Preoperative hypoalbuminemia is associated with an increased risk for intra-abdominal septic complications after primary anastomosis for Crohn's disease

Impact of hypoalbuminemia on outcomes following pancreaticoduodenectomy: a NSQIP retrospective cohort analysis of 25,848 patients

BACKGROUND

Efforts to preoperatively risk stratify and optimize patients before pancreaticoduodenectomy continue to improve outcomes. This study aims to determine the impact of hypoalbuminemia on outcomes following pancreaticoduodenectomy and outline optimal hypoalbuminemia cut-off values in this population.

METHODS

The ACS-NSQIP (2016-2021) database was used to extract patients who underwent pancreaticoduodenectomy, comparing those with hypoalbuminemia (< 3.0 g/L) to those with normal albumin. Demographics and 30-day outcomes were compared. Multivariable modeling evaluated factors including hypoalbuminemia to characterize their independent effect on serious complications, and mortality. Optimal albumin cut-offs for serious complications and mortality were evaluated using receiver-operating characteristic curves.

RESULTS

We evaluated 25,848 pancreaticoduodenectomy patients with 2712 (10.5%) having preoperative hypoalbuminemia. Patients with hypoalbuminemia were older (68.2 vs. 65.1; p < 0.0001), and were significantly more likely to be ASA class 4 or higher (13.9% vs. 6.7%; p < 0.0001). Patients with hypoalbuminemia had significantly more 30-day complications and after controlling for comorbidities hypoalbuminemia remained a significant independent factor associated with 30-day serious complications (OR 1.80, p < 0.0001) but not mortality (OR 1.37, p = 0.152).

CONCLUSIONS

Hypoalbuminemia plays a significant role in 30-day morbidity following pancreaticoduodenectomy. Preoperative albumin may serve as a useful marker for risk stratification and optimization.

A guide to developing population files for physiologically-based pharmacokinetic modeling in the Simcyp Simulator

The Simcyp Simulator is a software platform widely used in the pharmaceutical industry to conduct stochastic physiologically-based pharmacokinetic (PBPK) modeling. This approach has the advantage of combining routinely generated in vitro data on drugs and drug products with knowledge of biology and physiology parameters to predict a priori potential pharmacokinetic changes in absorption, distribution, metabolism, and excretion for populations of interest. Combining such information with pharmacodynamic knowledge of drugs enables planning for potential dosage adjustment when clinical studies are feasible. Although the conduct of dedicated clinical studies in some patient groups (e.g., with hepatic or renal diseases) is part of the regulatory path for drug development, clinical studies for all permutations of covariates potentially affecting pharmacokinetics are impossible to perform. The role of PBPK in filling the latter gap is becoming more appreciated. This tutorial describes the different input parameters required for the creation of a virtual population giving robust predictions of likely changes in pharmacokinetics. It also highlights the considerations needed to qualify the models for such contexts of use. Two case studies showing the step-by-step development and application of population files for obese or morbidly obese patients and individuals with Crohn's disease are provided as the backbone of our tutorial to give some hands-on and real-world examples.

Nutrition, Nutritional Status, Micronutrients Deficiency, and Disease Course of Inflammatory Bowel Disease

During the disease course, most Inflammatory Bowel Disease patients present a condition of malnutrition, undernutrition, or even overnutrition. These conditions are mainly due to suboptimal nutritional intake, alterations in nutrient requirements and metabolism, malabsorption, and excessive gastrointestinal losses. A suboptimal nutritional status and low micronutrient serum levels can have a negative impact on both induction and maintenance of remission and on the quality of life of Inflammatory Bowel Disease patients. We performed a systematic review including all the studies evaluating the connection between nutrition, nutrition status (including undernutrition and overnutrition), micronutrient deficiency, and both disease course and therapeutic response in Inflammatory Bowel Disease patients. This systematic review was performed using PubMed/MEDLINE and Scopus. Four main clinical settings concerning the effect of nutrition on disease course in adult Inflammatory Bowel Disease patients were analyzed (induction of remission, maintenance of remission, risk of surgery, post-operative recurrence, and surgery-related complications). Four authors independently reviewed abstracts and manuscripts for eligibility. 6077 articles were found; 762 duplicated studies were removed. Out of 412 full texts analyzed, 227 were included in the review. The evidence summarized in this review showed that many nutritional aspects could be potential targets to induce a better control of symptoms, a deeper remission, and overall improve the quality of life of Inflammatory Bowel Disease patients.

