Non-oncotic properties of albumin. A multidisciplinary vision about the implications for critically ill patients

Pathogenic spectrum and drug resistance of bloodstream infection in patients with acute myeloid leukaemia: a single centre retrospective study

Background

Bloodstream infection (BSI) represent a prevalent complication in haematological malignancies (HMs). Typically, Patients with BSI usually undergo empirical treatment pending pathogen identification. The timely and effective management of BSIs significantly influences patient prognosis. However, pathogen distribution in BSIs exhibits regional variation. In this study, we investigated the clinical characteristics, pathogen spectrum, drug resistance, risk factors of short-term prognosis and long-term prognostic factors of acute myeloid leukemia (AML) patients with BSI at Zhejiang Provincal People's Hospital.

Methods

From 2019 to 2021, a total of 56 AML patients with BSI were treated in the Department of Haematology at Zhejiang Province People's Hospital. Data regarding pathogen spectrum and drug resistance were collected for analysis. The patients were stratified into non-survivor cohort and survivor cohort within 30 days after BSI, and the predictors of 30-days mortality were identified through both univariate and multivariate Logistic regression analyses. Furthermore, Kaplan-Meier survival analysis and Cox regression analysis were employed to ascertain the risk factors associated with poor prognosis in AML patients complicated by BSI.

Results

A total of 70 strains of pathogenic bacteria were isolated from 56 AML patients with BSI. Gram-negative bacteria constituted the predominant pathogens (71.4%), with Klebsiella pneumoniae being the most prevalent (22.9%). Gram-positive bacteria and fungi accounted for 22.9% and 5.7%, respectively. Univariate and multivariate analyses revealed significant differences in total protein, albumin levels, and the presence of septic shock between the non-survivor cohort and the survior cohort 30 days post-BSI. COX regression analysis showed that agranulocytosis duration exceeding 20 days (HR:3.854; 95% CI: 1.451-10.242) and septic shock (HR:3.788; 95% CI: 1.729-8.299) were independent risk factors for poor prognosis in AML patients complicated by BSI. Notably, the mortality rate within 30 days after Stenotrophomonas maltophilia infection was up to 71.4%.

Conclusions

In this study, Gram-negative bacteria, predominantly Klebsiella pneumoniae, constituted the primary pathogens among AML patients with BSIs. Serum albumin levels and the presence of septic shock emerged as independent risk factors for mortality within 30 days among AML patients with BSI. In terms of long-term prognosis, extended agranulocytosis duration exceeding 20 days and septic shock were associated with elevated mortality rates in AML patients with BSI. Additionally, in our centre, Stenotrophomonas maltophilia infection was found to be associated with a poor prognosis. Early intervention for Stenotrophomonas maltophilia infection in our centre could potentially improve patient outcomes.

Applying GC-MS based serum metabolomic profiling to characterize two traditional Chinese medicine subtypes of diabetic foot gangrene

Traditional Chinese medicine (TCM) has a long history and particular advantages in the diagnosis and treatment of diabetic foot gangrene (DFG). Patients with DFG are mainly divided into two subtypes, tendon lesion with edema (GT) and ischemic lesion without edema (GI), which are suitable for different medical strategies. Metabolomics has special significance in unravelling the complexities of multifactorial and multisystemic disorders. This study acquired the serum metabolomic profiles of two traditional Chinese medicine subtypes of DFG to explore potential molecular evidence for subtype characterization, which may contribute to the personalized treatment of DFG. A total of 70 participants were recruited, including 20 with DM and 50 with DFG (20 with GI and 30 with GT). Conventional gas chromatography-mass spectrometry (GC-MS) followed by orthogonal partial least-squares discriminant analysis (OPLS-DA) were used as untargeted metabolomics approaches to explore the serum metabolomic profiles. Kyoto encyclopedia of genes and genomes (KEGG) and MetaboAnalyst were used to identify the related metabolic pathways. Compared with DM patients, the levels of 14 metabolites were altered in the DFG group, which were also belonged to the differential metabolites of GI (13) and GT (7) subtypes, respectively. Among these, urea, α-D-mannose, cadaverine, glutamine, L-asparagine, D-gluconic acid, and indole could be regarded as specific potential metabolic markers for GI, as well as L-leucine for GT. In the GI subtype, D-gluconic acid and L-asparagine are positively correlated with activated partial thromboplastin time (APTT) and fibrinogen (FIB). In the GT subtype, L-leucine is positively correlated with the inflammatory marker C-reactive protein (CRP). Arginine and proline metabolism, glycine, serine and threonine metabolism, phenylalanine, tyrosine and tryptophan biosynthesis are the most important metabolic pathways associated with GI. The main metabolic pathways related to GT include pyrimidine metabolism, glutathione metabolism, biosynthesis of valine, leucine, and isoleucine, as well as valine, serine, and isoleucine with metabolites. The results of this study indicate that patients with different DFG subtypes have distinct metabolic profiles, which reflect the pathological characteristics of each subtype respectively. These findings will help us explore therapeutic targets for DFG and develop precise treatment strategies.

Effect of 5% albumin on endothelial glycocalyx degradation during off-pump coronary artery bypass

PURPOSE

The integrity of the endothelial glycocalyx (EG), a critical player in vascular homeostasis, reportedly influences the outcomes of critically ill patients. We investigated the effect of 5% albumin, which preserved EG integrity in preclinical studies, vs balanced crystalloid solution on EG degradation in patients undergoing off-pump coronary surgery.

METHODS

Patients were randomized to receive either 5% albumin (N = 51) or balanced crystalloid solution (Plasma-Lyte [Baxter Incorporated, Seoul, Republic of Korea]; N = 53) for intravenous volume replacement during surgery (double-blinded). The primary outcome was plasma syndecan-1 concentration, a marker of EG degradation, measured after anesthetic induction (baseline), completion of grafting, and sternal closure. Secondary outcomes were atrial natriuretic peptide (ANP), tumour necrosis factor (TNF)-α, soluble thrombomodulin, and perioperative fluid balance.

RESULTS

The mean (standard deviation) fluid requirements were 833 (270) mL and 1,323 (492) mL in the albumin and Plasma-Lyte group, respectively (mean difference, -489 mL; 95% confidence interval [CI], -643 to -335; P < 0.001). Plasma syndecan-1 concentration increased after completion of grafting (median difference, 116 ng·mL-1; 95% CI, 67 to 184; P < 0.001) and sternal closure (median difference, 57 ng·mL-1; 95% CI, 36 to 80; P < 0.001) compared with those at baseline, without any intergroup differences. Atrial natriuretic peptide, TNF-α, and soluble thrombomodulin concentrations were similar between the two groups. The amount of chest tube drainage was greater in the albumin group than that in the Plasma-Lyte group (median difference, 190 mL; 95% CI, 18 to 276; P = 0.03).

CONCLUSION

Off-pump coronary surgery was associated with significant EG degradation. Yet, intraoperative fluid therapy with 5% albumin could not ameliorate EG degradation when compared with balanced crystalloid solution.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03699462); first posted 9 October 2018.

Development and validation of a predictive model for 30-day mortality in patients with severe community-acquired pneumonia in intensive care units

Background

Based on the high prevalence and fatality rates associated with severe community-acquired pneumonia (SCAP), this study endeavored to construct an innovative nomogram for early identification of individuals at high risk of all-cause death within a 30-day period among SCAP patients receiving intensive care units (ICU) treatment.

Methods

In this single-center, retrospective study, 718 SCAP patients were screened from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database for the development of a predictive model. A total of 97 patients eligible for inclusion were included from Chongqing General Hospital, China between January 2020 and July 2023 for external validation. Clinical data and short-term prognosis were collected. Risk factors were determined using the least absolute shrinkage and selection operator (LASSO) and multiple logistic regression analysis. The model's performance was evaluated through area under the curve (AUC), calibration curve, and decision curve analysis (DCA).

Results

Eight risk predictors, including age, presence of malignant cancer, heart rate, mean arterial pressure, albumin, blood urea nitrogen, prothrombin time, and lactate levels were adopted in a nomogram. The nomogram exhibited high predictive accuracy, with an AUC of 0.803 (95% CI: 0.756-0.845) in the training set, 0.756 (95% CI: 0.693-0.816) in the internal validation set, 0.778 (95% CI: 0.594-0.893) in the external validation set concerning 30-day mortality. Meanwhile, the nomogram demonstrated effective calibration through well-fitted calibration curves. DCA confirmed the clinical application value of the nomogram.

Conclusion

This simple and reliable nomogram can help physicians assess the short-term prognosis of patients with SCAP quickly and effectively, and could potentially be adopted widely in clinical settings after more external validations.

Use of Albumin for Drug Delivery as a Diagnostic and Therapeutic Tool

Drug delivery is an important topic that has attracted the attention of researchers in recent years. Albumin nanoparticles play a significant role in drug delivery as a carrier due to their unique characteristics. Albumin is non-toxic, biocompatible, and biodegradable. Its structure is such that it can interact with different drugs, which makes the treatment of the disease faster and also reduces the side effects of the drug. Albumin nanoparticles can be used in the diagnosis and treatment of many diseases, including cancer, diabetes, Alzheimer's, etc. These nanoparticles can connect to some compounds, such as metal nanoparticles, antibodies, folate, etc. and create a powerful nanostructure for drug delivery. In this paper, we aim to investigate albumin nanoparticles in carrier format for drug delivery application. In the beginning, different types of albumin and their preparation methods were discussed, and then albumin nanoparticles were discussed in detail in diagnosing and treating various diseases.

