Complement C5a and Clinical Markers as Predictors of COVID-19 Disease Severity and Mortality in a Multi-Ethnic Population

Coronavirus disease-2019 (COVID-19) was declared as a pandemic by WHO in March 2020. SARS-CoV-2 causes a wide range of illness from asymptomatic to life-threatening. There is an essential need to identify biomarkers to predict disease severity and mortality during the earlier stages of the disease, aiding treatment and allocation of resources to improve survival. The aim of this study was to identify at the time of SARS-COV-2 infection patients at high risk of developing severe disease associated with low survival using blood parameters, including inflammation and coagulation mediators, vital signs, and pre-existing comorbidities. This cohort included 89 multi-ethnic COVID-19 patients recruited between July 14th and October 20th 2020 in Doha, Qatar. According to clinical severity, patients were grouped into severe (n=33), mild (n=33) and asymptomatic (n=23). Common routine tests such as complete blood count (CBC), glucose, electrolytes, liver and kidney function parameters and markers of inflammation, thrombosis and endothelial dysfunction including complement component split product C5a, Interleukin-6, ferritin and C-reactive protein were measured at the time COVID-19 infection was confirmed. Correlation tests suggest that C5a is a predictive marker of disease severity and mortality, in addition to 40 biological and physiological parameters that were found statistically significant between survivors and non-survivors. Survival analysis showed that high C5a levels, hypoalbuminemia, lymphopenia, elevated procalcitonin, neutrophilic leukocytosis, acute anemia along with increased acute kidney and hepatocellular injury markers were associated with a higher risk of death in COVID-19 patients. Altogether, we created a prognostic classification model, the CAL model (C5a, Albumin, and Lymphocyte count) to predict severity with significant accuracy. Stratification of patients using the CAL model could help in the identification of patients likely to develop severe symptoms in advance so that treatments can be targeted accordingly.

Low serum albumin levels and in-hospital outcomes in patients with ST segment elevation myocardial infarction

BACKGROUND AND AIMS

Low serum albumin (SA) is associated with an increased risk of long-term adverse events (AEs) among patients with chronic coronary syndromes. Its prognostic role in patients with ST-elevation myocardial infarction (STEMI) is less clear. To investigate the association between low SA and in-hospital AEs in STEMI patients.

METHODS AND RESULTS

Multicenter retrospective cohort study of 220 STEMI patients undergoing primary percutaneous coronary intervention within 12 h from the onset of symptoms. Hypoalbuminemia was defined by serum SA <35 g/L. SA. In-hospital AEs were defined as cardiogenic shock, resuscitated cardiac arrest and death. Median SA was 38 (IQR 35.4-41.0) g/L and 37 (16.8%) patients showed hypoalbuminemia (<35 g/L) on admission. Patients with hypoalbuminemia were older, more frequently women and diabetics, prior CAD and HF. Furthermore, they showed lower hemoglobin levels and impaired renal function. At multivariable logistic regression analysis, diabetes (odds ratio [OR]:4.59, 95% confidence interval [CI] 1.71-12.28, p = 0.002) and haemoglobin (OR:0.52, 95%CI 0.37-0.72, p < 0.001) were associated with low SA. In a subgroup of 132 patients, SA inversely correlated with D-Dimer (rS -0.308, p < 0.001). Globally, twenty-eight (14.6%) AEs were recorded. Hypoalbuminemia (OR:3.43, 95%CI 1.30-9.07, p = 0.013), high-sensitive (HS)-Troponin peak above median (OR:5.41, 95%CI 1.99-14.7, p = 0.001), C-reactive protein (CRP) peak above median (OR:6.03, 95%CI 2.02-18.00, p = 0.001), and in-hospital infection (OR:3.61, 95%CI 1.21-10.80, p = 0.022) were associated with AEs.

CONCLUSION

Low SA levels are associated with worse in-hospital AEs in STEMI patients, irrespective of HS-troponin and CRP plasma levels. Our findings suggest that low SA may contribute to the pro-thrombotic phenotype of these patients.

Nationwide study of surgery for primary infected abdominal aortic and common iliac artery aneurysms

BACKGROUND

Primary infected aneurysms of the abdominal aorta and iliac arteries are potentially life-threatening. However, because of the rarity of the disease, its pathogenesis and optimal treatment strategy remain poorly defined.

METHODS

A nationwide retrospective cohort study investigated patients who underwent surgical treatment for a primary infected abdominal aortic and/or common iliac artery (CIA) aneurysm between 2011 and 2017 using a Japanese clinical registry. The study evaluated the relationships between preoperative factors and postoperative outcomes including 90-day and 3-year mortality, and persistent or recurrent aneurysm-related infection. Propensity score matching was used to compare survival between patients who underwent in situ prosthetic grafting and those who had endovascular aneurysm repair (EVAR).

RESULTS

Some 862 patients were included in the analysis. Preceding infection was identified in 30.2 per cent of the patients. The median duration of postoperative follow-up was 639 days. Cumulative overall survival rates at 30 days, 90 days, 1 year, 3 years and 5 years were 94.0, 89.7, 82.6, 74.9 and 68.5 per cent respectively. Age, preoperative shock and hypoalbuminaemia were independently associated with short-term and late mortality. Compared with open repair, EVAR was more closely associated with persistent or recurrent aneurysm-related infection (odds ratio 2.76, 95 per cent c.i. 1.67 to 4.58; P < 0.001). Propensity score-matched analyses demonstrated no significant differences between EVAR and in situ graft replacement in terms of 3-year all-cause and aorta-related mortality rates (P = 0.093 and P =0.472 respectively).

CONCLUSION

In patients undergoing surgical intervention for primary infected abdominal aortic and CIA aneursyms, postoperative survival rates were encouraging. Eradication of infection following EVAR appeared less likely than with open repair, but survival rates were similar in matched patients between EVAR and in situ graft replacement.

The associations of plant-based protein intake with all-cause and cardiovascular mortality in patients on peritoneal dialysis

BACKGROUND AND AIMS

Plant-based protein intake is associated with all-cause and/or cardiovascular disease (CVD) mortality in general population, but such data are scarce in dialysis patients. Thus, we examined the associations of plant-based protein-total protein ratio with all-cause and CVD mortality in patients on peritoneal dialysis (PD).

METHODS AND RESULTS

The study enrolled 884 incident patients who started PD between October 2002 and August 2014. All demographic and laboratory data were recorded at baseline. Repeated measurements for laboratory and nutrition parameters were recorded at regular intervals and thus calculated as time-averaged values. Multivariable Cox regression models were used to estimate the hazard ratio (HR) of plant-based protein-total protein ratio and mortality based on baseline and time-averaged covariates, respectively. There were 437 (49%) patients died during a mean follow-up period of 45 months, of which 178 (40.8%) were due to CVD. Each 10% in increase in time-averaged plant-based protein-total protein ratio was associated with a reduction of 71% (95% CI, 90%-14%) and 89% (95% CI, 98%-29%) for all-cause and CVD mortality, respectively. Based on examination on interactive effects, we further found both baseline and time-averaged plant-based protein-total protein ratio were inversely associated with all-cause and CVD mortality in the subgroups of female, age ≥60 years, and albumin >35 g/L.

CONCLUSIONS

The present study suggested that a diet with a higher plant-based protein-total protein ratio is associated with lower all-cause and CVD mortality in PD patients, and is more significant in female and elderly patients, and those without hypoalbuminemia.

Trends in admission serum albumin and mortality in patients with hospital readmission

AIMS

To determine the relationship between trends in admission serum albumin and long-term mortality in medical patients with hospital readmission.

MATERIALS AND METHODS

We used a cohort of patients admitted to five departments of internal medicine during 3 years. Survival analysis was performed based on mean admission serum albumin levels and trends in albumin values from recurrent admissions.