Perioperative nutrition for gastrointestinal surgery: On the cutting edge

Evidence on perioperative nutrition interventions in gastrointestinal surgery is rapidly evolving. We conducted a narrative review of various aspects of nutrition support, including formula choice and route of administration, as well as duration and timing of nutrition support therapy. Studies have demonstrated that nutrition support is associated with improved clinical outcomes in malnourished patients and those at nutrition risk, emphasizing the importance of nutrition assessment, for which several validated nutrition risk assessment tools exist. The assessment of serum albumin levels has fallen out of favor, as it is an unreliable marker of nutrition status, whereas imaging evidence of sarcopenia has prognostic value and may emerge as a standard component of nutrition assessment. Preoperatively, evidence supports limiting fasting to reduce insulin resistance and improve oral tolerance. Benefits to preoperative carbohydrate loading remain unclear, whereas literature suggests preoperative parenteral nutrition (PN) may reduce postoperative complications in high-risk patients with malnutrition or sarcopenia. Postoperatively, early oral feeding is safe with benefits in time to return of bowel function and reduced hospital stay. There is a signal for potential benefit to early postoperative PN in critically ill patients, though evidence is sparse. There has also been a recent emergence in randomized studies evaluating the use of ω-3 fatty acids, amino acids, and immunonutrition. Meta-analyses have reported favorable outcomes for these supplements, though individual studies are small and with significant methodological limitations and risk of bias, emphasizing the need for high-quality randomized studies to guide clinical practice.

Relative decline in serum albumin help to predict anastomotic leakage for female patients following sphincter-preserving rectal surgery

BACKGROUND

Patients with normal preoperative serum albumin still suffer from a significant reduction in serum albumin after major abdominal surgery. The current study aims to explore the predictive value of ∆ALB for AL in patients with normal serum albumin and examine whether there is a gender difference in the prediction of AL.

METHODS

Medical reports of consecutive patients undergoing elective sphincter-preserving rectal surgery between July 2010 and June 2016 were reviewed. Receiver operating characteristic (ROC) analysis was adopted to examine the predictive ability of ∆ALB and determine the cut-off value according to the Youden index. The logistic regression model was performed identify independent risk factors for AL.

RESULTS

Out of the 499 eligible patients, 40 experienced AL. Results of the ROC analyses showed that ΔALB displayed a significant predictive value for females, and the AUC value was 0.675 (P = 0.024), with a sensitivity of 93%. In male patients, the AUC was 0.575 (P = 0.22), but did not reach a significant level. In the multivariate analysis, ∆ALB ≥ 27.2% and low tumor location prove to be independent risk factors for AL in female patients.

CONCLUSIONS

The current study suggested that there may be a gender difference in the prediction of AL and ∆ ALB can serve as a potential predictive biomarker for AL in females. A cut-off value of the relative decline in serum albumin can help predict AL in female patients as early as postoperative day 2. Although our study needs further external validation, our findings may provide an earlier, easier and cheaper biomarker for the detection of AL.

Altered Bioavailability and Pharmacokinetics in Crohn's Disease: Capturing Systems Parameters for PBPK to Assist with Predicting the Fate of Orally Administered Drugs

Backgrond and Objective

Crohn’s disease (CD) is a chronic inflammatory bowel disease that affects a wide age range. Hence, CD patients receive a variety of drugs over their life beyond those used for CD itself. The changes to the integrity of the intestine and its drug metabolising enzymes and transporters (DMETs) can alter the oral bioavailability of drugs. However, there are other changes in systems parameters determining the fate of drugs in CD, and understanding these is essential for dose adjustment in patients with CD.