Geriatric nutritional risk index as a prognostic marker of first-line immune checkpoint inhibitor combination therapy in patients with renal cell carcinoma: a retrospective multi-center study

PURPOSE

This study aimed to investigate the effectiveness of the Geriatric Nutritional Risk Index (GNRI) in predicting the efficacy of first-line immune checkpoint inhibitor (ICI) combination therapy for metastatic or unresectable renal cell carcinoma (RCC) and associated patient prognosis.

METHODS

A retrospective study was conducted using data from 19 institutions. The GNRI was calculated using body mass index and serum albumin level, and patients were classified into two groups using the GNRI values, with 98 set as the cutoff point.

RESULTS

In all, 119 patients with clear cell RCC who received first-line drug therapy with ICIs were analyzed. Patients with GNRI ≥ 98 had significantly better overall survival (OS) (p = 0.008) and cancer-specific survival (CSS) (p = 0.001) rates than those with GNRI < 98; however, progression-free survival (PFS) did not differ significantly. Inverse probability of treatment weighting analysis showed that low GNRI scores were significantly associated with poor OS (p = 0.004) and CSS (p = 0.015). Multivariate analysis showed that the Karnofsky performance status (KPS) score was a better predictor of prognosis (OS; HR 5.17, p < 0.001, CSS; HR 4.82, p = 0.003) than GNRI (OS; HR 0.36, p = 0.066, CSS; HR 0.35, p = 0.072). In a subgroup analysis of patients with a good KPS and GNRI ≥ 98 vs < 98, the 2-year OS rates were 91.4% vs 66.9% (p = 0.068), 2-year CSS rates were 91.4% vs 70.1% (p = 0.073), and PFS rates were 39.7% vs 21.4 (p = 0.27), respectively.

CONCLUSION

The prognostic efficiency of GNRI was inferior to that of the KPS score at the initiation of the first-line ICI combination therapy for clear cell RCC.

Low geriatric nutritional risk index as a poor prognostic biomarker for immune checkpoint inhibitor treatment in solid cancer

Objective

In this investigation, we focused on the geriatric nutritional risk index (GNRI), a comprehensive metric that takes into account the patient's ideal weight, actual weight, and serum albumin levels to measure malnutrition. Our primary objective was to examine the predictive value of GNRI-defined malnutrition in determining the response to immunotherapy among cancer patients.

Methods

Relevant articles for this study were systematically searched in PubMed, the Cochrane Library, EMBASE, and Google Scholar up to July 2023. Our analysis evaluated overall survival (OS), progression-free survival (PFS), objective response rate (ORR), and disease control rate (DCR) as clinical outcomes.

Results

This analysis comprised a total of eleven articles encompassing 1,417 patients. The pooled results revealed that cancer patients with low GNRI levels exhibited shorter OS (HR: 2.64, 95% CI: 2.08-3.36, p < 0.001) and PFS (HR: 1.87, 95% CI: 1.46-2.41, p < 0.001), and lower ORR (OR: 0.46, 95% CI: 0.33-0.65, p < 0.001) and DCR (OR: 0.42, 95% CI: 0.29-0.61, p < 0.001). Sensitivity analyses confirmed that the above results were stable. Egger's and Begg's tests revealed that there was no publication bias in the above results.

Conclusion

Our results imply that the GNRI is a useful predictor of immunotherapy response in cancer patients.

Factors influencing the degree of disability in patients with neuromyelitis optica spectrum disorders

OBJECTIVE

To investigate the factors influencing the degree of disability in patients with neuromyelitis optica spectrum disorder (NMOSD) and provide evidence for disease monitoring and clinical intervention.

METHODS

Eighty-four patients with NMOSD at Xuanwu Hospital Capital Medical University were enrolled in this retrospective study. Before treatment, blood was collected from all patients, and their expanded disability status scores were assessed.

RESULTS

Of the 84 patients assessed, 66 (78.57%) had an expanded disability status scale score < 7, and 18 (21.43%) had scores ≥ 7. The univariate analysis showed that the total bilirubin (TBil), cerebrospinal fluid albumin (CSF ALB), cerebrospinal fluid immunoglobulin G (CSF IgG), QALB, and QIgG levels in the group with scores ≥ 7 were significantly different from those with scores < 7 (P < 0.05). In addition, Spearman's correlation analysis showed a significant correlation between ALB and expanded disability status scores in patients with NMOSD (P < 0.05), and the multivariate logistic regression analysis showed that TBil was an independent factor influencing the degree of disability in patients with NMOSD (P < 0.05). The receiver operating characteristic curve was constructed using TBil values; the area under the curve of TBil was 0.729 (P < 0.01), and the best cut-off value was 11.015 g/L. Its sensitivity in predicting the severity of disability in NMOSD patients was 51.5% while its specificity was 88.9%.

CONCLUSION

TBil is an independent factor that influences the severity of disability in patients with NMOSD. In addition, ALB is closely related to NMOSD severity, and some factors associated with the BBB are significantly increased in severely disabled NMOSD patients.

Interpretations of the Role of Plasma Albumin in Prognostic Indices: A Literature Review

This review assesses how publications interpret factors that influence the serum or plasma albumin (PA) level in prognostic indices, focusing on inflammation and nutrition. On PubMed, a search for "albumin AND prognosis" yielded 23,919 results. From these records, prognostic indices were retrieved, and their names were used as search strings on PubMed. Indices found in 10 or more original research articles were included. The same search strings, restricted to "Review" or "Systematic review", retrieved yielded on the indices. The data comprised the 10 latest original research articles and up to 10 of the latest reviews. Thirty indices had 294 original research articles (6 covering two indices) and 131 reviews, most of which were from recent years. A total of 106 articles related the PA level to inflammation, and 136 related the PA level to nutrition. For the reviews, the equivalent numbers were 54 and 65. In conclusion, more publications mention the PA level as a marker of nutrition rather than inflammation. This is in contrast to several general reviews on albumin and nutritional guidelines, which state that the PA level is a marker of inflammation but not nutrition. Hypoalbuminemia should prompt clinicians to focus on the inflammatory aspects in their patients.

Serum Albumin Levels: A Biomarker to Be Repurposed in Different Disease Settings in Clinical Practice

Serum albumin (ALB), one of the most important proteins in human physiology, has the main functions of maintaining plasma oncotic pressure and plasma volume, transporting hormones, vitamins, oligominerals and drugs, and exerting a powerful antioxidant-anti-inflammatory role. Its prognostic value in liver and malabsorption syndromes is well known. In this narrative review, an analysis of the most important studies evaluating the prognostic significance of low serum ALB levels in hospitalized patients was performed. Specifically, the risk in emergency medicine, cardiovascular diseases, Coronavirus Disease 19 (COVID-19) infection, nephrology, oncology, and autoimmune rheumatic diseases has been examined to fully explore its clinical value. ALB is a negative acute-phase reactant and the reduction in its serum levels represents a threatening parameter for long-term survival in several clinical settings, and a strong biomarker for a poor prognosis in most diseases. Therefore, clinicians should consider serum ALB as a valuable tool to assess the efficacy of specific therapies, both in hospitalized patients and in chronic follow-up.

Establishment of risk model for elderly CAP at different age stages: a single-center retrospective observational study

Community-acquired pneumonia (CAP) is one of the main reasons of mortality and morbidity in elderly population, causing substantial clinical and economic impacts. However, clinically available score systems have been shown to demonstrate poor prediction of mortality for patients aged over 65. Especially, no existing clinical model can predict morbidity and mortality for CAP patients among different age stages. Here, we aimed to understand the impact of age variable on the establishment of assessment model and explored prognostic factors and new biomarkers in predicting mortality. We retrospectively analyzed elderly patients with CAP in Minhang Hospital, Fudan University. We used univariate and multiple logistic regression analyses to study the prognostic factors of mortality in each age-based subgroup. The prediction accuracy of the prognostic factors was determined by the Receiver Operating Characteristic curves and the area under the curves. Combination models were established using several logistic regressions to save the predicted probabilities. Four factors with independently prognostic significance were shared among all the groups, namely Albumin, BUN, NLR and Pulse, using univariate analysis and multiple logistic regression analysis. Then we built a model with these 4 variables (as ABNP model) to predict the in-hospital mortality in all three groups. The AUC value of the ABNP model were 0.888 (95% CI 0.854-0.917, p < 0.000), 0.912 (95% CI 0.880-0.938, p < 0.000) and 0.872 (95% CI 0.833-0.905, p < 0.000) in group 1, 2 and 3, respectively. We established a predictive model for mortality based on an age variable -specific study of elderly patients with CAP, with higher AUC value than PSI, CURB-65 and qSOFA in predicting mortality in different age groups (66-75/ 76-85/ over 85 years).