RESULTS

A total of 5396 patients had 16 640 admissions (readmission cohort), another 9422 patients were admitted only once (single admission cohort). Readmitted patients with low mean albumin were older, predominantly females and had higher comorbidity index than patients with normal mean albumin. The 6-month all-cause mortality rate of the normal and low mean albumin groups was 5.2% and 24.2%, respectively (P < 0.001). Survival analysis showed that patients with persistently normal albumin levels had the highest survival rates at 6 months (97.7%), compared with patients who had hypoalbuminemia at index admission but normalised their albumin levels in subsequent admissions (92%), patients with declining albumin trends (85.6%) and patients with persistently low albumin levels (68.9%) (P < 0.0001).

CONCLUSIONS

Serum albumin is strongly associated with long-term mortality in readmitted medical patients. Persistent hypoalbuminemia during recurrent admissions is associated with increased risk of long-term mortality.

Sepsis patients with complication of hypoglycemia and hypoalbuminemia are an early and easy identification of high mortality risk

Either hypoglycemia or hypoalbuminemia alone is an independent condition associated with increased risk of mortality in critical illness. This study evaluates whether the mortality risk increases in septic patients if these conditions are combined. Patients admitted to our hospital from 2008 to 2015 who satisfied the definition of sepsis were targeted (n = 336). We classified cases into three groups based on blood glucose (BG) level measured at admission: hypoglycemia (Hypo-G; BG < 80 mg/dl), intermediate glycemia (Inter-G; 80-199 mg/dl), and hyperglycemia (Hyper-G; ≥ 200 mg/dl) group, and then estimated mortality. We also compared the clinical data of these glycemic groups in combination with hypoalbuminemia (Hypo-A) or Inter-G with non-hypoalbuminemia (Inter-G + Nonhypo-A), as a secondary analysis. Diagnostic cut-off level of Hypo-A (< 2.8 mg/dl) was determined using the ROC curve between blood albumin and mortality. In Hypo-G group (n = 40), APACHE II/SOFA scores are significantly higher than in the Inter-G (n = 196) and Hyper-G groups (n = 100). Mortality is 52.5% in the Hypo-G and 60.0% in the Hypo-G with Hypo-A (Hypo-G + Hypo-A) groups. Significantly higher APACHE II or SOFA scores and mortality are observed in the Hypo-G + Hypo-A group compared to the Inter-G + Nonhypo-A group. A higher mortality risk is observed in cases with Hypo-G + Hypo-A (OR 5.065) than those with Hypo-G (OR 3.503), Inter-G (OR 1.175), Hyper-G (OR 1.756) or Hypo-A (OR 3.243), calculated by a single logistic-regression analysis. Hypo-G + Hypo-A in patients with sepsis is related to higher ICU mortality. Physicians should be keenly aware of these conditions to provide immediate intensive treatment after admission of septic patients.

Hypoalbuminemia is a frequent marker of increased mortality in cardiogenic shock

INTRODUCTION

The prevalence of hypoalbuminemia, early changes of plasma albumin (P-Alb) levels, and their effects on mortality in cardiogenic shock are unknown.

MATERIALS AND METHODS

P-Alb was measured from serial blood samples in 178 patients from a prospective multinational study on cardiogenic shock. The association of hypoalbuminemia with clinical characteristics and course of hospital stay including treatment and procedures was assessed. The primary outcome was all-cause 90-day mortality.

RESULTS

Hypoalbuminemia (P-Alb < 34g/L) was very frequent (75%) at baseline in patients with cardiogenic shock. Patients with hypoalbuminemia had higher mortality than patients with normal albumin levels (48% vs. 23%, p = 0.004). Odds ratio for death at 90 days was 2.4 [95% CI 1.5-4.1] per 10 g/L decrease in baseline P-Alb. The association with increased mortality remained independent in regression models adjusted for clinical risk scores developed for cardiogenic shock (CardShock score adjusted odds ratio 2.0 [95% CI 1.1-3.8], IABP-SHOCK II score adjusted odds ratio 2.5 [95%CI 1.2-5.0]) and variables associated with hypoalbuminemia at baseline (adjusted odds ratio 2.9 [95%CI 1.2-7.1]). In serial measurements, albumin levels decreased at a similar rate between 0h and 72h in both survivors and nonsurvivors (ΔP-Alb -4.6 g/L vs. 5.4 g/L, p = 0.5). While the decrease was higher for patients with normal P-Alb at baseline (p<0.001 compared to patients with hypoalbuminemia at baseline), the rate of albumin decrease was not associated with outcome.

CONCLUSIONS

Hypoalbuminemia was a frequent finding early in cardiogenic shock, and P-Alb levels decreased during hospital stay. Low P-Alb at baseline was associated with mortality independently of other previously described risk factors. Thus, plasma albumin measurement should be part of the initial evaluation in patients with cardiogenic shock.

TRIAL REGISTRATION

NCT01374867 at ClinicalTrials.gov.

A practical risk scale for predicting morbidity and mortality in the emergency general surgical setting: A prospective multi-center study

BACKGROUND

Low albumin is a prognostic factor associated with poor surgical outcomes. We aimed to examine the predicative ability of easily obtainable point-of-care variables in combination, to derive a practical risk scale for predicting older adults at risk of poor outcomes on admission to the emergency general surgical setting.

METHODS

This is an international multi-center prospective cohort study conducted as part of the Older Persons Surgical Outcomes Collaboration (www.OPSOC.eu). The effect of having hypoalbuminemia (defined as albumin ≤3.5 g/dL) on selected outcomes was examined using fully adjusted multivariable models. In a subgroup of patients with hypoalbuminemia, we observed four risk characteristics (Male, Anemia, Low albumin, Eighty-five and over [MALE]). Subsequently, the impact of incremental increase in MALE score (each characteristic scoring 1 point (maximum score 4) on measured outcomes was assessed.

RESULTS

The cohort consisted of 1406 older patients with median (IQR) age of 76 (70-83) years. In fully adjusted models, hypoalbuminemia was significantly associated with undergoing emergency surgery (1.32 (95%CI 1.03-1.70); p = 0.03), 30-day mortality (4.23 (2.22-8.08); p < 0.001), 90-day mortality (3.36 (2.14-5.28); p < 0.001) (primary outcome), and increased hospital length of stay, irrespective of whether a patient received emergency surgical intervention. Every point increase in MALE score was associated with higher odds of mortality, with a MALE score of 4 being associated with 30-day mortality (adjusted OR(95% CI) = 33.38 (3.86-288.7); p = 0.001) and 90-day mortality (11.37 (3.85-33.59); p < 0.001) compared to the reference category of those with MALE score 0.

CONCLUSIONS

The easy to use and practical MALE risk score calculated at point of care identifies older adults at a greater risk of poor outcomes, thereby allowing clinicians to prioritize patients who may benefit from early comprehensive geriatric assessment in the emergency general surgical setting.

Association of admission vs. nadir serum albumin concentration with short-term treatment outcomes in patients with acute heart failure

Objectives

Hypoalbuminemia occurs in 25% to 76% of patients hospitalized for acute heart failure (HF) and is associated with increased mortality. Hypoalbuminemia may predispose patients to intravascular volume depletion, hypotension, and acute worsening of renal function; however, its association with treatment outcomes during hospitalization is unknown.

Methods

This retrospective cohort study involved 414 adult patients hospitalized for HF requiring intravenous diuretics. Temporal changes in serum albumin and the association of hypoalbuminemia with urine output, renal function changes, blood pressure, use of intravenous vasoactive drugs, and short-term outcomes were assessed.

Results

Serum albumin decreased in most patients (72%) during hospitalization. Hypoalbuminemia was present in 29% and 50% of patients based on the mean admission and nadir serum albumin level, respectively. Hypoalbuminemia as assessed by the nadir albumin level was associated with an increased risk of acute worsening of renal function. A nadir albumin level of <3.0 g/dL remained significantly associated in the multivariate analyses.

Conclusions

Serum albumin commonly decreases during hospitalization for acute HF. Hypoalbuminemia assessed using the nadir level during hospitalization, not the admission level, was associated with an increased risk of acute worsening of renal function. The timing of serum albumin measurement may influence its utility as a biomarker.