Methods

The current analysis gathered all the available clinical data on the kinetics of drugs in CD (by March 2021), focusing on orally administered small molecule drugs. A meta-analysis of the systems parameters affecting oral drug pharmacokinetics was conducted. The systems information gathered on intestine, liver and blood proteins and other physiological parameters was incorporated into a physiologically based pharmacokinetic (PBPK) platform to create a virtual population of CD patients, with a view for guiding dose adjustment in the absence of clinical data in CD.

Results

There were no uniform trends in the reported changes in reported oral bioavailability. The nature of the drug as well as the formulation affected the direction and magnitude of variation in kinetics in CD patients relative to healthy volunteers. Even for the same drug, the reported changes in exposure varied, possibly due to a lack of distinction between the activity states of CD. The highest alteration was seen with S-verapamil and midazolam, 8.7- and 5.3-fold greater exposure, respectively, in active CD patients relative to healthy volunteers. Only one report was available on liver DMETs in CD, and indicated reduced CYP3A4 activity. In a number of reports, mRNA expression of DMETs in the ileum and colon of CD patients was measured, focussing on P-glycoprotein (p-gp) transporter and CYP3A4 enzyme, and showed contradictory results. No data were available on protein expression in duodenum and jejunum despite their dominant role in oral drug absorption.

Conclusion

There are currently inadequate dedicated clinical or quantitative proteomic studies in CD to enable predictive PBPK models with high confidence and adequate verification. The PBPK models for CD with the available systems parameters were able to capture the major physiological influencers and the gaps to be filled by future research. Quantification of DMETs in the intestine and the liver in CD is warranted, alongside well-defined clinical drug disposition studies with a number of index drugs as biomarkers of changes in DMETs in these patients, to avoid large-scale dedicated studies for every drug to determine the effects of disease on the drug’s metabolism and disposition and the consequential safety and therapeutic concerns.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40262-022-01169-4.

Factors associated with stoma formation in ileocolic resection for Crohn's disease and the development of a predictive scoring system

PURPOSE

The likelihood of a stoma following ileocolic resection (ICR) for Crohn's disease (CD) is an important consideration. This study aims to identify the factors associated with an increased likelihood of a stoma and develop a predictive scoring system (SS).

METHODS

Patient data were collected from St. Marks Hospital, London, UK and Humanitas Clinical and Research Center, Milan, Italy, on all patients who underwent an ICR for CD from 2005 to 2017. A logistic regression analysis was used for multivariate analysis. The SS was developed from the logistic regression model. The performance of the SS was evaluated using receiver operating characteristics area under the curve (AUROC).

RESULTS

A total of 628 surgeries were included in the analysis. Sixty-nine surgeries were excluded due to missing data. The remaining 559 were divided into two cohorts for the scoring system's development (n = 434) and validation (n = 125). The regression model was statistically significant (p < 0.0001). The statistically significant independent variables included sex, preoperative albumin and haemoglobin levels, surgical access and simultaneous colonic resection. The AUROC for the development and validation cohorts were 0.803 and 0.905, respectively (p < 0.0001). Youden's index suggested the cut-off score of - 95.9, with a sensitivity of 87.6% and a specificity of 62.9%.

CONCLUSIONS

Male sex, low preoperative albumin, anaemia, laparoscopic conversion and simultaneous colonic resection were associated with an increased likelihood of requiring a stoma and were used to develop an SS. The calculator is available online at https://rebrand.ly/CrohnsStoma .

Prehabilitation prior to intestinal resection in Crohn’s disease patients: An opinion review