Clinical and economic outcomes associated with intravenous albumin fluid use in the intensive care unit: a retrospective cohort study

OBJECTIVES

This study was undertaken to evaluate the prescribing practice of albumin in the intensive care unit (ICU) and to compare the clinical and economic outcomes associated with intravenous (IV) albumin compared to crystalloids in the ICU.

METHODS

This was a retrospective cohort study of ICU adult patients admitted to King Abdullah University Hospital during 2018-2019. Patient demographics, clinical characteristics, and admission charges were retrieved from medical records and billing system. Survival analysis, multivariable regression models, and propensity score matching estimator were performed to evaluate the impact of IV resuscitation fluid types on the clinical and economic outcomes.

RESULTS

Albumin administration in the ICU was associated with significantly lower hazards of ICU death (HR = 0.57; P value <0.001), but without improving overall death probability compared to crystalloids. Albumin was associated with significant prolongation in the ICU length of stay (5.86 days; P value <0.001). Only 88 patients (24.3%) were prescribed albumin for Food and Drug Administration (FDA)-approved indications. Admission charges were significantly higher for patients treated with albumin (p value <0.001).

CONCLUSIONS

IV Albumin use in the ICU was not associated with significant improvement in clinical outcomes, but with a remarkable increase in economic burden. The majority of patients received albumin for non-FDA-approved indications.

Target attainment and population pharmacokinetics of flucloxacillin in critically ill patients: a multicenter study

PURPOSE

Insufficient antimicrobial exposure has been associated with worse clinical outcomes. Reportedly, flucloxacillin target attainment in critically ill patients was heterogeneous considering the study population selection and reported target attainment percentages. Therefore, we assessed flucloxacillin population pharmacokinetics (PK) and target attainment in critically ill patients.

METHODS

This prospective, multicenter, observational study was conducted from May 2017 to October 2019 and included adult, critically ill patients administered flucloxacillin intravenously. Patients with renal replacement therapy or liver cirrhosis were excluded. We developed and qualified an integrated PK model for total and unbound serum flucloxacillin concentrations. Monte Carlo dosing simulations were performed to assess target attainment. The unbound target serum concentration was four times the minimum inhibitory concentration (MIC) for ≥ 50% of the dosing interval (ƒT_>4xMIC ≥ 50%).

RESULTS

We analyzed 163 blood samples from 31 patients. A one-compartment model with linear plasma protein binding was selected as most appropriate. Dosing simulations revealed 26% ƒT_>2 mg/L ≥ 50% following continuous infusion of 12 g flucloxacillin and 51% ƒT_>2 mg/L ≥ 50% for 24 g.

CONCLUSION

Based on our dosing simulations, standard flucloxacillin daily doses of up to 12 g may substantially enhance the risk of underdosing in critically ill patients. Prospective validation of these model predictions is needed.

Effect of albumin solutions on endothelial oxidant injury: A microfluidic study

BACKGROUND

Studies have suggested a beneficial effect of early plasma-based resuscitation in patients following trauma-hemorrhagic shock. The underlying mechanism(s) are unknown but may be owing to protective effects of plasma components on the endothelium and its glycocalyx layer. Albumin, the major protein in plasma, influences vascular integrity and has antioxidant properties in vivo. Sphingosine 1-phosphate is a bioactive sphingolipid with diverse signaling functions, which include endothelial barrier protection in part owing to preservation of the glycocalyx. Sphingosine 1-phosphate is bound mainly to albumin and high-density lipids in the plasma. Debate continues about the beneficial effect of albumin solutions in shock resuscitation. Pharmacologic preparations may modify constituents of albumin solutions for clinical use. We examined the relative effects of sphingosine 1-phosphate concentrations in albumin solutions on the endothelial-glycocalyx barrier in an in vitro microfluidic platform.

METHODS

Endothelial cell monolayers were established in microfluidic perfusion devices and exposed to control or biomimetic shock conditions followed by 5% plasma or different albumin solutions ± exogenous sphingosine 1-phosphate perfusion. Biomarkers of endothelial and glycocalyx activation, damage, and oxidant injury were then determined.

RESULTS

Endothelial cell and glycocalyx barriers were damaged after biomimetic shock conditions. Plasma and sphingosine 1-phosphate loaded albumin solutions protected against barrier injury. Modest protective effects were noted with albumin alone; the efficacy varied with sphingosine 1-phosphate content of the albumin solution.

CONCLUSION

The protective effect of albumin on the endothelia-glycocalyx barrier against oxidant injury was dependent on its sphingosine 1-phosphate concentration. Our data may help explain the discrepancies regarding the effectiveness of albumin solutions in shock resuscitation.

Pre-transplant hypoalbuminemia is not associated with worse short-term outcomes among kidney transplant recipients

INTRODUCTION

Serum albumin is an indicator of overall health status, but it remains unclear how pre-transplant hypoalbuminemia is associated with early post-transplant outcomes.

METHODS

This study included all adult kidney transplant recipients (KTRs) at our center from 01/01/2001-12/31/2017 with serum albumin measured within 30 days before transplantation. KTRs were grouped based on pretransplant albumin level normal (≥4.0 g/dL), mild (≥3.5 - < 4.0g/dL), moderate (≥3.0 - < 3.5g/dL), or severe hypoalbuminemia (<3.0g/dL). Outcomes of interest included: length of hospital stay (LOS), readmission within 30 days, delayed graft function(DGF), and re-operation related to post-transplant surgical complications. We also analyzed rejection, graft failure, and death within 6 months post-transplant.

RESULTS

A total of 2807 KTRs were included 43.6% had normal serum albumin, 35.3% mild, 16.6% moderate, and 4.5% severe hypoalbuminemia. Mild and moderate hypoalbuminemia were associated with a shorter LOS by 1.22 (p < 0.001) and 0.80 days (p = 0.01), respectively, compared to normal albumin. Moderate (HR: 0.58; 95% CI: 0.37-0.91; p = 0.02) and severe hypoalbuminemia (HR: 0.21; 95% CI: 0.07-0.68; p = 0.01) were associated with significantly lower rates of acute rejection within 6 months post-transplant.

CONCLUSION

Patients with pre-transplant hypoalbuminemia have post-transplant outcomes similar to those with normal serum albumin, but with a lower risk of acute rejection based on the degree of hypoalbuminemia.

Endogenous humoral determinants of vascular endothelial dysfunction as triggers of acute poisoning complications

The vascular endothelium is not only the semipermeable membrane that separates tissue from blood but also an organ that regulates inflammation, vascular tone, blood clotting, angiogenesis and synthesis of connective tissue proteins. It is susceptible to the direct cytotoxic action of numerous xenobiotics and to the acute hypoxia that accompanies acute poisoning. This damage is superimposed on the preformed state of the vascular endothelium, which, in turn, depends on many humoral factors. The probability that an exogenous toxicant will cause life-threatening dysfunction of the vascular endothelium, thereby complicating the course of acute poisoning, increases with an increase in the content of endogenous substances in the blood that disrupt endothelial function. These include ammonia, bacterial endotoxin, indoxyl sulfate, para-cresyl sulfate, trimethylamine N-oxide, asymmetric dimethylarginine, glucose, homocysteine, low-density and very-low-density lipoproteins, free fatty acids and products of intravascular haemolysis. Some other endogenous substances (albumin, haptoglobin, haemopexin, biliverdin, bilirubin, tetrahydrobiopterin) or food-derived compounds (ascorbic acid, rutin, omega-3 polyunsaturated fatty acids, etc.) reduce the risk of lethal vascular endothelial dysfunction. The individual variability of the content of these substances in the blood contributes to the stochasticity of the complications of acute poisoning and is a promising target for the risk reduction measures. Another feasible option may be the repositioning of drugs that affect the function of the vascular endothelium while being currently used for other indications.

Clinical features of patients with MOG-IgG associated disorders and analysis of the relationship between fibrinogen-to-albumin ratio and the severity at disease onset

Objective

The study aimed to investigate the differences in clinical features between pediatric and adult patients with first-episode MOG-IgG associated disorders (MOGAD) and evaluate the relationship between the fibrinogen-to-albumin ratio (FAR) and the severity of neurological deficits at disease onset.

Methods

We retrospectively collected and analyzed biochemical test results, imaging characteristics, clinical manifestations, expanded disability status scale (EDSS) score, and FAR. The Spearman correlation analysis and logistic regression models were used to examine the association between FAR and severity. Receiver operating characteristic (ROC) curve analysis was to analyze the predictive ability of FAR for the severity of neurological deficits.

Results

Fever (50.0%), headache (36.1%), and blurred vision (27.8%) were the most common clinical manifestations in the pediatric group (<18 years old). However, in the adult group (≥18 years old), the most common symptoms were blurred vision (45.7%), paralysis (37.0%), and paresthesia (32.6%). Fever was more common in the pediatric group, while paresthesia was more common in the adult patients, with all differences statistically significant (P < 0.05). The most frequent clinical phenotype in the pediatric group was acute disseminated encephalomyelitis (ADEM; 41.7%), whereas optic neuritis (ON; 32.6%) and transverse myelitis (TM; 26.1%) were more common in the adult group. The differences in clinical phenotype between the two groups were statistically significant (P < 0.05). In both pediatric and adult patients, cortical/subcortical and brainstem lesions were the most common lesions on cranial magnetic resonance imaging (MRI), whereas, for spinal MRI, cervical and thoracic spinal cord lesions were the most commonly observed. According to binary logistic regression analysis, FAR was an independent risk factor for the severity of neurological deficits (odds ratio = 1.717; 95% confidence interval = 1.191-2.477; P = 0.004). FAR (r = 0.359, P = 0.001) was positively correlated with the initial EDSS score. The area under the ROC curve was 0.749.