Long-term clinical impact of serum albumin in coronary artery disease patients with preserved renal function

BACKGROUND AND AIMS

Low serum albumin level is reportedly associated with worse clinical outcomes in patients with chronic kidney disease (CKD). However, associations between decreased serum albumin level and outcomes in non-CKD patients with coronary artery disease (CAD) remain unclear. Therefore, we aimed to evaluate the prognostic value of serum albumin concentrations in stable CAD patients with preserved renal function.

METHODS AND RESULTS

We studied 1316 patients with CAD and preserved renal function (estimated glomerular filtration rate ≥60 mL/min/1.73 m²) who underwent their first PCI between 2000 and 2011 and had data available for pre-procedural serum albumin. Patients were assigned to quartiles based on pre-procedural albumin concentrations. The incidence of major adverse cardiac events (MACE), including all-cause death and non-fatal myocardial infarction, was evaluated. Mean albumin concentration was 4.1 ± 0.4 g/dL. During the median follow-up of 7.5 years, 181 events occurred (13.8%). Kaplan-Meier curves revealed that patients with decreased serum albumin concentrations showed a higher event rate for MACE (log-rank, p < 0.0001). Using the highest tertiles (>4.3 g/dL) as reference, adjusted hazard ratios were 1.97 (95% CI, 1.12-3.55), 1.77 (95% CI, 0.99-3.25), and 1.19 (95% CI, 0.68-2.15) for serum albumin concentrations of <3.9, 3.9-4.0, and 4.1-4.3 g/dL, respectively. Decreased serum albumin concentration was associated with MACE even after adjusting for other independent variables (HR, 2.21 per 1-g/dL decrease; 95% CI, 1.37-3.56, p = 0.001).

CONCLUSION

Decreased serum albumin concentration independently predicted worse long-term prognosis in non-CKD patients after PCI. Pre-procedural serum albumin concentration could offer a useful predictor for patients with CAD and preserved renal function.

Long-Term Mortality in Patients Operated for Perforated Peptic Ulcer: Factors Limiting Longevity are Dominated by Older Age, Comorbidity Burden and Severe Postoperative Complications

BACKGROUND

Perforated peptic ulcer (PPU) is a surgical emergency associated with high short-term mortality. However, studies on long-term outcomes are scarce. Our aim was to investigate long-term survival after surgery for PPU.

MATERIALS AND METHODS

A population-based, consecutive cohort of patients who underwent surgery for PPU between 2001 and 2014 was reviewed, and the long-term mortality was assessed. Survival was investigated by univariate analysis (log-rank test) and displayed using Kaplan-Meier survival curves. Multivariable analysis of risk factors for long-term mortality was assessed by Cox proportional hazards regression and reported as hazard ratio (HR) with 95 % confidence intervals (CI).

RESULTS

A total of 234 patients were available for the calculation of ninety-day, one-year and two-year mortality, and the results showed rates of 19.2 % (45/234), 22.6 % (53/234) and 24.8 % (58/234), respectively. At the end of follow-up, a total of 109 of the 234 patients (46.6 %) had died. Excluding 37 (15.2 %) patients who died within 30 days of surgery, 197 patients had long-term follow-up (median 57 months, range 1-168) of which 36 % (71/197) died during the follow-up period. In multivariable analyses, age >60 years (HR 3.95, 95 % CI 1.81-8.65), active cancer (HR 3.49, 95 % CI 1.73-7.04), hypoalbuminemia (HR 1.65, 95 % CI 0.99-2.73), pulmonary disease (HR 2.06, 95 % CI 1.14-3.71), cardiovascular disease (HR 1.67, 95 % CI 1.01-2.79) and severe postoperative complications (HR 1.76, 95 % CI 1.07-2.89) during the initial stay for PPU were all independently associated with an increased risk of long-term mortality. Cause of long-term mortality was most frequently (18 of 71; 25 %) attributed to new onset sepsis and/or multiorgan failure.

CONCLUSION

The long-term mortality after surgery for PPU is high. One in every three patients died during follow-up. Older age, comorbidity and severe postoperative complications were risk factors for long-term mortality.

Significance of admission hypoalbuminemia in acute intracerebral hemorrhage

Low levels of serum albumin may increase the risk of infections and mortality in critically ill patients. We tested the hypothesis that admission hypoalbuminemia predicted infectious complications and poor outcome in subjects with acute intracerebral hemorrhage (ICH). We analyzed a single center cohort of ICH patients collected between 1994 and 2015. Pneumonia, urinary tract infection and sepsis were retrospectively identified, according to validated criteria. Serum albumin was measured on admission and hypoalbuminemia was defined as total albumin ≤3.5 g/dL. The association between albumin levels, infections, and mortality at 90 days was tested with multivariable logistic regression analyses. A total of 2010 patients were included (median age 74 years, 54.5% males) of whom 444 (22.1%) had hypoalbuminemia on admission and 763 (38%) died within 90 days. The frequency of pneumonia, urinary tract infection, and sepsis was 19.9, 15.1, and 2.7%, respectively. Hypoalbuminemic patients had lower admission Glasgow coma scale, higher frequency of intraventricular hemorrhage and were more likely to have a history of chronic kidney or liver disease. After adjustment for potential confounders, hypoalbuminemia was an independent predictor of pneumonia [odds ratio (OR) 1.76, 95% confidence interval (CI) 1.34-2.33, p < 0.001] and sepsis (OR 2.29, 95% CI 1.22-4.30, p = 0.010). Low levels of albumin were also independently associated with higher mortality at 90 days (OR 1.78, 95% CI 1.30-2.44, p < 0.001). In conclusion, early hypoalbuminemia is common and predicts poor outcome in ICH patients. Increased susceptibility to pneumonia and sepsis may be the pathophysiological mechanism underlying this association.

Noncancer-Related Health Events and Mortality in Head and Neck Cancer Patients After Definitive Radiotherapy: A Prospective Study

The survival of patients with head and neck squamous cell carcinoma (HNSCC) can be affected not only by progression of the original cancer or occurrence of a second cancer but also by noncancer health event (NCHE). In this study, we evaluated the prognostic significance of early NCHEs in HNSCC patients after definitive radiotherapy (RT) or chemoradiotherapy (CRT).The prospective study cohort comprised 190 HNSCC patients who underwent definitive RT (n = 75) or CRT (n = 115). An early NCHE was defined as an event requiring hospital readmission of the patient within 12 months after treatment. Univariate and multivariate analyses were performed to identify clinicopathologic factors associated with early NCHEs, and competing and all-cause mortalities.Thirty-three patients suffered an NCHE (17.3%) and 8 succumbed to a competing cause of mortality (4.2%). Twenty-two (11.6%) patients had an early NCHE: respiratory (22.8%), cerebrovascular (13.7%), gastrointestinal (13.7%), and others (50.0%). In multivariate analysis, hypoalbuminemia (P = 0.022, hazard ratio [HR] = 3.66, 95% confidence interval [CI] = 1.21-11.1), chemotherapy (P = 0.047, HR = 3.02, 95% CI = 1.01-8.98), and tumor recurrence (P = 0.024, HR = 2.66, 95% CI = 1.14-6.22) were independent predictors of an early NCHE. Patients with early NCHEs were at high risk of competing mortality (P < 0.001, HR = 22.6, 95% CI = 4.21-121.00) and all-cause mortality (P = 0.002, HR = 4.44, 95% CI = 1.76-11.2).Early NCHEs are a major contributor to competing and all-cause mortality in HNSCC patients receiving RT or CRT. The risk factors identified could be used to predict early NCHEs.

Serum albumin perturbations in cyanotics after cardiac surgery: Patterns and predictions

INTRODUCTION

Hypoalbuminemia is a well-recognized predictor of general surgical risk and frequently occurs in patients with cyanotic congenital heart disease (CCHD). Moreover, cardiopulmonary bypass (CPB)-induced an inflammatory response, and the overall surgical stress can effect albumin concentration greatly. The objective of his study was to track CPB-induced changes in albumin concentration in patients with CCHD and to determine the effect of hypoalbuminemia on postoperative outcomes.

