information including demographics, comorbidities, clinical symptoms, complications, laboratory tests, treatment, and outcomes of patients diagnosed with COVID-19 from three hospitals in Wuhan, China. We compared the indexes between patients with hypoalbuminemia and normal albumin. Regression model was used to evaluate various influencing factors of patients with hypoalbuminemia and their relationship with clinical outcomes. We also compared the changes of particular laboratory indexes in patients with hypoalbuminemia before and after enteral nutrition therapy.

RESULTS

A total of 482 patients were enrolled in the study. About 53.7% patients developed hypoalbuminemia during admission. Patients with hypoalbuminemia were older, had a higher proportion of combined diabetes mellitus, fever, dyspnea, and natriuresis, and had a relatively poorer prognosis than patients with normal albumin. Patients with hypoalbuminemia had higher levels of CRP, leukocytes, ALT, AST, total bilirubin, ALP, GGT, LDH, creatine kinase, D-dimer, globulin, and lower levels of lymphocytes and eosinophils. Severe, older, anorexia, elevated CRP, and decreased lymphocytes were the independent predictors for decreased albumin in COVID-19 patients. In addition, decreased albumin is correlated with adverse outcomes. Nutritional support therapy to correct serum albumin may improve patient outcomes.

CONCLUSION

COVID-19 patients with hypoalbuminemia tend to have more severe clinical manifestations and more abnormal biochemical tests, which may result in poorer clinical outcomes. Nutritional support therapy may improve the clinical outcome of these patients.

[Effect of omega-3 fatty acids on hypoalbuminemia in acute heart failure patients with increased inflammatory activity]

INTRODUCTION

inflammatory activity (IA) is a cause of hypoalbuminemia in patients with acute heart failure (AHF).

OBJECTIVES

the main objective of this study was to evaluate whether an AI modulator treatment contributes to correcting albuminemia in this context.

METHODS

in this clinical trial 43 patients with AHF, hypoalbuminemia (serum albumin  3.4 g/dl), and elevated IA [C-reactive protein (CRP)  25 mg/l] were randomly assigned to receive omega-3 fatty acids (4 g daily) or placebo for 4 weeks. Albuminemia and CRP were reassessed at weeks 1 and 4. An analysis of variance for repeated measures was performed.

RESULTS

mean age was 75.6 ± 8.8 years, 72.1 % were male, and the most frequent etiology was ischemic (46.5 %). The two groups were homogeneous in their baseline characteristics. A significant increase in albumin concentration was found at week 4 from baseline (p for the effect of time < 0.001), with no differences between groups at week 1 or week 4. CRP decreased significantly in week 1 (p for the effect of time < 0.001), with no differences between groups in either week 1 or week 4.

CONCLUSION

in patients with AHF, hypoalbuminemia, and elevated AI albuminemia normalizes in week 4, while CRP already drops significantly during the first week. In this context both effects are independent of the addition of high doses of omega-3 fatty acids.

Relationship of Nutritional Status, Inflammation, and Serum Albumin Levels During Acute Illness: A Prospective Study

BACKGROUND

Low serum albumin levels resulting from inflammation-induced capillary leakage or disease-related anorexia during acute illness are associated with poor outcomes. We investigated the relationship of nutritional status and inflammation with low serum albumin levels and 30-day mortality in a large cohort.

METHODS

We prospectively enrolled adult patients in the medical emergency department of a Swiss tertiary care center and investigated associations of C-reactive protein (CRP) and Nutritional Risk Screening 2002 as markers of inflammation and poor nutritional status, respectively, with low serum albumin levels and mortality using multivariate regression analyses.

RESULTS

Among the 2465 patients, 1019 (41%) had low serum albumin levels (<34 g/L), 619 (25.1%) had increased nutritional risk (Nutritional Risk Screening 2002 ≥3), and 1086 (44.1%) had CRP values >20 mg/L. Multivariate analyses adjusted for age, gender, diagnosis, and comorbidities revealed elevated CRP values (adjusted odds ratio [OR] 10.51, 95% confidence interval, 7.51-14.72, P <.001) and increased malnutrition risk (adjusted OR 2.87, 95% confidence interval, 1.98-4.15, P <.001) to be associated with low serum albumin levels, even adjusting for both parameters. Low serum albumin levels, elevated CRP values, and increased nutritional risk independently predicted 30-day mortality, with areas under the curve of 0.77, 0.70, and 0.75, respectively. Combination of these 3 parameters showed an area under the curve of 0.82 to predict mortality.