Conclusion

The current study found age-dependent phenotypes in MOGAD patients as ADEM was more commonly observed in patients < 18 years old, while ON and TM were more frequently found in patients ≥18 years old. A high FAR level was an independent indicator for more severe neurological deficits at disease onset in patients with a first episode of MOGAD.

Retrospective case-control study on screening risk factors of antibiotic-associated encephalopathy in patients with chronic kidney disease

OBJECTIVE

The renal excretion function of patients with chronic kidney disease (CKD) is reduced, and the nervous system toxic reactions of antibiotics are prone to occur. The purpose of this study is to screen out some risk factors for patients with CKD to suffer from antibiotic-associated encephalopathy (AAE).

DESIGN

A case-control study.

SETTING

A tertiary hospital in China.

PARTICIPANTS

The medical records of patients who were hospitalised for CKD and infectious diseases in our hospital from January 2010 to December 2019. All patients used antibiotics to treat infectious diseases during hospitalisation. All patients were divided into two groups according to whether they developed AAE during hospitalisation. The patients with CKD without AAE were selected as the control group (n=120), and the patients with CKD with AAE were regarded as the AAE group (n=102).

INTERVENTIONS

This study systematically analysed its clinical manifestations, laboratory examinations, prognosis, etc, and summarised the risk factors related to AAE in patients with CKD.

PRIMARY OUTCOME

Screening risk factors of AAE in patients with CKD.

RESULTS

Logistic regression analysis showed that coronary heart disease, as well as abnormal indicators of haemoglobin, albumin, uric acid and blood phosphorus were independent risk factors for patients with CKD with AAE (OR values were 4.137, 0.963, 0.849, 0.996 0.161, respectively, all p<0.05). The case fatality rate (Pearson χ²=7.524, p=0.006), rehospitalisation rate (Pearson χ²=6.187, p=0.013) and treatment costs (t=-8.44, p<0.001) in encephalopathy group are significantly higher than the control group.

CONCLUSIONS

Patients with CKD with AAE will increase the case fatality rate and cause poor prognosis. Coronary heart disease, as well as decreased levels of haemoglobin, albumin, uric acid, and blood phosphorus are independent risk factors for patients with CKD with AAE. Timely intervention of these risk factors may reduce the incidence of AAE and improve the prognosis.

Exploration of prognostic factors for prediction of mortality in elderly CAP population using a nomogram model

Background

The incidence and mortality rate of community-acquired pneumonia (CAP) in elderly patients were higher than the younger population. The assessment tools including CURB-65 and qSOFA have been applied in early detection of high-risk patients with CAP. However, several disadvantages exist to limit the efficiency of these tools for accurate assessment in elderly CAP. Therefore, we aimed to explore a more comprehensive tool to predict mortality in elderly CAP population by establishing a nomogram model.

Methods

We retrospectively analyzed elderly patients with CAP in Minhang Hospital, Fudan University. The least absolute shrinkage and selection operator (LASSO) logistic regression combined with multivariate analyses were used to select independent predictive factors and established nomogram models via R software. Calibration plots, decision curve analysis (DCA) and receiver operating characteristic curve (ROC) were generated to assess predictive performance.

Results

LASSO and multiple logistic regression analyses showed the age, pulse, NLR, albumin, BUN, and D-dimer were independent risk predictors. A nomogram model (NB-DAPA model) was established for predicting mortality of CAP in elderly patients. In both training and validation set, the area under the curve (AUC) of the NB-DAPA model showed superiority than CURB-65 and qSOFA. Meanwhile, DCA revealed that the predictive model had significant net benefits for most threshold probabilities.

Conclusion

Our established NB-DAPA nomogram model is a simple and accurate tool for predicting in-hospital mortality of CAP, adapted for patients aged 65 years and above. The predictive performance of the NB-DAPA model was better than PSI, CURB-65 and qSOFA.

The glycocalyx as a permeability barrier: basic science and clinical evidence

Preclinical studies in animals and human clinical trials question whether the endothelial glycocalyx layer is a clinically important permeability barrier. Glycocalyx breakdown products in plasma mostly originate from 99.6–99.8% of the endothelial surface not involved in transendothelial passage of water and proteins. Fragment concentrations correlate poorly with in vivo imaging of glycocalyx thickness, and calculations of expected glycocalyx resistance are incompatible with measured hydraulic conductivity values. Increases in plasma breakdown products in rats did not correlate with vascular permeability. Clinically, three studies in humans show inverse correlations between glycocalyx degradation products and the capillary leakage of albumin and fluid.

Preoperative hypoalbuminemia in patients undergoing cardiac surgery: a meta-analysis

The preoperative serum albumin level has been shown to be associated with adverse postoperative complications, meaning that hypoalbuminemia may also be a risk factor. We performed a meta-analysis to evaluate the association of serum albumin levels with survival and complication rates after cardiac surgery. Relevant articles were identified through seven databases. Twenty studies with 22553 patients (hypoalbuminemia group, n = 9903; normal group, n = 12650) who underwent cardiac surgery met the inclusion criteria after screening. The primary outcomes were that hypoalbuminemia was significantly correlated with serious long-term all-cause mortality (hazard ratio [HR]: 1.95 [1.54-2.48]; P < 0.00001) and increased mortality (risk ratio [RR] = 1.91 [1.61-2.27], P < 0.00001). Hypoalbuminemic patients with cardiopathy were more likely to suffer postoperative complications (bleeding, infections, renal injury, and others) than those whose serum albumin levels were normal. Furthermore, hypoalbuminemia increased the time in the intensive-care unit (ICU) (mean difference [MD] = 1.18 [0.49-1.87], P = 0.0008), length of hospital stay (LOS) (MD = 3.34, 95% CI: 1.88-4.80, P < 0.00001), and cardiopulmonary bypass time (CPB) (MD = 12.40 [1.13-23.66], P = 0.03). Hypoalbuminemia in patients undergoing cardiac surgery appears to have a poor all-cause mortality or increased risk of complications. Adjusted perioperative serum albumin levels and treatment strategies for this high-risk population have the potential to improve the survival.

Low serum albumin: A neglected predictor in patients with cardiovascular disease

Albumin, the most abundant circulating protein in blood, is an essential protein which binds and transports various drugs and substances, maintains the oncotic pressure of blood and influences the physiological function of the circulatory system. Albumin also has anti-inflammatory, antioxidant, and antithrombotic properties. Evidence supports albumin's role as a strong predictor of cardiovascular (CV) risk in several patient groups. Its protective role extends to those with coronary artery disease, heart failure, hypertension, atrial fibrillation, peripheral artery disease or ischemic stroke, as well as those undergoing revascularization procedures or with aortic stenosis undergoing transcatheter aortic valve replacement, and patients with congenital heart disease and/or endocarditis. Hypoalbuminemia is a strong prognosticator of increased all-cause and CV mortality according to several cohort studies and meta-analyses in hospitalized and non-hospitalized patients with or without comorbidities. Normalization of albumin levels before discharge lowers mortality risk, compared with hypoalbuminemia before discharge. Modified forms of albumin, such as ischemia modified albumin, also has prognostic value in patients with coronary or peripheral artery disease. When albumin is combined with other risk factors, such as uric acid or C-reactive protein, the prognostic value is enhanced. Although albumin supplementation may be a plausible approach, its efficacy has not been established and in patients with hypoalbuminemia, priority is focused on diagnosing and managing the underlying condition. The CV effects of hypoalbuminemia and relevant issues are considered in this review. Large cohort studies and meta-analyses are tabulated and the physiologic effects of albumin and the deleterious effects of low albumin are pictorially illustrated.

Genetically Predicted Serum Albumin and Risk of Colorectal Cancer: A Bidirectional Mendelian Randomization Study

Purpose

Colorectal cancer (CRC) is the third–most frequently diagnosed cancer globally. Studies have linked low serum albumin with increased risk of CRC, but the causal nature of the association remains unclear. In the present study, we explored the potential causal relationship using bidirectional Mendelian randomization (MR).

Methods

Instrumental variants for albumin were obtained from a genome-wide association study (GWAS) on 102,223 Eastern Asian participants to investigate the effect of albumin on CRC. Summary statistics of CRC were obtained from a GWAS on 7,062 CRC cases and 195,745 controls of Eastern Asian ancestry. Bidirectional MR analysis was performed using inverse variance weighting (IVW) for primary analysis, supplemented with a maximum likelihood–based method, MR-PRESSO test, leave-one-out analysis, and MR-Egger regression. Stratification analyses were further performed.

Results

We found that genetically predicted serum albumin per unit was associated with a lower risk of CRC (OR 0.75, 95% CI 0.59–0.95 with IVW). No evidence of pleiotropy was observed. Sex-stratified MR analysis showed that serum albumin was inversely associated with risk of CRC in men (OR 0.71, 95% CI 0.53–0.96), but not in women (OR 0.81, 95% CI 0.55–1.19) using IVW. Reverse MR analysis suggested a genetic predisposition toward CRC was not associated with serum albumin.