MATERIALS AND METHODS

Prospective observational study conducted in 150 patients, Group 1 ≤18 years (n = 75) and Group 2 >18 years (n = 75) of age. Albumin levels were measured preoperatively (T1), after termination of CPB (T2) and 48 h post-CPB (T3). Primary parameters (mortality, duration of postoperative ventilation, duration of inotropes and duration of Intensive Care Unit [ICU] stay) and secondary parameters (urine output, oliguria, arrhythmias, and hemodynamic parameters) were recorded.

RESULTS

The albumin levels in Group 1 at T1, T2, and T3 were 3.8 ± 0.48, 3.2 ± 0.45 and 2.6 ± 0.71 mg/dL; and in Group 2 were 3.7 ± 0.50, 3.2 ± 0.49 and 2.7 ± 0.62 mg/dL respectively. All patients showed a significant decrease in albumin concentration 48 h after surgery (P < 0.01). Analysis between the groups, however, showed no statistical difference. Eleven patients expired during the study period, and nonsurvivors showed significantly lower serum albumin concentration 48 h after surgery 2.3 ± 0.62 mg/dL versus 3.7 ± 0.56 mg/dL in the survivors (P < 0.05). Receiver operating characteristic curve showed that a baseline albumin cut-off value of 3.3 g/dL predicts mortality with a positive predictive value 47.6% and a negative predictive value of 99.2% (P < 0.05). A strong correlation was seen between albumin levels at 48 h with duration of CPB (r2 = 0.6321), ICU stay (r2 = 0.7447) and incidence of oliguria (r2 = 0.8803).

CONCLUSIONS

The study demonstrated similar fall in albumin concentration in cyanotic patients (both adult and pediatric) in response to CPB. Low preoperative serum albumin concentrations (<3.3 g/dL) can be used to identify and prognosticate subset of cyanotics predisposed to additional surgical risk.

Hypoalbuminaemia predicts outcome in adult patients with congenital heart disease

BACKGROUND

In patients with acquired heart failure, hypoalbuminaemia is associated with increased risk of death. The prevalence of hypoproteinaemia and hypoalbuminaemia and their relation to outcome in adult patients with congenital heart disease (ACHD) remains, however, unknown.

METHODS

Data on patients with ACHD who underwent blood testing in our centre within the last 14 years were collected. The relation between laboratory, clinical or demographic parameters at baseline and mortality was assessed using Cox proportional hazards regression analysis.

RESULTS

A total of 2886 patients with ACHD were included. Mean age was 33.3 years (23.6-44.7) and 50.1% patients were men. Median plasma albumin concentration was 41.0 g/L (38.0-44.0), whereas hypoalbuminaemia (<35 g/L) was present in 13.9% of patients. The prevalence of hypoalbuminaemia was significantly higher in patients with great complexity ACHD (18.2%) compared with patients with moderate (11.3%) or simple ACHD lesions (12.1%, p<0.001). During a median follow-up of 5.7 years (3.3-9.6), 327 (11.3%) patients died. On univariable Cox regression analysis, hypoalbuminaemia was a strong predictor of outcome (HR 3.37, 95% CI 2.67 to 4.25, p<0.0001). On multivariable Cox regression, after adjusting for age, sodium and creatinine concentration, liver dysfunction, functional class and disease complexity, hypoalbuminaemia remained a significant predictor of death.

CONCLUSIONS

Hypoalbuminaemia is common in patients with ACHD and is associated with a threefold increased risk of risk of death. Hypoalbuminaemia, therefore, should be included in risk-stratification algorithms as it may assist management decisions and timing of interventions in the growing ACHD population.

The epidemiology and distribution of pathogens and risk factors for mortality in liver transplant recipients with Gram negative bacteremia

BACKGROUND/AIMS

More data on the epidemiology and distribution of pathogens and the risk factors for mortality in liver transplant recipients with Gram negative bacteremia are needed. METHODs: Among a cohort of 228 liver transplant recipients, we identified 35 patients with initial episodes of Gram negative bacteremia after operation. The association between the risk factors and Gram negative bacteremia related mortality was assessed.

RESULTS

Forty-seven episodes of Gram negative bacteremia occurred in 15.4% of liver transplant recipients. The mean age for these 35 patients was 46.1 years. Among patients with Gram negative bacteremia, 51.4% had an intra-abdominal/biliary source of infection and Escherichia coli was the most common microorganism. There were 18 deaths with a mortality rate of 51.4%. Multivariate logistic regression showed that the independent risk factors for mortality are serum albumin level < 3.0 mg/ dL (odds ratio[OR] = 17.6, 95% confidence interval[CI] = 1.4-224.6, P = 0.027) and septic shock (OR = 37.5, 95% CI = 3.6-386.7, P = 0.002).

CONCLUSIONS

The risk factors significantly associated with increased mortality due to Gram negative bacteremia in liver transplant recipients are decreased serum albumin level and septic shock.

Hypoalbuminemia is a strong predictor of 30-day all-cause mortality in acutely admitted medical patients: a prospective, observational, cohort study

Objective

Emergency patients with hypoalbuminemia are known to have increased mortality. No previous studies have, however, assessed the predictive value of low albumin on mortality in unselected acutely admitted medical patients. We aimed at assessing the predictive power of hypoalbuminemia on 30-day all-cause mortality in a cohort of acutely admitted medical patients.

Methods

We included all acutely admitted adult medical patients from the medical admission unit at a regional teaching hospital in Denmark. Data on mortality was extracted from the Danish Civil Register to ensure complete follow-up. Patients were divided into three groups according to their plasma albumin levels (0–34, 35–44 and ≥45 g/L) and mortality was identified for each group using Kaplan-Meier survival plot. Discriminatory power (ability to discriminate patients at increased risk of mortality) and calibration (precision of predictions) for hypoalbuminemia was determined.

Results

We included 5,894 patients and albumin was available in 5,451 (92.5%). A total of 332 (5.6%) patients died within 30 days of admission. Median plasma albumin was 40 g/L (IQR 37–43). Crude 30-day mortality in patients with low albumin was 16.3% compared to 4.3% among patients with normal albumin (p<0.0001). Patients with low albumin were older and admitted for a longer period of time than patients with a normal albumin, while patients with high albumin had a lower 30-day mortality, were younger and were admitted for a shorter period. Multivariable logistic regression analyses confirmed the association of hypoalbuminemia with mortality (OR: 1.95 (95% CI: 1.31–2.90)). Discriminatory power was good (AUROC 0.73 (95% CI, 0.70–0.77)) and calibration acceptable.

Conclusion

We found hypoalbuminemia to be associated with 30-day all-cause mortality in acutely admitted medical patients. Used as predictive tool for mortality, plasma albumin had acceptable discriminatory power and good calibration.

Combined evaluation of the Glasgow prognostic score and carcinoembryonic antigen concentration prior to hepatectomy predicts postoperative outcomes in patients with liver metastasis from colorectal cancer

BACKGROUND/AIMS

Little is known about the ability of the inflammation-based Glasgow prognostic score (GPS).

METHODOLOGY

106 patients who underwent curative resection for colorectal liver metastasis (CRLM) were analyzed. Patients with an elevated Creactive protein concentration (>10 mg/L) and hypoalbuminemia (<35 g/L) at admission were assigned a GPS 2, those with only 1 of these biochemical abnormalities were assigned a GPS 1, and those without either abnormality were assigned a GPS 0.

RESULTS

Multivariate analysis showed that 2 variables, carcinoembryonic antigen (CEA) concentration > 30 ng/mL and a GPS 1 or 2, were independently prognostic of survival. Patients were classified into 3 groups on the basis of these 2 variables. Patients with GPS 1 or 2 and CEA concentration > 30 ng/mL were assigned a new score of 2, those with either 1 factor were assigned a new score of 1, and those with neither factors were assigned a new score of 0. The 5-year overall survival rates of new scores of 0, 1, 2 were 71.5%, 31.6%, and 0%, respectively (P < 0.0001).

CONCLUSIONS

This simple staging system may be able to identify a subgroup of patients who are eligible for curative resection but show poor prognosis.

Clinical characteristics and prognostic significance of serum albumin changes in an internal medicine ward

BACKGROUND

The prognostic significance of hypoalbuminemia and the dynamic changes in serum albumin during hospitalization in internal medicine wards has not been sufficiently investigated.