CONCLUSIONS

Elevated parameters of inflammation and high nutritional risk were independently associated with hypoalbuminemia. All 3 parameters independently predicted mortality. Combining them during initial evaluation of patients in emergency departments facilitates mortality risk stratification.

The prognostic nutritional index for postoperative infectious complication in patients with ulcerative colitis undergoing proctectomy with ileal pouch-anal anastomosis following subtotal colectomy

Objectives: Restorative proctocolectomy and ileal pouch-anal anastomosis is frequently performed in patients with ulcerative colitis and factors suspected of increasing the risk of postoperative infectious complications. Using a three-stage approach may result in improvement in overall outcomes, because this leads to improvement in nutritional status and reduction of immunosuppressive doses. However, the influence of preoperative nutritional status on postoperative infectious complications after this procedure has not been examined. The aim of this study was to clarify the potential associations between nutritional status and postoperative infectious complications in patients with ulcerative colitis undergoing proctectomy with ileal pouch-anal anastomosis. Methods: The records of 110 patients who had undergone proctectomy with ileal pouch-anal anastomosis from January 2000 to March 2018 in Mie University and met the eligibility criteria were reviewed and possible associations between postoperative infectious complications and clinical factors were assessed. Results: Of the remaining 110 patients, 18 (16.4%) had developed postoperative infectious complications. Multivariate analysis revealed that operative bleeding ≥270 g and prognostic nutritional index <47 were significant predictors of postoperative infectious complications (P = 0.033, 0.0076, respectively). Various variables associated with immunosuppressives before ileal pouch-anal anastomosis were not associated with postoperative infectious complications. Conclusions: Our findings suggest that immunosuppressives have no association with postoperative infectious complications, whereas a poor prognostic nutritional index may be a significant predictor of postoperative infectious complications in patients with ulcerative colitis undergoing proctectomy with ileal pouch-anal anastomosis.

Early discharge after pancreatoduodenectomy: what helps and what prevents?

OBJECTIVES

Shorter hospital stay after pancreatoduodenectomy (PD) is a desired goal. Implementation of enhanced recovery after surgery (ERAS) protocols can possibly help in achieving this target. We aimed to determine the factors influencing the successful implementation of ERAS protocols by analyzing their relation to the surrogate marker of enhanced recovery, namely, duration of hospital stay.

METHODS

A retrospective analysis of a prospectively maintained ERAS database of 208 consecutive patients who underwent PD at a tertiary referral care center was done.

RESULTS

Two hundred eight patients underwent a classical PD with a median duration of hospital stay of 8 days (range, 4-52 days) with an overall morbidity rate of 34.5% and a mortality rate of 3.8%. The 30-day readmission rate was 4% (8 patients). An elevated body mass index (relative risk, 1.098; 95% confidence interval, 1.015-1.188; P = 0.02) and respiratory comorbidities (relative risk, 8.024; 95% confidence interval, 2.018-31.904; P = 0.003) were independent factors resulting in a longer (>8 days) hospital stay.

CONCLUSIONS

Being overweight or obese and respiratory comorbidities are independent predictors of prolonged hospital stay despite the implementation of ERAS protocol. Hypoalbuminemia does not have a direct effect on hospital stay but may predispose the patient to the development of complications.

Perioperative catabolism

PURPOSE

This article reviews the pathophysiology, clinical relevance, and therapy of the catabolic response to surgical stress.

PRINCIPLE FINDINGS

The key clinical features of perioperative catabolism are hyperglycemia and loss of body protein, both metabolic consequences of impaired insulin function. Muscle weakness and (even moderate) increases in perioperative blood glucose are associated with morbidity after major surgery. Although the optimal glucose concentration for improving clinical outcomes is unknown, most medical associations recommend treatment of random blood glucose > 10 mmol·L(-1). Neuraxial anesthesia blunts the neuroendocrine stress response and enhances the anabolic effects of nutrition. There is evidence to suggest that the avoidance of preoperative fasting prevents insulin resistance and accelerates recovery after major abdominal surgery.

