Factors affecting serum albumin in the perioperative period of colorectal surgery: a retrospective study

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.

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.

The Risk Factors for Perioperative Serum Albumin Variation in Pediatric Patients Undergoing Major Gastroenterology Surgery

Background: The albumin, a negative acute-phase protein, is important for perioperative morbidity, even in patients with normal preoperative levels. This study intend to determine the perioperative factors related with the postoperative reduction in serum albumin (ΔALB) and its influence on perioperative outcome in a pediatric general surgical cohort.

Methods: This single-center retrospective review included 939 pediatric patients who underwent major gastroenterology surgery from August 2010 to August 2019. The patients were dichotomized into a high ΔALB group (≥14.6%) and a low ΔALB group (<14.6%) based on the mean value of ΔALB (14.6%). the independent risk factors for ΔALB, were explored using the propensity score matching to minimize potential selection bias and subjected to method multivariable logistic regression model. Furthermore, in 366 matched patients, the influences of operating time on perioperative outcomes were analyzed.

Results: Among the 996 patients reviewed, 939 patient records were enrolled in the final analysis. Controlling for other factors, multivariable analysis showed that a high CRP on POD 3 or 4 [odds ratio (OR) = 2.36 (95% CI, 1.51–3.86); p = 0.007], a longer operating time [OR = 1.18 (95% CI, 1.00–1.53); p = 0.014), and the presence of Charcot's triad [OR = 1.73 (95% CI, 1.05–2.83); p = 0.031] were factors that predicted a high ΔALB level. A high ΔALB level was also related with gastrointestinal functional recovery delay, reflected by the postoperative defecation (p = 0.013) and bowel movement (p = 0.019) delay and the high occurrence of postoperative complications (16.1 vs. 10.9%, OR, 1.57; 95% CI, 1.02–2.41, P = 0.0026).

Conclusions: The high ΔALB level was correlated with postoperative outcome. To obtain a safe recovery and discharge after a major abdominal operation, the above risk factors for ΔALB could be addressed in the perioperative period.

Correlation of postoperative fluid balance and weight and their impact on outcomes

INTRODUCTION

Normovolemia after major surgery is critical to avoid complications. The aim of the present study was to analyze correlation between fluid balance, weight gain, and postoperative outcomes.

METHODS

All consecutive patients undergoing elective or emergency major abdominal surgery needing intermediate care unit (IMC) admission from September 2017 to January 2018 were included. Postoperative fluid balances and daily weight changes were calculated for postoperative days (PODs) 0-3. Risk factors for postoperative complications (30-day Clavien) and prolonged length of IMC and hospital stay were identified through uni- and multinominal logistic regression.

RESULTS

One hundred eleven patients were included, of which 55% stayed in IMC beyond POD 1. Overall, 67% experienced any complication, while 30% presented a major complication (Clavien ≥ III). For the entire cohort, median cumulative fluid balance at the end of PODs 0-1-2-3 was 1850 (IQR 1020-2540) mL, 2890 (IQR 1610-4000) mL, 3890 (IQR 2570-5380) mL, and 4000 (IQR 1890-5760) mL respectively, and median weight gain was 2.2 (IQR 0.3-4.3) kg, 3 (1.5-4.7) kg, and 3.9 (2.5-5.4) kg, respectively. Fluid balance and weight course showed no significant correlation (r = 0.214, p = 0.19). Extent of surgery, analyzed through Δ albumin and duration of surgery, significantly correlated with POD 2 fluid balances (p = 0.04, p = 0.006, respectively), as did POD 3 weight gain (p = 0.042). Prolonged IMC stay of ≥ 3 days was related to weight gain ≥ 3 kg at POD 2 (OR 2.8, 95% CI 1.01-8.9, p = 0.049).

CONCLUSION

Fluid balance and weight course showed only modest correlation. POD 2 weight may represent an easy and pragmatic tool to optimize fluid management and help to prevent fluid-related postoperative complications.