Conclusion

Our study revealed a suggestive sex disparity in the effect of albumin, which deserves further exploration of the potential biological mechanism.

Use of Hyperoncotic Human Albumin Solution in Severe Traumatic Brain Injury Revisited-A Narrative Review and Meta-Analysis

A significant proportion of patients with a severe traumatic brain injury (TBI) have hypoalbuminemia and require fluid resuscitation. Intravenous fluids can have both favorable and unfavorable consequences because of the risk of hyperhydration and hypo- or hyperosmolar conditions, which may affect the outcome of a TBI. Fluid resuscitation with human albumin solution (HAS) corrects low serum albumin levels and aids in preserving euvolemia in non-brain-injured intensive care units and in perioperative patients. However, the use of HAS for TBI remains controversial. In patients with TBI, the infusion of hypooncotic (4%) HAS was associated with adverse outcomes. The side effects of 4% HAS and the safety and efficacy of hyperoncotic (20-25%) HAS used in the Lund concept of TBI treatment need further investigation. A nonsystematic review, including a meta-analysis of controlled clinical trials, was performed to evaluate hyperoncotic HAS in TBI treatment. For the meta-analysis, the MEDLINE and EMBASE Library databases, as well as journal contents and reference lists, were searched for pertinent articles up to March 2021. Four controlled clinical studies involving 320 patients were included. The first was a randomized trial. Among 165 patients treated with hyperoncotic HAS, according to the Lund concept, 24 (14.5%) died vs. 59 out of 155 control patients (38.1%). A Lund concept intervention using hyperoncotic HAS was associated with a significantly reduced mortality (p = 0.002). Evidence of the beneficial effects of fluid management with hyperoncotic HAS on mortality in patients with TBI is at a high risk of bias. Prospective randomized controlled trials are required, which could lead to changes in clinical practice recommendations for fluid management in patients with TBI.

The nonlinear association between albumin levels and risk of noninvasive fungal rhinosinusitis

PURPOSE

The preoperative diagnosis of noninvasive fungal rhinosinusitis (NIFRS) is inaccurate, and biomarkers to assist the diagnosis are urgently needed. We aimed to evaluate the relationship between albumin levels and NIFRS to assist in early diagnosis.

METHODS

Patients with NIFRS and chronic sinusitis were enrolled in this study. Appropriate statistical methods were used to determine whether there was a statistical difference between the groups. Subgroup analysis was performed to investigate the relationship between albumin levels and NIFRS, and a generalised additive model (GAM) was used to perform nonlinear relationships.

RESULTS

A total of 620 patients were included, including 240 patients with NIFRS. A close relationship was found between albumin levels and NIFRS (P < 0.0001), and the low albumin group was associated with a higher incidence of NIFRS, which was reduced by 60 and 70% in the middle and high albumin groups, respectively. The subgroup analysis also demonstrated an association between albumin levels and NIFRS, except in patients with an alcohol history (P = 0.0665). Interestingly, a nonlinear relationship is observed according to the adjusted GAM. The inflection point was set at 37.0 g/L. A negative correlation was observed among patients with albumin > 37.0 g/L. When the albumin count was <37.0 g/L, the Y value obviously increased and was saturated at 70%, with no further significant increase.

CONCLUSION

Albumin levels were significantly negatively correlated with the incidence of NIFRS, and the incidence increased markedly among patients with albumin < 37.0 g/L.

Therapeutic solutions of human albumin - The possible effect of process-induced molecular alterations on clinical efficacy and safety

Human albumin solutions were developed as therapeutic during the Second World War to address blood loss due to battlefield injury. This indication was based on the recognition that albumin provided most of the oncotic capacity of human plasma. For the succeeding sixty years, this formed the basis for the use of albumin in traumatology and emergency medicine. In more recent times, the pharmacological properties arising from albumin's complex structure have become a focus of attention by clinical researchers. In particular, albumin, through anti-inflammatory and anti-oxidant properties, has been proposed as an agent for the treatment of sepsis, cirrhosis and other inflammatory states. Some evidence for these indications has accrued from a number of small clinical trials and observational studies. These studies have not been confirmed in other large trials. Together with other investigators, we have shown that the process of plasma fractionation results in alterations in the structure of albumin, including those parts of the molecule involved in anti-oxidant and anti-inflammatory effects. Albumin products from diverse manufacturers show heterogeneity in their ability to address these effects. In this article, we review the historical development of albumin solutions, pointing out the variations in fractionation chemistries which different manufacturers have adopted. We suggest ways by which the manufacturing processes have contributed to variations in the physico-chemical properties of molecule. We review the outcomes of clinical studies assessing the role of albumin in ameliorating conditions such as sepsis and cirrhosis, and we speculate as to the extent which heterogeneity in the products may have contributed to variable clinical outcomes. Finally, we argue for a change in the perception of the plasma product industry and its regulatory overseers. Historically, albumin has been viewed as a generic commodity, with different preparations being interchangeable in their clinical application. We suggest that this implied biosimilarity is not necessarily applicable for different albumin solutions. The use of albumin, in indications other than its historical role as a plasma expander, can only be validated by clinical investigation of each separate albumin product.

Targeting repair of the vascular endothelium and glycocalyx after traumatic injury with plasma and platelet resuscitation

•

Endothelial glycocalyx shedding is a key instigator of the endotheliopathy of trauma.

•

Plasma and platelet transfusions preserve vascular integrity in pre-clinical models.

•

However, platelets may be less effective than plasma in preserving the glycocalyx.

Severely injured patients with hemorrhagic shock can develop endothelial dysfunction, systemic inflammation, and coagulation disturbances collectively known as the endotheliopathy of trauma (EOT). Shedding of the endothelial glycocalyx occurs early after injury, contributes to breakdown of the vascular barrier, and plays a critical role in the pathogenesis of multiple organ dysfunction, leading to poor outcomes in trauma patients. In this review we discuss (i) the pathophysiology of endothelial glycocalyx and vascular barrier breakdown following hemorrhagic shock and trauma, and (ii) the role of plasma and platelet transfusion in maintaining the glycocalyx and vascular endothelial integrity.

CURB-65 plus hypoalbuminemia: a new score system for prediction of the in-hospital mortality risk in patients with SARS-CoV-2 pneumonia

INTRODUCTION

There is the need of a simple but highly reliable score system for stratifying the risk of mortality and Intensive Care Unit (ICU) transfer in patients with SARS-CoV-2 pneumonia at the Emergency Room.

PURPOSE

In this study, the ability of CURB-65, extended CURB-65, PSI and CALL scores and C-Reactive Protein (CRP) to predict intra-hospital mortality and ICU admission in patients with SARS-CoV-2 pneumonia were evaluated.

METHODS

During March-May 2020, a retrospective, single-center study including all consecutive adult patients with diagnosis of SARS-CoV-2 pneumonia was conducted. Clinical, laboratory and radiological data as well as CURB-65, expanded CURB-65, PSI and CALL scores were calculated based on data recorded at hospital admission.

RESULTS

Overall, 224 patients with documented SARS-CoV-2 pneumonia were included in the study. As for intrahospital mortality (24/224, 11%), PSI performed better than all the other tested scores, which showed lower AUC values (AUC=0.890 for PSI versus AUC=0.885, AUC=0.858 and AUC=0.743 for expanded CURB-65, CURB-65 and CALL scores, respectively). Of note, the addition of hypoalbuminemia to the CURB-65 score increased the prediction value of intra-hospital mortality (AUC=0.905). All the tested scores were less predictive for the need of ICU transfer (26/224, 12%), with the best AUC for extended CURB-65 score (AUC= 0.708).

CONCLUSION

The addition of albumin level to the easy-to-calculate CURB-65 score at hospital admission is able to improve the quality of prediction of intra-hospital mortality in patients with SARS-CoV-2 pneumonia.

Association of the Geriatric Nutritional Risk Index With the Survival of Patients With Non-Small Cell Lung Cancer After Nivolumab Therapy

The nutritional status has the potential to affect cancer immunity. We evaluated the relationship between the nutritional status and the efficacy of nivolumab in patients with non-small cell lung cancer (NSCLC). This study was a post hoc analysis of a prospective, multicenter cohort study conducted at 14 institutions in Japan between July 2016 and December 2018. The Geriatric Nutritional Risk Index (GNRI), calculated from body weight and serum albumin, was evaluated in 158 patients with NSCLC who received nivolumab. GNRI was graded as low, moderate, and high. Low GNRI was associated with significantly shorter progression-free survival [median, 1.9 mo; 95% confidence interval (CI)=0.6-3.3 mo] than moderate (median, 4.0 mo; 95% CI=2.3-5.8 mo; P=0.017) and high GNRI (median, 3.0 mo; 95% CI=1.9-7.2 mo; P=0.014). Low GNRI was also linked to significantly shorter overall survival (OS) (median, 7.8 mo; 95% CI=2.6-12.0 mo) than moderate (median, 13.0 mo; 95% CI=9.6-15.2 mo; P=0.006) and high GNRI (median, 20.6 mo; 95% CI=15.6 mo-not reached; P<0.001). High GNRI was associated with significantly longer OS than moderate GNRI (P=0.015). In multivariate Cox proportional hazard analyses, increased GNRI was predictive of longer progression-free survival and OS, similarly as tumor programmed cell death-ligand 1 expression. In patients with NSCLC receiving nivolumab. GNRI was predictive of survival and may be useful for predicting the efficacy of immune checkpoint inhibitor therapy.

