Low serum albumin as a risk factor for infection-related in-hospital death among hemodialysis patients hospitalized on suspicion of infectious disease: a Japanese multicenter retrospective cohort study

Hypoalbuminemia is a risk factor for invasive fungal infections and poor outcomes in infected kidney transplant recipients

INTRODUCTION

Invasive fungal infections (IFI), are estimated to occur in 2%-14% of kidney transplant recipients (KTRs) in the current era of immune suppression and are associated with high mortality rates. We hypothesized that hypoalbuminemia in KTRs is a risk factor for IFI and would be associated with poor outcomes.

METHODS

In this study, using data from a prospective cohort registry, we describe the frequency of IFI due to Blastomycosis, Coccidioidomycosis, Histoplasmosis, Aspergillosis, and Cryptococcus in KTRs with serum albumin levels measured 3-6 months before diagnosis. Controls were selected based on incidence density sampling. KTRs were divided into three groups based on the pre-IFI serum albumin level: normal (≥4 g/dL), mild (3-4 g/dL), or severe (<3 g/dL) hypoalbuminemia. Outcomes of interest were uncensored graft failure after IFI and overall mortality.

RESULTS

A total of 113 KTRs with IFI were compared with 348 controls. The incidence rate of IFI among individuals with normal, mild, and severe hypoalbuminemia was 3.6, 8.7, and 29.3 per 100 person-years, respectively. After adjustment for multiple variables, the trend for risk of uncensored graft failure following IFI was greater in KTRS with mild (HR = 2.1; 95% CI, .75-6.1) and severe (HR = 4.47; 95% CI, 1.56-12.8) hypoalbuminemia (P-trend < .001) compared to those with normal serum albumin. Similarly, mortality was higher in severe hypoalbuminemia (HR = 1.9; 95% CI, .67-5.6) compared to normal serum albumin (P-trend < .001).

CONCLUSION

Hypoalbuminemia precedes the diagnosis of IFI in KTRs, and is associated with poor outcomes following IFI. Hypoalbuminemia may be a useful predictor of IFI in KTRs and could be incorporated into screening algorithms.

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.

Low Preoperative Albumin Associated With Increased Risk of Superficial Surgical Site Infection Following Midfoot, Hindfoot, and Ankle Fusion

BACKGROUND

This study investigates the effect of malnutrition, defined by hypoalbuminemia, on rates of complication, readmission, reoperation, and mortality following midfoot, hindfoot, or ankle fusion.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was queried from 2005 to 2019 to identify 500 patients who underwent midfoot (n = 233), hindfoot (n = 261), or ankle (n = 117) fusion. Patients were stratified into normal (n = 452) or low (n = 48) albumin group, which was defined by preoperative serum albumin level <3.5 g/dL. Demographics, medical comorbidities, hospital length of stay (LOS), and 30-day complication, readmission, and reoperation rates were compared between groups. The mean age of the cohort was 58.7 (range, 21-89) years.

RESULTS

Hypoalbuminemia patients were significantly more likely to have diabetes (P < .001), be on dialysis (P < .001), and be functionally dependent (P < .001). The LOS was significantly greater among the low albumin group (P < .001). The hypoalbuminemia cohort also exhibited a significantly increased likelihood of superficial infection (P = .048). Readmission (P = .389) and reoperation (P = .611) rates did not differ between the groups.

CONCLUSION

This study shows that malnourished patients have an increased risk of superficial infection following foot and ankle fusions but are not at an increased risk of readmission or reoperation, suggesting that low albumin confers an elevated risk of surgical site infection.

LEVELS OF EVIDENCE

Level III, Retrospective cohort study.

Albumin Infusion May Improve the Prognosis of Critical COVID-19 Patients with Hypoalbuminemia in the Intensive Care Unit: A Retrospective Cohort Study

Background

The coronavirus disease 2019 (COVID-19) pandemic has caused enormous mortality worldwide. Low albumin level is a risk factor for increasing mortality among patients in the intensive care unit (ICU). This study investigated the effect of albumin infusion on critical COVID-19 patients with hypoalbuminemia.

Methods

A total of 114 COVID-19 ICU patients with hypoalbuminemia were recruited from Wuhan Leishenshan Hospital and Zhongnan Hospital of Wuhan University. Clinical features and laboratory variables were collected through electronic medical records. The cohorts were divided into two groups: albumin infusion and non-albumin infusion. Propensity-matched analysis was used to compare patients who received albumin to controls. Statistical analyses were used to investigate the survival time and inflammation-related blood biomarkers between groups.