The effects of nutritional support on selected laboratory parameters in patients with colorectal cancer undergoing surgical resection of the colon

The benefit of the nutritional support provided to patients with colorectal cancer who have undergone the planned resection of the colon in relation to the laboratory markers of nutrition was examined. And it is currently being discussed, that pre-operative optimization of nutritional status reduces the incidence of post-operative complications in cancer patients and regulates selected laboratory parameters. This was a retrospective study where the treatment group (n = 52) received the enteral nutritional support 21 days prior to the scheduled surgery and the other group was formed of patients without preoperative enteral nutrition (n = 52). Laboratory parameters (CRP, leukocytes, albumin, total proteins) were monitored for at least one month before the planned surgery and just before the operation, and the effect of supplemental enteral nutrition on selected laboratory parameters between these two groups was compared. In a group of patients with enteral nutrition, serum albumin levels increased significantly, while CRP was significantly reduced during preoperative enteral nutrition (albumin S-ALB from 35.42 to 37.48, p = 0.0008, C reactive protein from 26.5 to 14.092, p = 0.0007). Nutritional support 21 days prior to surgery in oncological patients resulted in an improvement in laboratory parameters compared to the group of patients without nutritional enteric support. Malnutrition in patients who are candidates for major surgical intervention is a risk factor for postoperative morbidity and mortality. However, further studies are required to verify the effectiveness of this early nutritional intervention on medium and long-term clinical parameters in different types of cancer.

Association of hypoalbuminemia with short-term and long-term mortality in patients undergoing continuous renal replacement therapy

Background

Hypoalbuminemia reflects several pathological conditions, including nutritional deficiencies and chronic inflammation. However, its relationship with short-term and long-term mortality in patients undergoing continuous renal replacement therapy (CRRT) remains unclear. The present study aimed to assess the effect of hypoalbuminemia on mortality in a large cohort of patients undergoing CRRT.

Methods

The study retrospectively reviewed 1,581 patients who underwent CRRT for the treatment of acute kidney injury from 2010 to 2016. The patients were categorized by tertiles of serum albumin levels at CRRT initiation. The odds ratios and hazard ratios for the risk of all-cause mortality were calculated before and after adjustment for multiple covariates.

Results

The mean albumin level was 2.7 ± 0.6 g/dL at CRRT initiation. During a median follow-up period of 14 days (maximum, 4 years), 1,040 patients (65.8%) died. The risk of overall mortality was higher in the first tertile group than in the third tertile group (hazard ratio, 1.9 [1.63-2.21]). When the mortality rate was stratified by timeframe, the risk was steadily higher in the first tertile group than in the third tertile group (odds ratios: 3.0 [2.34-3.87] for 2-week mortality, 2.7 [2.12-3.52] for 1-month mortality, 2.7 [2.08-3.53] for 6-month mortality, and 2.8 [2.11-3.62] for 1-year mortality). Additionally, the rates of intensive care unit mortality and in-hospital mortality were higher in the first tertile group than in the third tertile group.

Conclusion

The initial hypoalbuminemia was independently associated with short-term and long-term mortality in patients undergoing CRRT. Thus, the serum albumin level should be monitored during CRRT.

Establishment and Validation of Nomogram Model Integrated With Inflammation-Based Factors for the Prognosis of Advanced Non-Small Cell Lung Cancer

OBJECTS

Inflammation is one of the hallmarks of cancer. Tumor-associated inflammatory response plays a crucial role in enhancing tumorigenesis. This study aimed to establish an effective predictive nomogram based on inflammation factors in patients with advanced non-small cell lung cancer (NSCLC).

METHODS

We retrospectively evaluated 887 patients with advanced NSCLC between November 2004 and December 2015 and randomly divided them into primary (n = 520) and validation cohorts (n = 367). Cox regression analysis was used to identify prognostic factors for building the nomogram. The predictive accuracy and discriminative ability of the nomogram were determined using a concordance index (C-index), calibration plot, and decision curve analysis and were compared to the TNM staging system.

RESULTS

The nomogram was established using independent risk factors (P < 0.05): age, TNM stage, C reaction protein-to-albumin ratio (CAR), and neutrophils (NEU). The C-index of the model for predicting OS had a superior discrimination power compared to that of the TNM staging system both in the primary [0.711 (95% CI: 0.675-0.747) vs 0.531 (95% CI: 0.488-0.574), P < 0.01] and validation cohorts [0.703, 95% CI: 0.671 -0.735 vs 0.582, 95% CI: 0.545-0.619, P < 0.01]. Decision curves also demonstrated that the nomogram had higher overall net benefits than that of the TNM staging system. Subgroup analyses revealed that the nomogram was a favorable prognostic parameter in advanced NSCLC (P < 0.05). The results were internally validated using the validation cohorts.

CONCLUSIONS

The proposed nomogram with inflammatory factors resulted in an accurate prognostic prediction in patients with advanced NSCLC.

Predictive utility of the C-reactive protein to albumin ratio in early allograft dysfunction in living donor liver transplantation: A retrospective observational cohort study

BACKGROUND

This study was performed to determine the association between the ratio of C-reactive protein to albumin (CRP/ALB) and the risk of early allograft dysfunction (EAD) in patients undergoing living donor liver transplantation (LDLT).