Association between plasma glycocalyx component levels and poor prognosis in severe influenza type A (H1N1)

Influenza A virus infection causes a series of diseases, but the factors associated with disease severity are not fully understood. Disruption of the endothelial glycocalyx contributes to acute lung injury in sepsis, but has not been well studied in H1N1 influenza. We aim to determine whether the plasma glycocalyx components levels are predictive of disease severity in H1N1 influenza. This prospective observational study included 53 patients with influenza A (H1N1) during the influenza season, and 30 healthy controls in our hospital. Patients were grouped by severity and survival. We collected clinical data and blood samples at admission. Inflammatory factors (tumor necrosis factor-α, interleukin-6, interleukin-10) and endothelial glycocalyx components (syndecan-1, hyaluronan, heparan sulfate) were measured. The plasma levels of syndecan-1, hyaluronan, and heparan sulfate were significantly higher in patients with severe influenza A (H1N1) than in mild cases. Syndecan-1 and hyaluronan were positively correlated with disease severity, which was indicated by the APACHE II and SOFA scores and lactate levels, and negatively correlated with albumin levels. At a cutoff point ≥ 173.9 ng/mL, syndecan-1 had a 81.3% sensitivity and 70.3% specificity for predicting of 28-day mortality. Kaplan–Meier analysis demonstrated a strong association between syndecan-1 levels and 28-day mortality (log-rank 11.04, P = 0.001). Elevated plasma levels of syndecan-1 has a potential role in systemic organ dysfunction and may be indicative of disease severity in patients with influenza A (H1N1).

Association of the Geriatric Nutritional Risk Index with the survival of patients with non-small-cell lung cancer after platinum-based chemotherapy

Background

The nutritional status can potentially affect the efficacy of cancer therapy. The Geriatric Nutritional Risk Index (GNRI), a simple index for evaluating nutritional status calculated from body weight and serum albumin levels, has been reported to be associated with the prognosis of various diseases. However, the relationships between GNRI and the efficacy of platinum-based chemotherapy in patients with non-small-cell lung cancer (NSCLC) are unknown.

Methods

The pretreatment levels of GNRI were retrospectively evaluated in 148 chemo-naïve patients with advanced NSCLC who received first-line platinum-based chemotherapy and scored as low or high.

Results

Patients with a high GNRI had a significantly higher overall response rate (ORR; 44.5% [95% confidence interval {CI} = 35.6%–53.9%] vs. 15.8% [95% CI = 7.4%–30.4%, p = 0.002), longer median progression-free survival (PFS; 6.3 months [95% CI = 5.6–7.2 months] vs. 3.8 months [95% CI = 2.5–4.7 months], p < 0.001), and longer median overall survival (OS; 22.8 months [95% CI = 16.7–27.2 months] vs. 8.5 months [95% CI = 5.4–16.0 months], p < 0.001) than those with low GNRI. High GNRI was independently predictive of better ORR in multivariate logistic regression analysis and longer PFS and OS in multivariate Cox proportional hazard analyses. In 71 patients who received second-line non-platinum chemotherapy, patients with high GNRI exhibited significantly longer PFS and OS than those with low GNRI (both p < 0.001).

Conclusions

GNRI was predictive of prolonged survival in patients with NSCLC who received first-line platinum-based chemotherapy and second-line non-platinum chemotherapy. Assessment of the nutritional status may be useful for predicting the efficacy of chemotherapy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-021-01782-2.

Inclusion of Albumin in the Initial Resuscitation of Adult Patients with Medical Sepsis or Septic Shock: a Propensity Score-Matched Analysis

INTRODUCTION

The impact of albumin resuscitation on sepsis outcomes is debated, particularly in the initial phase of resuscitation. We aimed to investigate the association between albumin use in the initial 6 h of resuscitation and subsequent outcomes in adult septic patients.

METHODS

This single-center, retrospective, propensity score-matched cohort study included adult patients admitted to intensive care units (ICUs) with sepsis or septic shock from January 1, 2006, to May 4, 2018, at a tertiary referral hospital. We compared two groups based on albumin receipt within the initial six resuscitation hours (albumin group vs. non-albumin group). We performed a 1:2 propensity score matching to assess shock-free time in ICU as the primary outcome.

RESULTS

Of 2,732 patients with medical sepsis, 286 cases in the albumin group were matched with 549 individuals in the non-albumin group. Compared to the non-albumin group, the albumin group required more intravenous fluids and had higher net fluid balance, lower mean arterial pressure, and lower serum base excess level in the initial 6 and 24 h of resuscitation. Shock-free time, ICU and hospital length of stay, and 28-day mortality were not different between albumin and non-albumin groups (56 vs. 66 h, P = 0.18; 3.5 days vs. 3.7 days, P = 0.61; 9.1 days vs. 9.5 days, P = 0.27; 36% vs. 32%, P = 0.25, respectively).

CONCLUSIONS

Using albumin during the initial 6 h of resuscitation was not associated with benefits in clinical outcomes of patients with medical sepsis.

Beneficial Effects of Oral Nutritional Supplements on Body Composition and Biochemical Parameters in Women with Breast Cancer Undergoing Postoperative Chemotherapy: A Propensity Score Matching Analysis

Aim: Recently, more attention has been paid to the role of nutritional intervention in preventing the side effects of chemotherapy in oncology patients. Therefore, the aim of the present study was to analyze the effects of oral nutritional supplements on the body composition and biochemical parameters in women with breast cancer receiving postoperative adjuvant chemotherapy. Patients and Methods: The study involved women diagnosed with breast cancer who underwent surgical treatment and were qualified for chemotherapy (doxorubicin and cyclophosphamide). Women were divided into two groups, depending on whether oral nutritional supplements were used during chemotherapy. Anthropometric and biochemical parameters were analyzed twice in all patients: before and after six weeks of chemotherapy. Propensity score (PS) matching was performed to select patients balanced in terms of age, BMI, and clinicopathological features of the tumor. Statistical comparisons were conducted in a propensity-matched cohort of patients. Results: The value of BMI was maintained constant in the supplemented women older than 56 years after six weeks of chemotherapy. Regardless of age in the supplemented women, a significant increase in muscle mass, fat free mass (FFM), and fat free mass index (FFMI) was demonstrated. An increase in fat mass (FM) including visceral fat was observed only in the non-supplemented control. Regardless of age or initial FM, supplemented women exhibited a constant level of albumin. Moreover, in the supplemented women with normal initial FM, the stable values of triglycerides and HDL cholesterol were maintained after six weeks of chemotherapy. Conclusion: The present study demonstrated that oral nutritional supplements could improve body composition and prevent hypoalbuminemia and lipid abnormalities in women with breast cancer undergoing chemotherapy.

Very-Short-Term Sleep Deprivation Slows Early Recovery of Lymphocytes in Septic Patients

Sleep plays an important role in immune function. However, the effects of very-short-term sleep deprivation on the early recovery of immune function after sepsis remain unclear. This study was conducted in the intensive care unit to investigate the effects of 2 consecutive days of sleep deprivation (SD) on lymphocyte recovery over the following few days in septic patients who were recovering from a critical illness. The patients' self-reports of sleep quality was assessed using the Richards–Campbell Sleep Questionnaire at 0 and 24 h after inclusion. The demographic, clinical, laboratory, treatment, and outcome data were collected and compared between the good sleep group and poor sleep group. We found that 2 consecutive days of SD decreased the absolute lymphocyte count (ALC) and ALC recovery at 3 days after SD. Furthermore, post-septic poor sleep decreased the plasma levels of atrial natriuretic peptide (ANP) immediately after 2 consecutive days of SD. The ANP levels at 24 h after inclusion were positively correlated with ALC recovery, the number of CD3⁺ T cells, or the number of CD3⁺ CD4⁺ cells in the peripheral blood on day 5 after inclusion. Our data suggested that very-short-term poor sleep quality could slow down lymphocyte recovery over the following few days in septic patients who were recovering from a critical illness. Our results underscore the significance of very-short-term SD on serious negative effects on the immune function. Therefore, it is suggested that continuous SD or several short-term SD with short intervals should be avoided in septic patients.

Hypoalbuminemia as Surrogate and Culprit of Infections

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

Supra-massive transfusion and interdisciplinary approach to cesarean hysterectomy due to complex placenta percreta: Case report

Placenta accreta spectrum encompasses a group of conditions of abnormal placental infiltration of the uterine wall and surrounding tissues. It is associated with significant blood loss, perioperative morbidity, and risk of death. A coordinated interdisciplinary approach to these complex cases and early resuscitation with blood products are critical factors in the successful management of patients affected by this disease. We describe the successful management of a patient with placenta percreta who required supra-massive transfusion of blood products and interventions by different specialized teams in a tertiary care center.