METHODS

Demographic, clinical and laboratory data were collected from 276 patients admitted to our internal medicine ward for a variety of acute disorders. Following discharge, all-cause mortality was recorded. These data were compared between patient groups, according to levels of albumin: hypoalbuminemia or normoalbuminemia (serum albumin <34 g/l and ≥ 34 g/l, respectively), on admission and discharge.

RESULTS

Hypoalbuminemia on admission and on discharge was found in 46% and 54% of patients, respectively. Anemia, renal dysfunction, malignant disease, hypocholesterolemia, lymphopenia and albuminuria were more prevalent in patients with hypoalbuminemia, compared to those with normoalbuminemia (p ≤ 0.03). During a median follow-up period of 23 months, 107 of 276 patients died. Mortality was significantly higher (p<0.001) in patients with hypoalbuminemia than normoalbuminemia on admission (52.0% vs. 27.5%) and on discharge (53.7% vs. 21.2%), including those admitted with normoalbuminemia and discharged with hypoalbuminemia (43.6%). Survival rate was higher for patients admitted with hypoalbuminemia and discharged with normoalbuminemia than for those remaining with hypoalbuminemia (82.4% vs. 42.8%, p=0.004). The level of albumin on discharge (each 10 g/l decrement) was the most powerful predictor of shortened survival (relative risk 2.79, 95% confidence interval 2.04-3.70).

CONCLUSIONS

Hypoalbuminemia on admission, as well as persistence or development of hypoalbuminemia throughout hospitalization, was associated with poor prognosis. Treatment aimed at increasing low albumin or maintaining its normal level may improve survival.

Pre-operative hypoalbuminemia in colorectal cancer patients undergoing elective surgery - a major risk factor for postoperative outcome

BACKGROUND

The incidence of hypoalbuminemia in surgical patients varies in different studies with age, tumor stage, time interval to the first referral to a doctor, symptoms of disease and nutritional habits of the population. The main objective of this study was to evaluate the incidence of hypoalbuminemia in colorectal cancer patients undergoing scheduled surgery in an academic hospital in Romania and the impact of hypoalbuminemia on perioperative outcome. The secondary objective was to identify other possible risk factors for the post operative outcome.

MATERIAL AND METHODS

252 patients undergoing scheduled colorectal surgery with anastomosis have been enrolled in the study. Incidence of hypoalbuminemia (serum albumin 3.5 g dL), fistulas and other postoperative complications (e.g.infections) has been evaluated. LOS and 30-days mortality have also been evaluated comparatively in patients with normal and low serum albumin.

RESULTS

28.9% of our patients were hypoalbuminemic. The incidence of fistulas was 5.5 % in the study group and 2.3% and 13.3% in patients with normal serum albumin and hypoalbuminemic patients, respectively (p=0.001). Multivariate analysis showed that the OR was 6.65 [95% CI:2.01-21.96] inpatients with moderate hypoalbuminemia and 24.75 [95% CI:6.75-90.67] in patients with severe hypoalbuminemia.Association between alcohol consumption and smoking increased risk ratio to 1.96 [95% CI: 0.51-7.46].

CONCLUSION

The high incidence of hypoalbuminemia in our patients justifies preoperative nutritional interventions and specific surgical protocols in emergency cases. Further studies are needed to exactly quantify the impact of smoking and alcohol consumption on postoperative outcome.

Serum albumin level as a risk factor for mortality in burn patients

OBJECTIVE

Hypoalbuminemia is a common clinical deficiency in burn patients and is associated with complications related to increased extravascular fluid, including edema, abnormal healing, and susceptibility to sepsis. Some prognostic scales do not include biochemical parameters, whereas others consider them together with comorbidities. The purpose of this study was to determine whether serum albumin can predict mortality in burn patients.

METHODS

We studied burn patients ≥16 years of age who had complete clinical documentation, including the Abbreviated Burn Severity Index, serum albumin, globulin, and lipids. Sensitivity and specificity analyses were performed to determine the cut-off level of albumin that predicts mortality.

RESULTS

In our analysis of 486 patients, we found that mortality was higher for burns caused by flame (p=0.000), full-thickness burns (p=0.004), inhalation injuries (p=0.000), burns affecting >30% of the body surface area (p=0.001), and burns associated with infection (p=0.008). Protein and lipid levels were lower in the patients who died (p<0.05). Albumin levels showed the highest sensitivity and specificity (84% and 83%, respectively), and the area under the receiver-operating characteristic curve (0.869) had a cut-off of 1.95 g/dL for mortality.

CONCLUSION

Patients with albumin levels <2 g/dL had a mortality risk of >80%, with 84% sensitivity and 83% specificity. At admission, the albumin level could be used as a sensitive and specific marker of burn severity and an indicator of mortality.

Hypoalbuminemia and lymphocytopenia are predictive risk factors for in-hospital mortality in patients with tuberculosis

OBJECTIVE

The aim of this study was to clarify the association between nutritional state on admission and in-hospital death in tuberculosis (TB) patients, including a high proportion of elderly patients.

METHODS

A retrospective cohort study of 246 TB patients was conducted. The serum albumin concentrations and peripheral blood lymphocyte counts were measured on admission, and the primary outcome of interest was in-hospital death. Patient mortality was categorized into two groups: TB death and non-TB death. A multivariate analysis was performed to evaluate the relationship between nutritional state on admission and in-hospital mortality in TB patients.

RESULTS

The median [interquartile range] patient age was 79 [69-83] years, and the in-hospital death rate was 20.73% (TB death: 26 patients; non-TB death: 25 patients). The multivariate analysis revealed that the serum albumin concentrations (OR: 0.21, 95% CI: 0.10-0.41; p<0.0001) and peripheral blood total lymphocyte counts (Category 2 [627.2-1,106.7/mm(3)] vs. 1 [<627.2/mm(3)]. OR: 0.28, 95% CI: 0.11-0.73; p=0.009, Category 3 [>1,106.7/mm(3)] vs. 1. OR: 0.24, 95% CI: 0.08-0.76, p=0.015) on admission were significantly associated with all in-hospital deaths in the TB patients. The serum albumin concentrations and peripheral blood total lymphocyte counts were also found to be associated with in-hospital deaths directly caused by TB.

CONCLUSION

Hypoalbuminemia and lymphocytopenia on admission are predictive risk factors for in-hospital mortality in TB patients. Nutritional defects should thus receive special attention in order to reduce TB patient mortality, particularly among elderly patients.

Hypoalbuminemia is an independent prognostic factor for overall survival in myelodysplastic syndromes

We hypothesized that hypoalbuminemia is an independent prognostic factor in patients with myelodysplastic syndromes (MDS). We analyzed records of 767 patients treated at Moffitt Cancer Center between January 2001 and December 2009 to evaluate the relationship between serum albumin (SA) at the time of presentation and overall survival (OS). Patients (median age of 69 years) were stratified into three groups based on SA concentration (≤3.5, 3.6-4.0, and >4.0 g/dL). Two-thirds of the patients had low or intermediate-1 International Prognostic Scoring System (IPSS)-based risk for MDS. Median OS by SA concentration of ≤3.5, 3.6-4.0, and >4.0 g/dL was 11, 23, and 34 months, respectively (P < 0.005), whereas rate of acute myeloid leukemia progression was highest in patients with low SA (≤3.5 g/dL). The SA level offered prognostic discrimination for outcomes within the lower and higher IPSS risk groups, as well as with the MD Anderson risk model. In multivariable analysis, SA was a significant independent co-variate for OS after adjustment for IPSS, age, serum ferritin, and transfusion dependence (hazard ratio = 0.8; 95% CI 0.6-0.9; P = 0.004). Our findings indicate that hypoalbuminemia is an independent prognostic biomarker that may serve as a surrogate representative of disease biology or comorbidities in patients with MDS.