Patients with Crohn’s disease (CD) are at a considerable risk for intestinal surgery. Approximately 25% of patients with CD will undergo an intestinal resection within 10 years of diagnosis. Postoperative complications after CD surgery have been reported in 20%-47% of the patients. Both general and CD-related risk factors are associated with postoperative complications, and comprise non-modifiable (e.g., age) and potentially modifiable risk factors (e.g., malnutrition). Prehabilitation focuses on the preoperative period with strategies designed to optimize modifiable risk factors concerning the physical and mental condition of the individual patient. The aim of prehabilitation is to enhance postoperative recovery and return to or even improve preoperative functional capacity. Preoperative improvement of nutritional status, physical fitness, cessation of smoking, psychological support, and critical revision of preoperative use of CD medication are important strategies. Studies of the effect on postoperative outcome in CD patients are scarce, and guidelines lack recommendations on tailored management. In this opinion review, we review the current evidence on the impact of screening and management of nutritional status, physical fitness, CD medication and laboratory values on the postoperative course following an intestinal resection in CD patients. In addition, we aim to provide guidance for individualized multimodal prehabilitation in clinical practice concerning these modifiable factors.

Influence of nutritional status in the postoperative period of patients with inflammatory bowel disease

Inflammatory bowel diseases (IBDs) are a group of chronic inflammatory diseases that affect the gastrointestinal tract, including Crohn's disease (CD) and ulcerative colitis. Surgery is a treatment option, and more than half of the patients with CD will undergo surgical interventions over the course of the disease. Postoperative complications are common in IBD patients, the most frequent being intra-abdominal sepsis, infection of the surgical site, and adynamic ileum, and nutritional status is a factor that can influence postoperative outcome. Recent studies have shown that malnutrition, obesity, sarcopenia, and myosteatosis are predictors of surgical complications. However, most were retrospective studies with small patient samples and heterogeneity of clinical and nutritional assessment methods, which limit the extrapolation of data. Therefore, knowing the pathophysiological mechanisms of IBD and identifying the best parameters for assessing nutritional status are essential for prompt implementation of adequate nutritional interventions.

Hypoalbuminemia Predicts Serious Complications Following Elective Bariatric Surgery

PURPOSE

The aims of this study were to (1) characterize the prevalence of hypoalbuminemia (HA), (2) compare complication rates among HA and non-HA patients, and (3) determine the influence of HA on postoperative complications and 30-day mortality among bariatric surgery patients.

MATERIALS AND METHODS

Data was extracted from the MBSAQIP registry from 2015 to 2018. A presurgical serum albumin level of [Formula: see text] 3.5 g/dL was used to organize the patient population into HA and non-HA cohorts. Bivariate analysis and multivariable logistic regression modeling were used.

RESULTS

Of 590,971 patients, 42,618 (7.2%) were identified as having serum albumin levels [Formula: see text] 3.5 g/dL. HA patients were younger (44.0 + / - 11.9 vs. 44.5 + / - 12.0 years; p < 0.0001), were of increased BMI (48.5 + / - 9.0 kg/m² vs. 45.1 + / - 7.7 kg/m²; p < 0.0001), and had a lower baseline functional status (1.6% vs. 1.0% dependent or partially dependent; p < 0.0001). HA patients had more anastomotic leaks (0.46% vs. 0.38%; p = 0.02), deep surgical site infections (0.37% vs. 0.24%; p < 0.0001), and composite serious complications (4.4% vs. 3.3%; p < 0.0001). At 30-day post-operation, complications including need for reintervention (1.6% vs. 1.2%; p < 0.0001), readmission (4.8% vs. 3.7%; p < 0.0001), and mortality (0.14% vs. 0.086%; p = 0.001) were all more prevalent among HA patients. After functional status, HA was the strongest modifiable predictor of serious complications but was not predictive of 30-day mortality.

CONCLUSION

We identified HA as one of the greatest modifiable factors predictive of serious complications. Adoption of strategies to identify and improve preoperative serum albumin levels may reduce overall serious complications among elective bariatric surgery 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.

Hypoalbuminaemia, Not Biologic Exposure, Is Associated with Postoperative Complications in Crohn's Disease Patients Undergoing Ileocolic Resection

BACKGROUND

There are limited data on the postoperative outcomes in Crohn's disease patients exposed to preoperative ustekinumab or vedolizumab. We hypothesised that preoperative biologic use in Crohn's disease is not associated with postoperative complications after ileocolic resection.