Similarities, Differences, and Potential Synergies in the Mechanism of Action of Albumin Dialysis Using the MARS Albumin Dialysis Device and the CytoSorb Hemoperfusion Device in the Treatment of Liver Failure

INTRODUCTION

Liver failure is characterized by compromised hepatic detoxification, protein synthesis, and metabolic derangements leading to an accumulation of a broad spectrum of water-soluble and lipophilic toxins as well as immune system mediators. Exploring complex detoxification mechanisms to therapeutically target those components, this article will focus on similarities, differences, and potential synergies in the mechanism of albumin dialysis and hemoperfusion.

METHODS

An in vitro two-compartment model for the comparison of liver support techniques was used to compare MARS albumin dialysis modified with novel charcoal adsorbents to CytoSorb hemoperfusion with added hemodialysis for effects on marker molecule removal.

RESULTS

MARS and CytoSorb performed similar in the removal of water-soluble toxins. Ammonia removal was increased using CytoSorb. CytoSorb lead to a statistically significant reduction of albumin-bound toxins, total bilirubin and subfractions. Bile acid removal was comparable. MARS demonstrated no removal of cytokines interleukin (IL)-6 and tumor necrosis factor-alpha (TNF-α), whereas CytoSorb allowed for near complete removal. Notably, CytoSorb displayed 50% of lipophilic substance and cytokine removal during the first hour of treatment.

CONCLUSION

Compared to MARS, CytoSorb hemoperfusion leads to an initially fast removal of cytokines, TNF-α and IL-6, as well as reduction of albumin-bound toxins such as indirect bilirubin and bile acids in our model. The initial removal is also associated with removal of albumin.

Postoperative resuscitation with hypertonic saline or hyperoncotic albumin in patients following cardiac surgery: A review of the literature

BACKGROUND

Over-resuscitation in postcardiac surgery patients is associated with significant morbidity and mortality. Accordingly, there is a growing interest in hyperoncotic albumin and hypertonic saline for resuscitation in patients following cardiac surgery. In this article, we will review the use of hyperosmolar fluid therapies for resuscitation in postcardiac surgical patients from the current literature.

METHODS

A literature search was conducted in MEDLINE (PubMed) utilizing keywords, narrowing publications from 2009 to 2020.

RESULTS

Patients receiving concentrated albumin after cardiac surgery required less fluid bolus therapy, less time on vasopressors, and had a lower positive fluid balance compared with patients receiving crystalloids. There was no difference in mortality in those given 20% albumin compared with crystalloids postcardiac surgery. Patients administered hypertonic saline following cardiac surgery had increased urinary output but its effect on total fluid and body weight was not significantly different compared with crystalloids.

CONCLUSIONS

In this analysis, publications on resuscitation with hyperoncotic albumin and hypertonic saline in patients following cardiac surgery were reviewed. While there is data supporting the use of alternative fluid therapies in other critically ill populations, the limited literature focused on concentrated albumin and hypertonic saline for resuscitation following cardiac surgery is equivocal.

Effect of Albumin on Tumor Cells In Vitro

The study examined the effect of BSA on cultured cells of breast cancer, erythroleukemia, and ovarian carcinoma. BSA cytotoxic activity was examined with light microscopy and spectrophotometry in the concentration range of 6.25 to 50 mg/ml. The high concentrations of BSA disrupted the tumor cells in parallel with formation of vesicular debris. The destruction parameters were similar in diverse types of cells: BSA (50 mg/ml) disrupted 75.5±0.7% breast cancer cells, 75.8±0.2% erythroleukemia cells, and 78.8±0.1% cells of ovarian carcinoma (p≥0.05). The effect of BSA was dose-dependent in each type of cells. The data attest that BSA can disrupt various tumor cells in vitro.

Phases of fluid management and the roles of human albumin solution in perioperative and critically ill patients

OBJECTIVE

Positive fluid balance is common among critically ill patients and leads to worse outcomes, particularly in sepsis, acute respiratory distress syndrome, and acute kidney injury. Restrictive fluid infusion and active removal of accumulated fluid are being studied as approaches to prevent and treat fluid overload. Use of human albumin solutions has been investigated in different phases of restrictive fluid resuscitation, and this narrative literature review was undertaken to evaluate hypoalbuminemia and the roles of human serum albumin with respect to hypovolemia and its management.

METHODS

PubMed/EMBASE search terms were: "resuscitation," "fluids," "fluid therapy," "fluid balance," "plasma volume," "colloids," "crystalloids," "albumin," "hypoalbuminemia," "starch," "saline," "balanced salt solution," "gelatin," "goal-directed therapy" (English-language, pre-January 2020). Additional papers were identified by manual searching of reference lists.

RESULTS

Restrictive fluid administration, plus early vasopressor use, may reduce fluid balance, but in some cases fluid overload cannot be entirely avoided. Deresuscitation, with fluid actively removed through diuretics or ultrafiltration, reduces duration of mechanical ventilation and intensive care unit stay. Combining hyperoncotic human albumin solution with diuretics increases hemodynamic stability and diuresis. Hyperoncotic albumin corrects hypoalbuminemia and raises colloid osmotic pressure, limiting edema formation and potentially improving endothelial function. Serum levels of albumin relative to C-reactive protein and lactate may predict which patients will benefit most from albumin therapy.

CONCLUSIONS

Hyperoncotic human albumin solution facilitates restrictive fluid therapy and the effectiveness of deresuscitative measures. Current evidence is mostly from observational studies, and more randomized trials are needed to better establish a personalized approach to fluid management.

Circulating liver function markers and colorectal cancer risk: A prospective cohort study in the UK Biobank

Evidence links the liver to development of colorectal cancer (CRC). However, it remains unknown how liver function may influence CRC risk in the general population. We conducted a prospective cohort study in the UK Biobank of 375 693 participants who provided blood samples in 2006 to 2010. Circulating levels of liver function markers (alanine transaminase [ALT], aspartate transaminase [AST], total bilirubin [TBIL], gamma glutamyltransferase [GGT], alkaline phosphatase [ALP], total protein [TP] and albumin [ALB]) were measured. Incident cancer cases were identified through linkage to the national cancer registry up to 2019. Repeated biomarker measurements were available from a subset of 11 320 participants who were re-assessed in 2012 to 2013. After a median follow-up of 10.0 years, we documented 2662 cases of CRC. Circulating levels of ALT, AST, TBIL, GGT, TP and ALB at baseline were inversely associated with CRC risk (P < .01), with multivariable hazard ratio (95% confidence interval) comparing decile 10 vs 1 of 0.62 (0.51-0.75), 0.63 (0.53-0.75), 0.85 (0.72-1.02), 0.74 (0.61-0.89), 0.70 (0.59-0.84) and 0.66 (0.55-0.79), respectively. Strengthened associations were found after recalibration for repeated measurements. The associations appeared stronger for proximal colon cancer than distal colon cancer and rectal cancer, but consistent for early-, mid- and late-onset CRC. In a large cohort of general population, the UK Biobank, higher circulating levels of ALT, AST, TBIL, GGT, TP and ALB, largely within the normal range, were associated with a lower risk of CRC. The findings support a link between liver function and CRC, and may spur future research on the gut-microbiota-liver axis.

A patient specific forecasting model for human albumin based on deep neural networks

BACKGROUND AND OBJECTIVES

Hypoalbuminemia can be life threatening among critically ill patients. In this study, we develop a patient-specific monitoring and forecasting model based on deep neural networks to predict concentrations of albumin and a set of selected biochemical markers for critically ill patients in real-time.

METHODS

Under the assumption that metabolism of a patient follows a patient-specific dynamical process that can be determined from sufficient prior data taken from the patient, we apply a machine learning method to develop the patient-specific model for a critically ill, poly-trauma patient. Six representative biochemical markers (albumin (ALB), creatinine (Cr), osmotic pressure (OSM), alanine aminotransferase (ALT), total bilirubin (TB), direct bilirubin (DB)) were collected from the patient while scheduled exogenous albumin injection was administered to the patient for the total of 27 consecutive days. A sliding window of data in 11 consecutive days were used to train and test the neural networks in the model.

RESULTS

The obtained dynamical system model represented by neural networks is used to forecast the biochemical markers of the patient in the next 24 h. The relative error between the predictions and the clinical data remains consistently lower than 2%.

CONCLUSIONS

This study demonstrates that a patient-specific dynamical system model can be established to monitor and forecast dynamical behavior of concentrations of patients' biochemical markers (including albumin) using deep learning methods on neural networks.