Results

Lactate dehydrogenase, interleukin (IL)-6, IL-2 receptor, and IL-8 levels were significantly downregulated in the albumin infusion group. Significant upregulations of lymphocyte counts and IL-10 were found in the albumin infusion group. There was a negative association between albumin level and D-dimer or procalcitonin levels after treatment. The albumin infusion group had a significantly longer survival time and shorter hospitalization time than control patients. Notably, a 1g increase in albumin level reduced the risk of death by approximately 7.3% after adjusting for age and sex. Patients with increased albumin levels after treatment had better prognoses than those without.

Conclusion

Albumin administration can regulate COVID-19-related biomarkers and reduce the risk of death in critical patients with hypoalbuminemia. Clinicians should pay more attention to these risk factors. Targeted clinical interventions should be implemented to minimize the negative impacts of hypoalbuminemia and improve disease outcomes.

Retrospective Analysis of the Risk Factors of Perioperative Bacterial Infection and Correlation with Clinical Prognosis in Kidney Transplant Recipients

Background

Infection remains a leading cause of morbidity and mortality in kidney transplant patients. This study aimed to investigate the risk factors of bacterial infection during the perioperative period of transplantation and the effects of infection on long-term clinical outcomes.

Methods

In total, 295 kidney transplantation recipients were included in this retrospective study and assigned to two groups: non-infected and infected. The tacrolimus concentration, pharmacogenomics, laboratory parameters, and clinical outcomes of both groups were evaluated.

Results

A relatively low incidence of urinary tract infection was observed in our cohort, and lung was identified as the most frequent site of infection. Gram-negative bacteria, such as Escherichia coli, Pseudomonas aeruginosa, and Klebsiella pneumoniae, were the most common infecting strains in kidney transplant recipients. Patients with diabetes showed greater susceptibility to infection. Compared with the non-infected group, tacrolimus concentration was significantly lower on day 7 and 14 in the infected group. White blood cell count, neutrophil count, and C-reactive protein (CRP) in the infected group were markedly higher post-transplantation, while albumin levels were lower relative to the non-infected group. ABCB1 (rs2032582) genotype showed clear associations with infection. Furthermore, the incidence of delayed graft function (DGF) and early acute rejection (AR) before infection was significantly greater in the infected group. Finally, early post-transplant infection was associated with a marked increase in the incidence of AR, post-transplant diabetes mellitus (PTDM), and secondary infection.

Conclusion

Pre-diabetes, longer duration of catheterization, lower albumin, higher CRP, tacrolimus concentration on the day 7 and 14, early AR before infection, and DGF were closely related to postoperative infection in kidney transplantation recipients. Moreover, bacterial infection during the perioperative period was closely associated with AR, PTDM and secondary infection.

Risk Factors for Herpes Zoster in Patients with Chronic Kidney Disease: A Case-Control Study

(1) Background: Chronic kidney disease (CKD) increases the susceptibility to the presence of herpes zoster (HZ). Little is known about the risk factors of HZ in CKD patients; (2) Methods: This is a case-control study. CKD patients diagnosed with HZ between January 2015 and June 2021 in a tertiary hospital were identified. One age- and gender- matched control was paired for each case, matched to the date of initial HZ diagnosis. Conditional multiple logistic regression was used to evaluate the risk factors associated with the presence of HZ; (3) Results: Forty-seven HZ patients and controls were identified. In general, about 73.40% (69 out of 94) patients were classified at IV to V stages of CKD. Immunosuppressive agents (p = 0.0012) and dialysis therapy (p = 0.021) were reported more frequently in the HZ cohort. Compared with the control group, the total white cell count and lymphocyte count were significantly lower in the HZ group (p value of 0.032 and 0.003, respectively). The conditional logistics regression model revealed that previous immunosuppressants administration (odds ratio: 10.861, 95% CI: 2.092~56.392, p = 0.005) and dialysis therapy (odds ratio: 3.293, 95% CI: 1.047~10.355, p = 0.041) were independent risk factors of HZ in the CKD population; (4) Conclusions: Dialysis and immunosuppressants therapy were associated with greater risk of HZ disease in CKD patients. Further guideline may highlight the necessity of zoster vaccine for patients with CKD, who undertake associated treatment.