METHODS

Crohn's disease patients who underwent ileocolic resection over 2009-2019 were identified at a large regional health system. Preoperative biologic use within 12 weeks of surgery was categorised as no biologic, anti-tumour necrosis factor, vedolizumab, or ustekinumab. The primary endpoint was 90-day intra-abdominal septic complication. Risk factors included preoperative medical therapies, demographics, disease characteristics, laboratory values, and surgical approach. Regression models assessed the association of biologic use with intra-abdominal septic complication.

RESULTS

A total of 815 Crohn's disease patients who underwent an ileocolic resection were included [62% no biologic, 31.4% anti-tumour necrosis factor, 3.9% vedolizumab, 2.6% ustekinumab]. Primary anastomosis was performed in 85.9% of patients [side-to-side 48.8%, end-to-side 26%, end-to-end 25%] in primarily a stapled [77.2%] manner. Minimally invasive approach was used in 41.4%. The 90-day postoperative intra-abdominal sepsis rate of 810 patients was 12%, abscess rate was 9.6%, and anastomotic leak rate was 3.2%. Multivariable regression modelling controlling for confounding variables demonstrated that preoperative biologic use with anti-tumour necrosis factor [p = 0.21], vedolizumab [p = 0.17], or ustekinumab [p = 0.52] was not significantly associated with intra-abdominal septic complication. Preoperative albumin < 3.5 g/dl was independently associated with intra-abdominal septic complication (odds ratio [OR] 1.76 [1.03, 3.01]).

CONCLUSIONS

In Crohn's disease patients undergoing ileocolic resection, preoperative biologics are not associated with 90-day postoperative intra-abdominal septic complication. Preoperative biologic exposure should not delay necessary surgery.

Immunomodulatory Effect of Urine-derived Stem Cells on Inflammatory Bowel Diseases via Downregulating Th1/Th17 Immune Responses in a PGE2-dependent Manner

BACKGROUND AND AIMS

Despite the therapeutic promise of stem cell therapy in the treatment of inflammatory bowel diseases [IBD], most donor cell populations have to be obtained via invasive approaches and often remain insufficiently validated. Urine-derived stem cells [USC] were recently shown to have regenerative properties and can be harvested in a safe, low-cost, and noninvasive way. This study aims to evaluate the immunomodulatory effect of USC and their efficacy in the management of IBD.

METHODS

Human USC were isolated and expanded from the urine of healthy male adult volunteers [n = 3, age range 24-30 years]. USC were characterised by cell surface marker expression profile and multipotent differentiation. The in vitro immunomodulatory effect of USC was evaluated by co-culturing with human CD4+ T cells upon stimulation with phytohaemagglutinin [PHA]. The proliferation of CD4+ T was measured by fluorescence-activated cell sorting [FACS]. Cytokine array and quantitative real-time polymerase chain reaction [RT-PCR] were applied to examine cytokine levels. In vivo therapeutic value of USC was assessed using a murine colitis model induced by dextran sulphate sodium [DSS] or 2, 4, 6-trinitrobenzene sulphonic acid [TNBS]. The immunomodulatory effect of USC and bone marrow-derived mesenchymal stem cells [BMSC] was compared when co-cultured with CD4+ T cells. The therapeutic efficacy of USC and BMSC on IBD was compared when administered in an acute DSS model in vivo.

RESULTS

USC were positive for mesenchymal stem cell markers but were negative for haematopoietic stem cell markers. These cells differentiated into osteo-, adipo-, and chondrogenic cell lineages. Similar to BMSC, the proliferation of CD4+ T cells was significantly inhibited when co-cultured with USC, as a consequence of Th1/Th17 immune response inhibition. Systemic administration of USC significantly ameliorated the clinical and histopathological severity of colitis and increased the survival rate in both acute and chronic murine colitis models. Moreover, implantation of USC led to downregulation of the Th1/Th17 immune responses in a PGE2-dependent manner.

CONCLUSIONS

This study demonstrated that implantation of USC reduces inflammation in an IBD rodent model via downregulation of Th1/Th17 immune responses, indicating that USC therapy serves as a potential cell-based therapeutic candidate treatment for IBD.