Admission C-Reactive Protein-to-Albumin Ratio Predicts the 180-Day Mortality of AIDS-Related Pneumocystis Pneumonia

Assessment tools are necessary for the adequate stratification of patients with AIDS-related pneumocystis pneumonia (PCP). The aim of this study was to evaluate the ability of severity assessment scores and inflammation- and nutrition-based parameters for predicting the 180-day mortality of AIDS-related PCP. This was a retrospective cohort study of patients with AIDS-related PCP admitted at the Beijing Di-Tan Hospital. The CURB-65 score, Pneumonia Severity Index (PSI) score, Acute Physiology And Chronic Health Evaluation II (APACHE II) score, C-reactive protein-to-albumin ratio (CAR), procalcitonin, neutrophil-to-lymphocyte ratio, lymphocyte-to-monocyte ratio, and platelet-to-lymphocyte ratio during the first 24 h of intensive care unit admission were analyzed. The prognostic values of the severity assessment scores and biomarkers for 180-day mortality were evaluated using receiver operating characteristic (ROC) curves and integrated discrimination improvement (IDI) indexes. A total of 123 patients with AIDS-related PCP were included. Fifty-five patients were dead, and 68 were still alive at 180 days after admission. CAR, CURB-65, PSI, and APACHE II were independent predictors of 180-day mortality. The optimal cutoff value of CAR was 2.0 mg/g [area under the ROC curve = 0.844, 95% credential interval (CI) = 0.776-0.913], and CAR >2.0 mg/g increased the prognostic value of all three severity assessment scores, with an IDI index of 5.1% for the CURB-65 score, 8.1% for the PSI score, and 4.1% for the APACHE II score (all p < .05). Combining CAR >2.0 mg/g enhanced the capability of CURB-65, APACHE II, and PSI in predicting the 180-day mortality of patients with AIDS-related PCP.

Effect of albumin administration on outcomes in hypoalbuminemic patients hospitalized with community-acquired pneumonia (ALBUCAP): a prospective, randomized, phase III clinical controlled trial-a trial protocol

Background

Community-acquired pneumonia (CAP) remains a leading cause of death worldwide, and hypoalbuminemia is associated with worse outcomes. However, it remains uncertain whether albumin administration could have any beneficial effects. We aim to assess whether the administration of albumin in hypoalbuminemic patients with CAP increases the proportion of clinically stable patients at day 5 compared with the standard of care alone.

Methods

This is a trial protocol for a superiority, non-blinded, multicenter, randomized, phase 3, interventional controlled clinical trial. The primary endpoint will be the proportion of clinical stable patients at day 5 (intention to treat), defined as those with stable vital signs for at least 24 h. The secondary endpoints will be time to clinical stability, duration of intravenous and total antibiotic treatment, length of hospital stay, intensive care unit admission, duration of mechanical ventilation and vasopressor treatment, adverse events, readmission within 30 days, and all-cause mortality. The trial has been approved by the Spanish Medicines and Healthcare Products Regulatory Agency. The investigators commit to publish the data in peer-reviewed journals within a year of the study completion date. Subjects will be recruited from three Spanish hospitals over a planned enrolment period of 2 years. A follow-up visit will be performed 1 month after discharge. We have estimated the need for a sample size of 360 patients at a two-sided 5% alpha-level with a power of 80% based on intention to treat. Eligible participants must be hospitalized, hypoalbuminemic (≤ 30 g/L), non-immunosuppressed, adults, and diagnosed with CAP. They will be randomly assigned (1:1) to receive standard care plus albumin (20 g in 100 mL) every 12 h for 4 days or standard care alone.

Discussion

If this randomized trial confirms the hypothesis, it should lead to a change in current clinical practice for the management of hypoalbuminemic patients with CAP.

Trial registration

European Clinical Trials Database (EudraCT) 2018-003117-18. Registered on 12 April 2019. ClinicalTrials.gov NCT04071041. Registered on 27 August 2019

Economic model of albumin infusion in septic shock: The EMAISS study

BACKGROUND

The cost-effectiveness of albumin-based fluid support in patients with septic shock is currently unknown.

METHODS

In a simulation study, we compared standard medical practice and systematic 20% albumin infusion. The study population consisted of patients with septic shock admitted to one of the 28 ICUs belonging to the Cub-Réa regional database between 1 January 2014 and 31 December 2016. Cost estimates were based on French diagnosis-related groups and fixed daily prices. Estimation of mortality reduction relied on ALBIOS trial data documenting a Risk Ratio of 0.87 in a non-preplanned subgroup of patients with septic shock. Life expectancy was estimated with follow up data of 184 patients with septic shock admitted in the year 2000 in the same ICUs. Several sensitivity analyses were performed including a one-way Deterministic Sensitivity Analysis (DSA) and a Probabilistic multivariate Sensitivity Analysis (PSA).

RESULTS

About 6406 patients were included. In the base-case scenario, the mean live years gained with albumin was 0.49. The mean extra cost of using albumin was €480 per year. The cost per year gained was €974. Sensitivity analyses confirmed the robustness of the results. The probability of albumin being cost-effective was 95% and 97% for a threshold fixed at €20 000 and €30 000 per life-year saved, respectively.

CONCLUSION

Based on the risk reduction observed in the septic shock subgroup analysis of the ALBIOS dataset, the application of the ALBIOS trial results to Cub-Réa data may suggest that albumin infusion is likely cost-effective in septic shock.

Role of albumin in the preservation of endothelial glycocalyx integrity and the microcirculation: a review

The endothelial glycocalyx comprises a complex layer of membrane-bound proteoglycans, secreted glycosaminoglycans, glycoproteins, glycolipids and bound plasma proteins such as albumin and antithrombin associated with the endothelial surface. The glycocalyx plays an important role in vascular homeostasis, regulating vascular permeability and cell adhesion, and acts as a mechanosensor for hemodynamic shear stresses; it also has antithrombotic and anti-inflammatory functions. Plasma proteins such as albumin are physiologically bound within the glycocalyx, thus contributing to stability of the layer. Albumin is the major determinant of plasma colloid osmotic pressure. In addition, albumin transports sphingosine-1-phosphate which has protective endothelial effects, acts as a free radical scavenger, and has immunomodulatory and anti-inflammatory effects. This review examines the physiological function of the endothelial glycocalyx and the role of human albumin in preserving glycocalyx integrity and the microcirculation.

Serum albumin level is associated with the severity of neurological dysfunction of NMOSD patients

BACKGROUND

Neuromyelitis optica spectrum disorder (NMOSD) is an inflammatory autoimmune disease of the central nervous system. Serum albumin (SA) has antioxidant, immunomodulatory and anti-inflammatory effects. However, the roles of SA in NMOSD have not been studied. The current study aimed to clarify the association of SA with disease severity and prognosis in NMOSD patients.

METHODS

Serum levels of albumin were measured by Bromcresol Green method. Serum level measurements of interleukins were performed using enzyme-linked immunoassay (ELISA) method.

RESULTS

Of all the 130 NMOSD patients, 96 patients were in the acute phase while 34 patients were in the remission phase of disease at the time of sampling. SA concentration was significantly correlated with EDSS score in patients in the acute phase but not in remission phase (r = - 0.388, p < 0.001 and r = - 0.467, p = 0.809, respectively). Logistic analysis revealed that SA was the only significant factor to predict severe NMOSD (EDSS 8.0-9.5) OR = 0.698, 95%CI 0.563-0.865, p = 0.001) after adjustment of other confounding factors. Furthermore, SA was negatively correlated with the serum level of IL-33 (r = -0.438, p = 0.016) in the acute phase of NMOSD patients.

CONCLUSION

The current study found that low level of SA was an independent indicator of more severe neurological deficit in patients in acute phase of NMOSD. SA concentration was negatively correlated with the serum level of IL-33 in the acute phase of the disease, which implies that SA might participate in the immunopathology of NMOSD partly through its interaction with IL-33.

The chimeric antigen receptor-intensive care unit (CAR-ICU) initiative: Surveying intensive care unit practices in the management of CAR T-cell associated toxicities

PURPOSE

A task force of experts from 11 United States (US) centers, sought to describe practices for managing chimeric antigen receptor (CAR) T-cell toxicity in the intensive care unit (ICU).

MATERIALS AND METHODS

Between June-July 2019, a survey was electronically distributed to 11 centers. The survey addressed: CAR products, toxicities, targeted treatments, management practices and interventions in the ICU.

RESULTS

Most centers (82%) had experience with commercial and non-FDA approved CAR products. Criteria for ICU admission varied between centers for patients with Cytokine Release Syndrome (CRS) but were similar for Immune Effector Cell Associated Neurotoxicity Syndrome (ICANS). Practices for vasopressor support, neurotoxicity and electroencephalogram monitoring, use of prophylactic anti-epileptic drugs and tocilizumab were comparable. In contrast, fluid resuscitation, respiratory support, methods of surveillance and management of cerebral edema, use of corticosteroid and other anti-cytokine therapies varied between centers.

CONCLUSIONS

This survey identified areas of investigation that could improve outcomes in CAR T-cell recipients such as fluid and vasopressor selection in CRS, management of respiratory failure, and less common complications such as hemophagocytic lymphohistiocytosis, infections and stroke. The variability in specific treatments for CAR T-cell toxicities, needs to be considered when designing future outcome studies of critically ill CAR T-cell patients.

Albumin: Indications in chronic liver disease

Albumin is currently employed as a plasma expander to prevent and treat specific complications of cirrhosis with ascites, such as the prevention of paracentesis-induced circulatory dysfunction and renal dysfunction induced by spontaneous bacterial peritonitis, as well as the diagnosis and treatment of acute kidney injury and hepatorenal syndrome. Recently, evidence has shown that long-term albumin administration in patients with decompensated cirrhosis reduces mortality and incidence of complications, eases the management of ascites, is cost effective, and has a good safety profile.