CONCLUSIONS

Current anticatabolic therapeutic strategies include glycemic control and perioperative nutrition in combination with optimal pain control and the avoidance of preoperative starvation. All these elements are part of Enhanced Recovery After Surgery (ERAS) programs.

Prognostic nutritional index predicts postoperative outcome in colorectal cancer

BACKGROUND

The prognostic nutritional index (PNI), which is calculated based on the serum albumin concentration and peripheral blood lymphocyte count, is a useful tool for predicting short-term and long-term postoperative outcome in patients undergoing cancer surgery. However, few studies have investigated PNI in colorectal cancer surgery. We examined the ability of PNI to predict short- and long-term outcomes in patients with colorectal cancer.

METHODS

This retrospective study included 365 patients who underwent resection for colorectal cancer. The prognostic nutritional status was calculated on the basis of admission data as follows: 10 × serum albumin (g/dl) + 0.005 × total lymphocyte count (per mm(3)). The primary outcomes measured were the impact of PNI on overall survival and postoperative complications.

RESULTS

Kaplan-Meier analysis and the log rank test revealed that low PNI was significantly associated with poor survival (P < 0.0001). In multivariate analysis for survival, preoperative low PNI was an independent prognostic factor for poor survival: odds ratio: 2.25, 95 % confidence interval 1.42-3.59). Moreover, low PNI significantly correlated with the incidence of postoperative complications, especially serious ones.

CONCLUSIONS

Preoperative PNI is a useful predictor of postoperative complications and survival in patients with colorectal cancer.

Hypoalbuminemia in acute heart failure patients: causes and its impact on hospital and long-term mortality

BACKGROUND

The causes of hypoalbuminemia in patients with acute heart failure (HF) remain poorly defined, and the association between hypoalbuminemia and hospital and long-term mortality has been only partially evaluated. This study sought to analyze the causes of hypoalbuminemia in acute HF patients and determine its impact on hospital and long-term mortality.

METHODS AND RESULTS

A total of 362 consecutive acute HF patients were assessed. The patients were divided into 2 groups according to the presence or absence of hypoalbuminemia (albumin ≤3.4 g/dL), and the independent association of each variable with hypoalbuminemia and hospital mortality was assessed with the use of multiple logistic regression. The association between hypoalbuminemia and long-term mortality was assessed with the use of Cox multivariate analysis. In total, 108 patients (29.8%) were classified as having hypoalbuminemia. Older age, higher C-reactive protein levels, and lower levels of total protein, prealbumin, transferrin, and lymphocytes were independently associated with hypoalbuminemia. Hospital mortality was 8% and was independently associated with hypoalbuminemia. A total of 333 patients were discharged. Hypoalbuminemia was an independent predictor of mortality.

CONCLUSIONS

Hypoalbuminemia in acute HF patients was associated with higher hospital mortality and served as an independent predictor of long-term mortality. Malnutrition and inflammation were factors causing hypoalbuminemia in this clinical setting.

The anabolic effect of perioperative nutrition depends on the patient's catabolic state before surgery

OBJECTIVE

We tested the hypothesis that the anabolic effect of hypocaloric, isonitrogenous nutrition in patients undergoing colorectal surgery depends on the patient's preoperative catabolic state.

BACKGROUND

Although there is evidence to suggest that total parenteral nutrition more effectively spares protein in depleted than in nondepleted cancer patients, the influence of preoperative catabolism on the anabolic effects of hypocaloric nutrition in patients undergoing elective surgery is unknown.

METHODS

Seventeen patients undergoing colorectal surgery received intravenous infusion of glucose with amino acids. Feeding was administered over 72 hours, from 24 hours before until 48 hours after surgery. Glucose provided 50% of the patient's measured resting energy expenditure. Amino acids provided 20% of the resting energy expenditure. Whole-body leucine balance (difference between the incorporation of leucine into protein = protein synthesis and endogenous leucine release = proteolysis) was determined using L-[1-(13)C]leucine kinetics before and 2 days after surgery. We analyzed the association between the postoperative increase in leucine balance and the following factors: preoperative leucine balance, protein breakdown, weight loss, oxygen consumption, circulating concentrations of glucose, free fatty acids, insulin, glucagon, cortisol, albumin, age, duration of surgery, and blood loss.