Albumin Neutralizes Hydrophobic Toxins and Modulates Candida albicans Pathogenicity

Albumin is abundant in serum but is also excreted at mucosal surfaces and enters tissues when inflammation increases vascular permeability. Host-associated opportunistic pathogens encounter albumin during commensalism and when causing infections. Considering the ubiquitous presence of albumin, we investigated its role in the pathogenesis of infections with the model human fungal pathogen, Candida albicans. Albumin was introduced in various in vitro models that mimic different stages of systemic or mucosal candidiasis, where it reduced the ability of C. albicans to damage host cells. The amphipathic toxin candidalysin mediates necrotic host cell damage induced by C. albicans. Using cellular and biophysical assays, we determined that albumin functions by neutralizing candidalysin through hydrophobic interactions. We discovered that albumin, similarly, can neutralize a variety of fungal (α-amanitin), bacterial (streptolysin O and staurosporin), and insect (melittin) hydrophobic toxins. These data suggest albumin as a defense mechanism against toxins, which can play a role in the pathogenesis of microbial infections. IMPORTANCE Albumin is the most abundant serum protein in humans. During inflammation, serum albumin levels decrease drastically, and low albumin levels are associated with poor patient outcome. Thus, albumin may have specific functions during infection. Here, we describe the ability of albumin to neutralize hydrophobic microbial toxins. We show that albumin can protect against damage induced by the pathogenic yeast C. albicans by neutralizing its cytolytic toxin candidalysin. These findings suggest that albumin is a toxin-neutralizing protein that may play a role during infections with toxin-producing microorganisms.

Risk factors for peritoneal dialysis withdrawal due to peritoneal dialysis-related peritonitis

BACKGROUND

Peritoneal dialysis has become commonly used for renal replacement therapy; however, some patients withdraw from peritoneal dialysis due to complications, including peritoneal dialysis-related peritonitis, resulting in the low number of patients on peritoneal dialysis. Risk factors for peritoneal dialysis withdrawal due to peritoneal dialysis-related peritonitis are less certain. This retrospective study aimed to investigate these risk factors.

METHODS

We retrospectively analyzed clinical characteristics, laboratory data, and causative microorganisms of 204 episodes of peritoneal dialysis-related peritonitis between 2007 and 2018 at our institution.

RESULTS

Of the 204 episodes, 38 resulted in withdrawal from peritoneal dialysis due to peritoneal dialysis-related peritonitis. The number of peritonitis episodes per patient-year and the incidence of cardiovascular disease were significantly higher in the withdrawal group. Similarly, this group had low levels of serum creatinine, urea nitrogen, serum albumin, alanine aminotransferase, cholinesterase and high C-reactive protein, and second dialysate cell counts after antibiotic administration. Multivariate logistic regression analysis revealed that serum albumin (odds ratio: 0.465; 95% confidence interval: 0.249-0.868; P=0.016) and cardiovascular disease (odds ratio: 2.508; 95% confidence interval: 1.184-5.315; P=0.016) exhibited significant differences.

CONCLUSIONS

The results of this study suggest that hypoalbuminemia and the presence of cardiovascular disease were independent risk factors for withdrawal from peritoneal dialysis due to peritoneal dialysis-related peritonitis.

Infectious Complications in Patients with Primary Glomerulonephritis over 10 Years: A Single-Center Experience in Turkey

INTRODUCTION

Infections can play an important role in the mortality and morbidity of patients with glomerulonephritis. However, the frequency of infectious complications in primary glomerulonephritis and their burden to the healthcare managements are not clear.

METHODS

We evaluated the infectious complications in patients with biopsy-proven focal segmental glomerulosclerosis, membranous glomerulonephritis, IgA nephropathy, minimal change disease, membranoproliferative glomerulonephritis, and chronic glomerulonephritis during the last 10 years in a single center. We recorded the demographic, clinical, and laboratory characteristics; treatment modalities; infectious episodes; and infection-related mortality and morbidity of the patients.

RESULTS

Of the patients, 154 (63.6%) received immunosuppressive treatment and 88 (34.4%) were followed up under conservative treatment. Overall, 118 infectious episodes were noted in 64 patients, with an infection rate of 0.20 per patient-year. Total infectious complications were higher in the immunosuppressive group than in the conservative group (42.1 vs. 23.3%, p = 0.005). Infection-related hospitalizations were also higher in the immunosuppressive group (p = 0.01). The most frequently infected area was the lungs (15.7%). Although bacterial infections were the most common in both groups, 14.9% of the immunosuppressive group had cytomegalovirus (CMV) replication. Age >50 years (OR 2.19, p = 0.03), basal serum albumin <2.5 g/dL (OR 2.28, p = 0.02), cyclophosphamide (OR 2.43, p = 0.02), and cyclosporine (OR 2.30, p = 0.03) were independently associated with experiencing infectious episodes.