Cardiovascular Risk Assessment for Noncardiac Surgery: Are We Ready for Biomarkers?

Biomarkers aided perioperative cardiac assessment is a relatively new concept. Cardiac biomarkers with historical significance (aspartate transaminase, dehydrogenase, creatinine kinase and myoglobin) have paved the way for traditional biomarkers (cardiac troponin, C-reactive protein, lipoprotein). Contemporary biomarkers like natriuretic peptides (BNP and ProBNP) are validated risk markers in both acute and chronic cardiac diseases and are showing remarkable promise in predicting serious cardiovascular complications after non-cardiac surgery. This review is intended to provide a critical overview of traditional and contemporary biomarkers for perioperative cardiovascular assessment and management. This review also discusses the potential utility of newer biomarkers like galectin-3, sST-2, GDF-15, TNF-alpha, MiRNAs and many others that can predict inflammation, cardiac remodeling, injury and endogenous stress and need further investigations to establish their clinical utility. Though promising, biomarker led perioperative care is still in infancy and it has not been determined that it can improve clinical outcomes.

Should we change reference range for serum albumin in major gastrointestinal surgery? Preoperative serum albumin as an important prognostic factor

INTRODUCTION

The aim of the study was to analyse prognostic value of laboratory markers of nutritional status in gastrointestinal surgery.

METHODS

We performed a retrospective analysis of clinical and laboratory data of 102 patients admitted to an Intensive Care Unit following elective gastrointestinal surgery. The outcome measures included hospital mortality, infectious complications, surgical complications and length of stay.

RESULTS

Forty-eight patients had all three laboratory markers of nutritional status determined before surgery and these patients constituted our study group. We found correlations between preoperative serum albumin and hospital mortality, risk of reoperation and urinary tract infection. Preoperative total serum protein correlated with urinary tract infection. Total lymphocyte count was predictive of bacteraemia. No statistically significant correlations were found between markers of nutritional status and length of stay.

CONCLUSIONS

Serum albumin concentration at the lower limit is associated with increased mortality, reoperation, urinary tract infection. Total serum protein predicts urinary tract infection, whereas total lymphocyte count predicts bacteraemia.

Hypoalbuminaemia and Postoperative Outcomes in Inflammatory Bowel Disease: the NSQIP Surgical Cohort

BACKGROUND

The inflammatory bowel diseases [IBD], including Crohn's disease [CD] and ulcerative colitis [UC], frequently lead to bowel surgery. Hypoalbuminaemia has been shown to be a prognostic factor for outcomes following surgery for other indications, and we sought to determine its role in predicting IBD-related postoperative outcomes.

METHODS

We included patients who underwent IBD-related major abdominal surgery in the American College of Surgeons' National Surgical Quality Improvement Program [ACS-NSQIP] between 2005 and 2012. We assessed the impact of indicators of protein-energy malnutrition [PEM] including hypoalbuminaemia, weight loss, and body mass index on postoperative outcomes.

RESULTS

We identified 10 913 IBD patients [6082 Crohn's disease and 4831 ulcerative colitis] who underwent bowel surgery. The prevalence of modest and severe hypoalbuminaemia was 17% and 24%, respectively; 30-day mortality was higher in Crohn's patients with modest and severe hypoalbuminaemia compared with those with normal albumin levels preoperatively [0.7% vs 0.2%, p <0.05; 2.4% vs 0.2%, p <0.01]. The same was true for patients with UC with modest and severe hypoalbuminaemia [0.9% vs 0.1%, p <0.01; 5.6% vs 0.1%, p <0.01]. Overall infectious complications were more common in the presence of severe hypoalbuminaemia for CD [20% vs 13%, p <0.01]. and UC [28% vs 15%, p <0.01] patients. Last, there were higher rates of extra-intestinal, non-septic complications in both CD and UC patients with hypoalbuminaemia compared with those with normal albumin levels.

CONCLUSIONS

This study suggests that moderate-severe hypoalbuminaemia is associated with worse IBD-related postoperative outcomes and may have a role in preoperative risk stratification.