RESULTS

Of 6 potentially relevant variables, 4 (weight loss, protein breakdown, albumin, and cortisol) were removed because they were not significant during the stepwise linear regression procedure. Leucine balance and age were the remaining 2 factors that remained with the final regression model: Δleucine balance = 19.1 - (0.20 × age [years]) - (0.58) × leucine balance(preOP)).

CONCLUSIONS

We demonstrate a significant association between the degree of preoperative catabolism, the patient's age, and the anabolic effect of hypocaloric nutrition (ClinicalTrials.gov registration ID: NCT01414946).

Hypoalbuminemia

Hypoalbuminemia is frequently observed in hospitalized patients and it can be associated with several different diseases, including cirrhosis, malnutrition, nephrotic syndrome and sepsis. Regardless of its cause, hypoalbuminemia has a strong predictive value on mortality and morbidity. Over the years, the rationale for the use of albumin has been extensively debated and the indications for human serum albumin supplementation have changed. As the knowledge of the pathophysiological mechanisms of the pertinent diseases has increased, the indications for intravenous albumin supplementation have progressively decreased. The purpose of this brief article is to review the causes of hypoalbuminemia and the current indications for intravenous administration of albumin. Based on the available data and considering the costs, albumin supplementation should be limited to well-defined clinical scenarios and to include patients with cirrhosis and spontaneous bacterial peritonitis, patients with cirrhosis undergoing large volume paracentesis, the treatment of type 1 hepatorenal syndrome, fluid resuscitation of patients with sepsis, and therapeutic plasmapheresis with exchange of large volumes of plasma. While albumin supplementation is accepted also in other clinical situations such as burns, nephrotic syndrome, hemorrhagic shock and prevention of hepatorenal syndrome, within these contexts it does not represent a first-choice treatment nor is its use supported by widely accepted guidelines.

[Malnutrition in hospitalized patients: prevalence and economic impact]

BACKGROUND AND OBJECTIVE

Malnutrition constitutes a serious problem of public health. We intended to know the prevalence of undernourishment in our hospital, as well as to assess the expenses generated by its presence.

PATIENTS AND METHOD

A study of cohorts was designed to evaluate the nutritional state of randomly selected patients admitted to a third level hospital. We carried out a protocol of nutritional evaluation and quantified the associated costs including drugs, diet, and hospital stay according to diagnosis-related groups.

RESULTS

In agreement with anthropometry and the index of corporal mass, the prevalence of malnutrition was 0.3% and 13.4%, respectively. When analyzing the biochemical markers, the prevalence rose to 65.7%. Patients with malnutrition at the time of admission underwent a 59.9% deterioration of their nutritional state. An increase of costs was observed in relation to the length of hospital stay (68.04% compared with normo-nourished patients). Costs related to consumption of medicines, especially antibiotics, were also higher, as well as costs related to nutritional support.

CONCLUSIONS

Malnutrition is a phenomenon frequently observed in a hospital setting. Malnutrition associated costs are significant.

Practices in relation to nutritional care and support--report from the Council of Europe

Disease-related undernutrition is significant in European hospitals but is seldom treated. In 1999, the Council of Europe decided to collect information regarding Nutrition programmes in hospitals and for this purpose a network consisting of national experts from 12 of the Partial Agreement member states was established. The aim was to review the current practice in Europe regarding hospital food provision, to highlight deficiencies and to issue recommendations in improve the nutritional care and support of hospitalised patients. The data collection regarding the nutritional care providers and their practices of nutritional care and support showed that the use of nutritional risk screening and assessment, and of nutritional support and counselling was sparse and inconsistent, and that the responsibilities in these contexts were unclear. Besides, the educational level with regard to nutritional care and support was limited at all levels. All patients have the right to expect that their nutritional needs will be fulfilled during a hospitalisation. Optimal supply of food is a prerequisite for an optimal effect of the specific treatment offered to patients. Hence, the responsibilities of staff categories and the hospital management with respect to procuring nutritional care and support should be clearly assigned. Also, a general improvement in the educational level of all staff groups is needed.