PATIENTS AND METHODS

A total of 588 adult patients undergoing LDLT were retrospectively investigated, after 22 were excluded because of signs of overt infection or history of ALB infusion. The study population was classified into high and low CRP/ALB ratio groups according to EAD. All laboratory variables, including CRP and ALB, had been collected on the day before surgery. A percentage value for the CRP/ALB ratio (%) was calculated as CRP/ALB × 100.

RESULTS

After LDLT, 83 patients (14.1%) suffered EAD occurrence. A higher CRP/ALB ratio was independently associated with risk of EAD, Model for End-stage Liver Disease score, fresh frozen plasma transfusion, and donor age. Based on a cutoff CRP/ALB ratio (i.e., > 20%), the probability of EAD was significantly (2-fold) higher in the high versus low CRP/ALB group. The predictive utility of CRP/ALB ratio for EAD was greater than those of other inflammatory markers. In addition, patients with a high CRP/ALB ratio had poorer survival than those with a low CRP/ALB ratio during the follow-up period.

CONCLUSIONS

The easily calculated CRP/ALB ratio may allow estimation of the risk of EAD after LDLT and can provide additional information that may facilitate the estimation of a patient's overall condition.

Exhaled acetone and isoprene in perioperative lung cancer patients under intensive oral care: possible indicators of inflammatory responses and metabolic changes

One of the most severe complications of lung resection is postoperative pneumonia, and its prevention and prediction are critical. Exhaled acetone and isoprene are thought to be related to metabolism; however, little is known on their relationship with bacteria living in the oral cavity or their meaning in the acute phase in perioperative lung cancer patients. We measured acetone and isoprene in exhaled breath of 13 Japanese patients with lung cancer (3 women and 10 men, age range 62-82 years, mean 72.4 years) before breakfast during hospitalization, and compared with two acute-phase proteins, C-reactive protein (CRP) and albumin in blood serum, as well as the total number of bacteria in saliva and their activity to produce acetone and isoprene. Before operation, intensive oral care was carried out for each patient to prevent postoperative pneumonia, and swallowing and cough reflexes were measured for 12 of 13 patients to assess risk of postoperative pneumonia. Breath and saliva were sampled before intensive oral care (T1), after oral care but before operation (T2), and after operation (T3) during hospitalization. The total number of oral bacteria in saliva decreased significantly from T1 to T2 among 13 patients. No acetone or isoprene was detected from saliva after in vitro incubation under anaerobic or aerobic conditions, but both acetone and isoprene were detected in breath. After operation, breath acetone correlated significantly with CRP (Spearman's ρ = 0.559, P = 0.03), but not with albumin. Breath isoprene correlated significantly with albumin (Spearman's ρ = 0.659, P = 0.008), but not with CRP after operation. Although the number of subjects was small, our results support the hypothesis that breath acetone and isoprene may be related with these acute-phase proteins, which reflect inflammatory reactions and subsequent changes in metabolism in the early postoperative phase of lung resection.

Perioperative changes of serum albumin are a predictor of postoperative pulmonary complications in lung cancer patients: a retrospective cohort study

Background

A decrease in serum albumin is commonly observed after lung cancer surgery, however, whether it is associated with postoperative outcomes is unknown. The objective of this study was to evaluate whether the reduction of serum albumin (ΔALB) on postoperative day one could serve as a predictor of postoperative pulmonary complications (PPCs) after thoracoscopic anatomical resection in lung cancer patients.

Methods

Patients characteristics were compared between groups of whether they experienced PPCs or not. The cutoff value of ΔALB was examined by receiver operating characteristic curve to find out the threshold value of ΔALB in predicting PPCs. Logistic regression analysis was conducted to identify potential risk factors for PPCs.

Results

Totally 533 patients were included into analysis, and among them, 52 experienced PPCs. The ΔALB was significant in the PPCs group than in the non-PPCs group (P<0.001), and ΔALB was observed an independent risk factor for PPCs (OR =2.268, 95% CI: 1.153-4.460). The cutoff value of ΔALB in predicting PPCs was 14.97%. Patients with ΔALB ≥14.97% were more likely to have PPCs (P<0.001).

Conclusions

A reduction of serum albumin with a cut-off value of 14.97% can be served as a predictor to identify patients at high risk of developing PPCs following thoracosopic anatomical lung cancer surgery.