Poor quality of life is associated with increased mortality in maintenance hemodialysis patients: a prospective cohort study

Despite all developments in hemodialysis (HD), the mortality rate is still apparently higher than that in the general population, and worse health-related quality of life (HRQOL) is associated with increased mortality. We prospectively investigated the mortality status of HD patients during a five-year period and the association between mortality, HRQOL, laboratory parameters and clinical and sociodemographic characteristics at baseline. At the end of the five years, 293 patients out of 420 patients were still on HD treatment and 127 patients died. Those who died had a higher mean age, lower mean values of serum creatinine and albumin, higher prevalence of diabetes mellitus, received more HD twice weekly for less than 4 h in almost all HD sessions and had lower HRQOL than the survivors. We conclude that age, comorbidity, HD sessions lasting less than 4 h, malnutrition [hypoalbuminemia, low body mass index (BMI)] and lower physical component scores of SF-36 survey (PCS) were associated with higher risk of death in the HD population.

Significance of albumin and C-reactive protein variations in 300 end stage renal disease patients in Tehran University of Medical Sciences Hospitals during year 2010

Protein- energy malnutrition, wasting and inflammation are frequent complication among patients with end-stage renal disease (ESRD). Malnutrition is associated with cardiac co-morbidity, inflammation and poor survival in ESRD patients. Serum albumin is a well-known marker of nutrition in ESRD patients. Serum albumin is still the most commonly used nutritional marker in ESRD patients. C-reactive protein (CRP), the major acute phase response (APR) protein is elevated in these patients. High CRP levels are linked to the degree of atherosclerosis in coronary, peripheral, and extracranial brain arteries. The aim of the present study was to investigate nutritional factor (albumin) and CRP levels in ESRD patients. In this cross- sectional study a total of 300 patients who had ESRD and had been on hemodialysis treatment for at least 6 months were selected. The laboratory tests consisted of measurement of CRP and albumin using high sensitive ELISA kits. The study patients included 157 males (52.3%) and 143 females (47.7%) with average age of 41.5 ± 14.3 years. Mean CRP level was 7.96 mg/ dl (±1.52), mean serum albumin was 4.07 g/dl (±0.19).Of 300 patients, 21 died (7%). These were patients with serum albumin <4 g/dl and CRP>9.5 mg/dl. This study showed that low albumin and high CRP levels are the main predictors for death. There was a significant difference between CRP and albumin levels in ESRD patients (P<0.0001). Measuring CRP as a marker of inflammation can be helpful in managing these patients.

Human albumin solution for resuscitation and volume expansion in critically ill patients

BACKGROUND

Human albumin solutions are used for a range of medical and surgical problems. Licensed indications are the emergency treatment of shock and other conditions where restoration of blood volume is urgent, such as in burns and hypoproteinaemia. Human albumin solutions are more expensive than other colloids and crystalloids.

OBJECTIVES

To quantify the effect on mortality of human albumin and plasma protein fraction (PPF) administration in the management of critically ill patients.

SEARCH STRATEGY

We searched the Cochrane Injuries Group Specialised Register (searched 31 May 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2), MEDLINE (Ovid) (1948 to week 3 May 2011), EMBASE (Ovid) (1980 to Week 21 2011), CINAHL (EBSCO) (1982 to May 2011), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED) (1970 to May 2011), ISI Web of Science: Conference Proceedings Citation Index - Science (CPCI-S) (1990 to May 2011), PubMed (www.ncbi.nlm.nih.gov/sites/entrez/) (searched 10 June 2011, limit: last 60 days). Reference lists of trials and review articles were checked, and authors of identified trials were contacted.

SELECTION CRITERIA

Randomised controlled trials comparing albumin or PPF with no albumin or PPF or with a crystalloid solution in critically ill patients with hypovolaemia, burns or hypoalbuminaemia.

DATA COLLECTION AND ANALYSIS

We collected data on the participants, albumin solution used, mortality at the end of follow up, and quality of allocation concealment. Analysis was stratified according to patient type.

MAIN RESULTS

We found 38 trials meeting the inclusion criteria and reporting death as an outcome. There were 1,958 deaths among 10,842 trial participants.For hypovolaemia, the relative risk of death following albumin administration was 1.02 (95% confidence interval (CI) 0.92 to 1.13). This estimate was heavily influenced by the results of the SAFE trial, which contributed 75.2% of the information (based on the weights in the meta-analysis). For burns, the relative risk was 2.93 (95% CI 1.28 to 6.72) and for hypoalbuminaemia the relative risk was 1.26 (95% CI 0.84 to 1.88). There was no substantial heterogeneity between the trials in the various categories (Chi(2) = 26.66, df = 31, P = 0.69). The pooled relative risk of death with albumin administration was 1.05 (95% CI 0.95 to 1.16).

AUTHORS' CONCLUSIONS

For patients with hypovolaemia, there is no evidence that albumin reduces mortality when compared with cheaper alternatives such as saline. There is no evidence that albumin reduces mortality in critically ill patients with burns and hypoalbuminaemia. The possibility that there may be highly selected populations of critically ill patients in which albumin may be indicated remains open to question. However, in view of the absence of evidence of a mortality benefit from albumin and the increased cost of albumin compared to alternatives such as saline, it would seem reasonable that albumin should only be used within the context of well concealed and adequately powered randomised controlled trials.

In my opinion: serum albumin should be maintained during neurocritical care

Hypoalbuminemia is common among critically ill/injured patients and is strongly associated with increased morbidity and mortality in the patients with and without neurological conditions. Normal serum albumin is important as the primary intravascular antioxidant, in transporting a variety of hormones, medications and electrolytes, in providing colloid osmotic pressure during trans-compartmental fluid movement, in enhancing organ and tissue blood flow, and in supporting acid-base balance. Studies of albumin administration during intravascular resuscitation have not addressed potential longer term benefits to sustaining serum albumin concentrations during critical care. Evidence for such benefit is present although additional prospective studies are needed.

Role of serum sodium in assessing hospital mortality in cancer patients with spontaneous tumour lysis syndrome inducing acute uric acid nephropathy

Spontaneous tumour lysis syndrome (STLS) inducing acute uric acid nephropathy, a rare and neglected disease, presents more insidiously than conventional post-treatment tumour lysis syndrome. Although STLS is a serious and potentially fatal complication in patients with neoplastic disorders, few investigations have addressed the relevance of clinical and laboratory features in assessing prognosis. A retrospective study was conducted, reviewing the records of all patients who developed acute renal failure (ARF) at Chang Gung memorial hospital between 1 July 1999 and 30 June 2003. STLS-induced acute uric acid nephropathy was identified in 12 of 1072 ARF patients (1.1%) during the study period. All patients had advanced stage tumours with large tumour burden, and 66.7% of cases had abdominal organ involvement. All 12 hyperuricemic patients became oliguric despite conservative therapy, and remained hyperuricemic (21.6 +/- 5.2 mg/dl) before dialysis therapy. Diuresis developed in eight patients (66.7%), with associated resolution of hyperuricemia, azotemia and metabolic derangements following dialysis initiation. Overall hospital mortality was 58.3%. Death in most patients was related to hyponatremia and hypoalbuminemia on admission. The serum sodium was found to have the best Youden index (0.86) and highest overall prediction accuracy (93%). Moreover, serum sodium and serum albumin for individual patients were significantly and positively correlated (r = 0.617, p = 0.032). This investigation confirms a grave prognosis for cancer patients with STLS inducing acute uric acid nephropathy. Hyponatremia and hypoalbuminemia on the first day of admission indicate poor prognosis in such patients.

The impact of admission hyperglycemia or hypoalbuminemia on need ventilator, time ventilated, mortality, and morbidity in critically ill trauma patients

BACKGROUND

The aim of this study was to evaluate the value of hypoalbuminemia or hyperglycemia as predictors for need ventilator and for weaning success in critically ill trauma patients.

METHODS

A single center, retrospective trial was done on 600 trauma patients = or >16 years old admitted for three or more days to the intensive care unit. Patients were classified into five different groups according to the reason for respiratory failure. The subsequent parameters were noted: serum albumin and glucose concentration, Acute Physiology and Chronic Health Evaluation III score, need ventilator, ventilator days, and fluid balance.