CONCLUSIONS

Because of high seropositivity for CMV in Turkey, it might be a wise approach to use prophylactic antiviral drugs in patients treated with immunosuppressive treatments. Close monitoring of patients with primary glomerulonephritis, especially those treated with immunosuppressive therapy, is important for reducing infection-related morbidity and mortality.

Serum Albumin Level Before Kidney Transplant Predicts Post-transplant BK and Possibly Cytomegalovirus Infection

Introduction

Opportunistic viral infections cause extensive morbidity and mortality in kidney transplant recipients (KTRs). Low serum albumin levels before and after transplant have been associated with negative outcomes. However, it is uncertain whether serum albumin levels before transplantation are associated with the risk for post-transplantation opportunistic BK polyomavirus (BKV) or cytomegalovirus (CMV).

Methods

We reviewed all KTRs transplanted at our institution between 1 January 2005 and 31 December 2015 with serum albumin measured within 45 days before transplantation in a retrospective observational cohort study. Selected patients were stratified into 3 groups: normal albuminemia (≥3.5 g/dl), moderate hypoalbuminemia (3.49–2.5 g/dl), and severe hypoalbuminemia (<2.5 g/dl). Patients were observed for post-transplantation BKV or CMV according to standard of care.

Results

We included 1717 patients in this study; 72.3% had normal serum albumin, 26.3% had moderate hypoalbuminemia, and 1.5% had severe hypoalbuminemia. Moderate and severe hypoalbuminemia incurred a higher risk for BKV compared with normal serum albumin levels in univariable analysis (moderate hypoalbuminemia: hazard ratio [HR] = 1.5; 95% confidence interval [CI], 1.14–1.90; P = .003); severe hypoalbuminemia: HR = 2.15; 95% CI, 1.01–4.56; P = 0.05). Although not significant after multivariable adjustment, there was still 18% increased risk in moderate hypoalbuminemia and 64% in severe hypoalbuminemia for BKV compared with the normal albumin group. Moderate hypoalbuminemia was associated with a higher risk for CMV infection than normal serum albumin levels in multivariable analysis, although it was not statistically significant (HR = 1.15; 95% CI, 0.36–3.64; P = 0.81).

Conclusions

These findings suggest that pretransplantation hypoalbuminemia is associated with a higher risk for post-transplantation BKV and possibly CMV. More intense screening is warranted for these viruses in recipients with pretransplant hypoalbuminemia.

Comorbidities, clinical signs and symptoms, laboratory findings, imaging features, treatment strategies, and outcomes in adult and pediatric patients with COVID-19: A systematic review and meta-analysis

INTRODUCTION

Since December 2019, a novel coronavirus (SARS-CoV-2) has triggered a world-wide pandemic with an enormous medical and societal-economic toll. Thus, our aim was to gather all available information regarding comorbidities, clinical signs and symptoms, outcomes, laboratory findings, imaging features, and treatments in patients with coronavirus disease 2019 (COVID-19).

METHODS

EMBASE, PubMed/Medline, Scopus, and Web of Science were searched for studies published in any language between December 1st, 2019 and March 28th, 2020. Original studies were included if the exposure of interest was an infection with SARS-CoV-2 or confirmed COVID-19. The primary outcome was the risk ratio of comorbidities, clinical signs and symptoms, laboratory findings, imaging features, treatments, outcomes, and complications associated with COVID-19 morbidity and mortality. We performed random-effects pairwise meta-analyses for proportions and relative risks, I2, T2, and Cochrane Q, sensitivity analyses, and assessed publication bias.

RESULTS

148 studies met the inclusion criteria for the systematic review and meta-analysis with 12'149 patients (5'739 female) and a median age of 47.0 [35.0-64.6] years. 617 patients died from COVID-19 and its complication. 297 patients were reported as asymptomatic. Older age (SMD: 1.25 [0.78-1.72]; p < 0.001), being male (RR = 1.32 [1.13-1.54], p = 0.005) and pre-existing comorbidity (RR = 1.69 [1.48-1.94]; p < 0.001) were identified as risk factors of in-hospital mortality. The heterogeneity between studies varied substantially (I2; range: 1.5-98.2%). Publication bias was only found in eight studies (Egger's test: p < 0.05).

CONCLUSIONS

Our meta-analyses revealed important risk factors that are associated with severity and mortality of COVID-19.

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.