C-Reactive Protein to Albumin Ratio Predicts 30-Day and 1-Year Mortality in Postoperative Patients after Admission to the Intensive Care Unit

C-reactive protein and albumin are associated with poor outcomes in critically ill patients. This study aimed to investigate the significance of the C-reactive protein/albumin (CRP/ALB) ratio as a novel prognostic factor for 30-day or 1-year mortality after admission to the postoperative intensive care unit (ICU). This retrospective study was conducted by examining the medical records of postoperative patients aged 19 years or older admitted to the ICU at a tertiary care hospital from January 2007 to July 2016. This study included data on 11,832 postoperative patients in the analysis. The cut-off value of the CRP/ALB ratio was set at 1.75 and 1.58 for 30-day and 1-year mortality after ICU admission, respectively. In postoperative patients with a high CRP/ALB ratio (>1.75 or >1.58), the probability of death within 30 days or 1 year after ICU admission were 30% or 43% higher than that in the group with the least CRP/ALB ratio, respectively (≤1.75 or ≤1.58)(p < 0.05). This study found the CRP/ALB ratio measured immediately after ICU admission to be an independent risk factor for 30-day and 1-year mortality in postoperative patients admitted to the ICU.

CONUT: a novel independent predictive score for colorectal cancer patients undergoing potentially curative resection

BACKGROUND

Controlling nutritional status (CONUT) score, calculated from serum albumin and total cholesterol concentrations and total lymphocyte count, is reportedly valuable for nutritional assessment. This study investigated whether CONUT score was predictive of outcomes in colorectal cancer (CRC) patients undergoing surgical resection.

METHODS

Preoperative CONUT scores were retrospectively evaluated in 417 CRC patients who underwent potentially curative resection at Kumamoto University Hospital from March 2005 to August 2014. Patients were divided into four groups based on preoperative CONUT scores: normal, light, moderate, and severe. The associations of CONUT score with clinicopathological factors, patient survival, and postoperative complications were examined.

RESULTS

CONUT score correlated significantly with age (P < 0.001), body mass index (P = 0.005), carcinoembryonic antigen (P = 0.002), and carbohydrate antigen 19-9 (P = 0.005) concentrations. Overall survival (OS) rate was significantly lower in patients with moderate/severe than light or normal CONUT scores. CONUT score was independently prognostic of OS [moderate/severe vs. normal, hazard ratio = 5.92, 95 % confidence interval (CI) 2.30-14.92; P < 0.001)]. Patients with moderate/severe CONUT scores were at greater risk for complications, especially for severe complications. Multivariate analysis showed that CONUT score was independently predictive of severe complications (moderate/severe vs. normal, odds ratio = 4.51, 95 % CI 1.89-10.74; P < 0.001).

CONCLUSIONS

CONUT score may predict survival and postoperative severe complications in CRC patients undergoing potentially curative resection. Management of CRC patients may need consideration of host nutritional status.

A New Inflammatory Prognostic Index, Based on C-reactive Protein, the Neutrophil to Lymphocyte Ratio and Serum Albumin is Useful for Predicting Prognosis in Non-Small Cell Lung Cancer Cases

Purpose: We aimed to establish an inflammatory prognostic index (IPI) in early and advanced non-small cell lung cancer (NSCLC) patients based on hematologic and biochemical parameters and to analyze its predictive value for NSCLC survival. Materials and Methods: A retrospective review of 685 patients with early and advanced NSCLC diagnosed between 2009 and 2014 was conducted with collection of clinical, and laboratory data. The IPI was calculated as C-reactive protein × NLR (neutrophil/ lymphocyte ratio)/serum albumin. Univariate and multivariate analyses were performed to assess the prognostic value of relevant factors. Results: The optimal cut-off value of IPI for overall survival (OS) stratification was determined to be 15. Totals of 334 (48.8%) and 351 (51.2%) patients were assigned to high and low IPI groups, respectively. Compared with low IPI, high IPI was associated with older age, greater tumor size, high lymph node involvement, distant metastases, advanced stage and poor performance status. Median OS was worse in the high IPI group (low vs high, 8.0 vs 34.0 months; HR, 3.5; p<0.001). Progression free survival values of the patients who had high vs low IPI were determined 6 months (95% CI:5.3-6.6) and 14 months (95% CI:12.1-15.8), respectively (HR; 2.4, P<0.001). On multivariate analysis, stage, performance status, lactate dehydrogenase and IPI were independent prognostic factors for OS. Subgroup analysis showed IPI was generally a significant prognostic factor in all clinical variables. Conclusion: The described IPI may be an inexpensive, easily accessible and independent prognostic index for NSCLC patients, useful for clinical practice.