RESULTS

The initial mean serum glucose concentration was 9.3 (167.4) +/- 0.2 (3.6 mg/dl) mmol/L and the initial mean serum albumin concentration was 30.2 (3.02) +/- 0.02 (0.2 g/dl) g/L. Even though the circulating albumin concentration was considerably lower and serum glucose concentration was significantly higher in ICU nonsurvivors than in ICU survivors, neither albumin (r=-0.031, p=0.23) nor blood glucose concentration (r=0.050, p=0.11) on ICU admission was a predictor of the duration of mechanical ventilation. The profile of albumin and glucose concentration changes was dissimilar between weaned and mechanical ventilation-dependent patients. An increase of 5 g/L (0.5 g/dl) in serum albumin concentration multiplied the relative success probability by 1.10. Patients with serum albumin concentration less than 30.3 (3.03 g/dl) g/L were 1.2 times more likely to need ventilator than normo-albuminemic patients (relative risk 1.2, 95% confidence interval 1.06-1.31). The risk of need mechanical ventilation did not increase with blood glucose concentration more than 11 mmol/L (200 mg/dl).

CONCLUSION

These results suggest that albumin and blood glucose are possible indexes of the metabolic status of the trauma patient, which could be essential in deciding the need ventilator and weanable status of the patients who are mechanically ventilated for extended periods of time.

Prognostic factors after resection of pancreatic cancer

OBJECTIVES

The purpose of this study was to identify important prognostic factors related to the status of a pancreatic tumor, its treatment, and the patient's general condition.

METHODS

Between April 1992 and December 2006, 140 patients underwent a pancreatic resection for invasive ductal carcinoma. Prognostic factors were defined by univariate and multivariate analyses.

RESULTS

The study included 103 tumors in the head of the pancreas and 37 tumors in the body or tail. The median survival time and the actuarial 5-year survival rate for all patients were 14.5 months and 12.3%, respectively. Using the significant prognostic factors identified by univariate analysis, multivariate analysis revealed that a preoperative serum CA19-9 concentration>100 U/ml (HR=1.84, p=0.0074), a tumor size>3 cm (HR=1.74, p=0.0235), venous involvement (HR=2.39, p=0.0006), a transfusion requirement of >or=1000 ml (HR=2.23, p=0.0006), and a serum albumin concentration on 1 postoperative month (1POM)<3 g/dl (HR=2.40, p=0.0009) were significant adverse prognostic factors. The presence of hypoalbuminemia on 1POM significantly correlated with a longer surgical procedure (p=0.0041), extended nerve plexus resection around the superior mesenteric artery (p=0.0456), and a longer postoperative hospital stay (p=0.0063).

CONCLUSION

To improve long-term survival, preserving the patient's general condition by performing a curative resection with a short operation time and minimal blood loss should be the most important principle in the surgical treatment of pancreatic cancer.

Low serum uric acid level is a risk factor for death in incident hemodialysis patients

BACKGROUND

A reverse epidemiology of classic cardiovascular risk factors was observed in hemodialysis patients with a high comorbidity burden. We hypothesized that uric acid, a novel cardiovascular risk factor, also has an altered association with survival in these patients.

METHODS

A retrospective study was conducted on 168 consecutive outpatient hemodialysis patients over a 6-year period. Serum uric acid, albumin levels and relevant laboratory information were recorded monthly. The disease severity was assessed using Comorbidity Index (CoI) scores. Patients were stratified into 3 groups according to their serum uric acid concentrations: group I was the lowest quintile, group II was the middle 3 quintiles and group III was the highest quintile. The risks of death were calculated utilizing a Cox regression model.

RESULTS

Using group II as a reference group, the hazard ratio of group I was 2.23 [95% confidence interval (CI) 1.21-4.11, p = 0.01] and group III was 0.89 (95% CI 0.47-1.71, p = 0.74). The serum uric acid levels correlated inversely with CoI scores (r = -0.31, 95% CI -0.44 to -0.17, p < 0.0001) and positively with serum albumin levels (r = 0.35, 95% CI 0.21-0.48, p < 0.0001).

CONCLUSION

Low serum uric acid is a mortality risk factor in incident hemodialysis patients with a high comorbidity burden and hypoalbuminemia.

Methylation status of fragile histidine triad (FHIT) gene and its clinical impact on prognosis of patients with multiple myeloma

Aberrant methylation of tumor suppressor genes (TSG) has been studied in multiple myeloma (MM). We determined the methylation status of the FHIT (fragile histidine triad) gene, a putative TSG, in 48 patients with MM. Clinical association with its methylation status was then analyzed. The FHIT gene methylation was observed in 21 of the 48 patients (44%). No association between FHIT gene methylation and clinical variables such as age, gender and clinical stage was found. However, the estimated 50% survival time of the methylated group was significantly shorter than that of the unmethylated group (18.2 vs. 45.1 months, P < 0.05). Univariate analysis revealed adverse prognostic factors: FHIT gene methylation (P = 0.028), poor performance status (I to IV, P = 0.002), anemia (< or =8.5 g/dL, P = 0.007), hypoalbuminemia (< or =3.5 g/dL, P < 0.002), high serum C-reactive protein levels (>0.5 mg/dL, P = 0.002), elevated beta-2-microglobulin serum levels (>6.5 mg/L, P < 0.001), and treatments not including autologous peripheral blood stem cell transplantation (auto-PBSCT) (P = 0.007). Multivariate analysis identified FHIT gene methylation [hazard ratio (HR) 1.722, 95% confidence interval (CI) 1.150-2.603, P = 0.009], elevated beta-2-microglobulin serum levels (>6.5 mg/L, HR 2.005, 95% CI 1.035-3.937, P = 0.004), and treatments not including auto-PBSCT are independent predictive variables. These findings indicate that aberrant methylation of the FHIT gene is an independent adverse prognostic factor in MM.

Hypoalbuminemia 3 months after hospital discharge: significance for long-term survival

OBJECTIVES

To determine change in albumin from hospital discharge to 3-month follow-up and the prognostic significance of persistent hypoalbuminemia in older veteran patients.

DESIGN

A prospective cohort study.

SETTING

A geriatric rehabilitation unit of a university-affiliated Department of Veterans Affairs hospital.

PARTICIPANTS

The study population consisted of 282 subjects (of 322 randomly selected discharges who were free of cancer and terminal conditions) that completed the 90-day postdischarge assessment; most were older (75.4+/-8.6), white (76%), and male (99%).

MEASUREMENTS

Each subject completed a comprehensive discharge assessment, had a repeat albumin an average of 94 days later, and was then tracked for 5 years. The strongest predictors of survival were identified using Cox proportional hazards regression analysis.

RESULTS

Between hospital discharge and the 3-month reassessment, albumins improved by more than 2 g/L in 122 subjects (43%), stayed the same in 112 subjects (40%), and deteriorated by more than 2 g/L in the rest. During follow-up, 190 subjects (67%) died. Of the 38 nutritional, functional, demographic, and illness severity variables evaluated, the 3-month postdischarge albumin was the strongest predictor of long-term mortality. Those with albumins less than 35 g/L had a 2.6 times greater mortality than those with albumins of 40 g/L or greater (relative risk=2.6, 95% confidence interval=1.8-3.8). After controlling for 3-month albumin, hospital-discharge albumin was not significantly associated with long-term mortality.

CONCLUSION

In older people, a low serum albumin 3 months after hospital discharge is associated with a poor long-term prognosis. It is not known whether this represents ongoing inflammation or inadequate nutrition.

Score based on hypoalbuminemia and elevated C-reactive protein predicts survival in patients with advanced gastrointestinal cancer

The presence of a systemic inflammatory response (as evidenced by elevated C-reactive protein concentrations) has been shown to be associated with loss of lean body mass and poor survival in cancer patients. The aim of this study is to assess the value of the combination of hypoalbuminemia and an elevated circulating concentration of C-reactive protein as a prognostic score in patients with advanced gastrointestinal cancer. Patients with advanced colorectal (n = 99) and gastric (n = 66) cancer and who had measurements of albumin and C-reactive protein were identified. Hypoalbuminemia (< 35 g/l/ > or = 35 g/l) and an elevated C-reactive protein (< or = 10 mg/l/ > 10 mg/l) were combined to form a prognostic score (0, 1, and 2). In patients with colorectal cancer, median survival was 12.1, 6.1, and 1.7 m (P < 0.001) for scores of 0, 1, and 2, respectively. In patients with gastric cancer the corresponding median survival was 6.1, 3.1, and 1.6 m, respectively (P < 0.01). The results of the present study suggest that, in patients with advanced gastrointestinal cancer, a cumulative score based on hypoalbuminemia and an elevated C-reactive protein may be useful. It has the advantage that it is based on routinely available well-standardized measurements and is simple to use.

Admission serum albumin is predicitve of outcome in critically ill trauma patients

There is a paucity of data evaluating serum albumin on admission as a predictor of outcome in adult trauma patients. Our objectives were to evaluate whether or not hypoalbuminemia on admission is a predictor of adverse outcome in trauma patients. Prospective data was collected daily on 1023 patients over a 2-year period. Patients were stratified by serum albumin level on admission, age, gender, injury severity, and comorbid conditions. Outcome was measured by ICU and hospital length of stay, ventilator days, incidence of infection, and mortality. Student t test, chi2, and multilinear regression analysis were used to determine level of significance. Blunt injuries accounted for the majority (78%) of the admissions. The mean age of the study population was 43+/-21 years with a mean Injury Severity Score (ISS) of 21.4+/-12. The majority of patients were male (74.5%). The mean albumin level on admission was 2.9+/-1.8. Five hundred ninety-three (58%) patients were admitted with a serum albumin level of > or =2.6 as compared to 430 patients (42%) with an admission albumin level of <2.6. Patients with a lower serum albumin level were found to have a significantly greater ICU (17.1 vs 14.2 days) and hospital length of stay (17.3 vs 20.1 days, P'< 0.05), ventilator days (11.1 vs 13.5 days, P < 0.05), and mortality (P = 0.008) when matched for age and injury severity. The relative risk of infection and mortality increased greater than 2.5-fold in patients with increased age and low serum albumin when analyzed by multilinear regression analysis, P < 0.001. An admission serum albumin level of <2.6 g/dL is a significant independent predictor of morbidity and mortality in trauma patients. The combination of increased age and low albumin level was most predictive of infection and mortality. Early nutrition should be considered in these high-risk patients.

Human albumin and starch administration in critically ill patients: A prospective randomized clinical trial

OBJECTIVE

To determine whether intravenous infusion of either human albumin or hydroxyethyl-starch (HES) in hypo-albuminemic critically ill may lead to an increase in colloid osmotic pressure and to a better clinical outcome, i.e. lower mortality and fewer complications, compared to fluid replacement with normal saline.

DESIGN

Prospective, randomized controlled clinical trial during 72 hours in 61 consecutively admitted severely ill patients. Randomisation took place by sealed envelope, kept outside of the hospital.

SETTING

Intensive care unit of the Twenteborg Hospital, Almelo, The Netherlands.

SUBJECTS

Sixty-three severely ill, hypo-albuminemic patients were selected; 27 patients had severe sepsis and 36 were post-surgical patients with SIRS. Two patients died shortly after randomization, 15 patients received human albumin, 15 HES 500 and 15 HES 1000 ml, and 16 saline.

INTERVENTIONS

The patients were randomized to receive 300 ml human albumin (20%) per day, or 1000 ml normal saline per day, or 500 ml or 1000 ml HES per day, all for 72 hours.

MAIN OUTCOME MEASURES

The primary outcome was plasma colloid osmotic pressure (COP). Secondary endpoints were fluid balance and the development of pulmonary edema.

RESULTS

Administration of human albumin was effective in raising COP (P<0.001 on day 2 and day 3, compared to saline and HES). Neither fluid balances nor the development of peripheral or pulmonary edema were different between the groups. Mortality as well as length of stay at ICU were slightly higher in the group receiving human albumin, although not statistically significant.

CONCLUSION

Raising colloid osmotic pressure with human albumin in hypoalbuminemic patients is not associated with improvement of the clinical outcome.

Albumin infusion for low serum albumin in preterm newborn infants

BACKGROUND

Intravenous albumin infusion to treat hypoalbuminaemia is used in intensive care nurseries. Hypoalbuminaemia occurs in a number of clinical situations including prematurity, the acutely unwell infant, respiratory distress syndrome (RDS), chronic lung disease (CLD), necrotising enterocolitis (NEC), intracranial haemorrhage, hydrops fetalis and oedema. Fluid overload is a potential side effect of albumin administration. Albumin is a blood product and therefore carries the potential risk of infection and adverse reactions. Albumin is also a scarce and expensive resource.

OBJECTIVES

The primary objective was to assess whether albumin infusions, in preterm neonates with low serum albumin, reduces mortality and morbidity. A secondary objective was to assess whether albumin infusion is associated with significant side effects.

SEARCH STRATEGY

Searches were made of MEDLINE from 1966 to April 2004, CINAHL from 1982 to April 2004 and the current Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library issue 1, 2004). Previous reviews (including cross references) and abstracts were also searched.

SELECTION CRITERIA

All randomised controlled trials in which individual patients were allocated to albumin infusion versus control were included. Cross-over studies were excluded. Quasi randomised trials were excluded. Participants were preterm infants who had hypoalbuminaemia. Types of interventions included albumin infusion versus placebo (e.g. crystalloid) or no treatment.

DATA COLLECTION AND ANALYSIS

The reviewers worked independently to search for trials for inclusion and to assess methodological quality. Studies were assessed using the following key criteria: blinding of randomisation, blinding of intervention, completeness of follow up and blinding of outcome measurement.

MAIN RESULTS

Only two small studies were found for inclusion in this review and only one reported clinically relevant outcomes - it found no significant differences for our primary outcome measure of death (RR 1.5 [95% confidence interval 0.3 - 7.43]) or secondary outcome measures of intraventricular haemorrhage, patent ductus arteriosus, necrotising enterocolitis, bronchopulmonary dysplasia, duration of mechanical ventilation and duration of oxygen therapy.

REVIEWERS' CONCLUSIONS

There is a lack of evidence from randomised trials to determine whether the routine use of albumin infusion, in preterm neonates with low serum albumin, reduces mortality or morbidity, and no evidence to assess whether albumin infusion is associated with significant side effects. There is a need for good quality, double-blind randomised controlled trials to assess the safety and efficacy of albumin infusions in preterm neonates with low serum albumin.

Hypoalbuminaemia in critically ill children: incidence, prognosis, and influence on the anion gap

AIMS

Hypoalbuminaemia has significance in adult critical illness as an independent predictor of mortality. In addition, the anion gap is predominantly due to the negative charge of albumin, thus hypoalbuminaemia may lead to its underestimation. We examine this phenomenon in critically ill children, documenting the incidence, early evolution, and prognosis of hypoalbuminaemia (<33 g/l), and quantify its influence on the anion gap.

METHODS

Prospective descriptive study of 134 critically ill children in the paediatric intensive care unit (ICU). Paired arterial blood samples were taken at ICU admission and 24 hours later, from which blood gases, electrolytes, and albumin were measured. The anion gap (including potassium) was calculated and then corrected for albumin using Figge's formula.

RESULTS

The incidence of admission hypoalbuminaemia was 57%, increasing to 76% at 24 hours. Neither admission hypoalbuminaemia, nor extreme hypoalbuminaemia (<20 g/l) predicted mortality; however, there was an association with increased median ICU stay (4.9 v 3.6 days). After correction for albumin the incidence of a raised anion gap (>18 mEq/l) increased from 28% to 44% in all samples (n = 263); this discrepancy was more pronounced in the 103 samples with metabolic acidosis (38% v 73%). Correction produced an average increase in the anion gap of 2.7 mEq/l (mean bias), with limits of agreement of +/-3.7 mEq/l.

CONCLUSION

Admission hypoalbuminaemia is common in critical illness, but is not an independent predictor of mortality. However, failure to correct the anion gap for albumin may underestimate the true anion gap, producing error in the interpretation of acid-base abnormalities. This may have treatment implications.