The clinical significance of hypoalbuminaemia

Albumin is a relatively small molecule with a radius of 7.5 nm and a molecular weight of 65 kDa. It is the most abundant protein in plasma, accounting for 60-75% of its oncotic pressure. Its concentration in plasma is merely one static measurement reflecting a dynamic and complex system of albumin physiology, and is the net result of several different processes, one or more of which may become deranged by disease or its treatment. It is also unsurprising that hypoalbuminaemia has proved to be an indicator of morbidity and mortality risk since the underlying conditions which cause it, including protein energy malnutrition, crystalloid overload, inflammation, and liver dysfunction are themselves risk factors. In some cases, its underlying cause may require treatment but mostly it is just a parameter to be monitored and used as one measure of clinical progress or deterioration. While malnutrition, associated with a low protein intake, may be a contributory cause of hypoalbuminaemia, in the absence of inflammation and/or dilution with crystalloid its development in response to malnutrition alone is slow compared with the rapid change caused by inflammatory redistribution or dilution with crystalloids. Other significant causes include liver dysfunction and serous losses. These causal factors may occur singly or in combination in any particular case. Treatment is that of the underlying causes and associated conditions such as a low plasma volume, not of hypoalbuminaemia per se.

Symptoms, Electrolyte Disturbances and Serum Albumin Levels in Palliative Oncology Patients Admitted Through Emergency: Characteristics and Survival Outcomes

Objectives

Our research aimed to examine the characteristics of palliative oncology patients hospitalised through an emergency to look for the symptom profile, characteristics of dyselectrolytemia and blood investigations, and possible associations with mortality.

Materials and Methods

After institutional review board approval, a retrospective, observational study of patients hospitalised in our tertiary care specialty oncology hospital was undertaken. Records of hospitalised cancer patients admitted from the emergency department under palliative care from January 2019 to October 2021 were examined. As all admissions during this period were through emergency due to institution COVID-19 protocols, all elective admissions were excluded from the study. Data collected included patient characteristics, blood investigations, and comorbid history of systemic diseases and factors that could be associated with electrolyte imbalance.

Results

There were 157 emergency admissions during the study period. A majority were patients with solid tumours (92.4%). Pain was the most frequent cardinal symptom, along with other symptoms (68/157) or in isolation (33/157), followed by reduced oral intake (32/157) and altered sensorium (24/157). sixty-six patients died within the hospitalisation period. On long-term follow-up, only 8 (5.1%) were surviving. Hyponatraemia (43%), Hypoalbuminaemia (66%), and altered renal function (33.1%) were prevalent. We observed a weak positive correlation between sodium levels and outcome (r = 0.199, P = 0.016) and a strong positive correlation between albumin levels and survival outcomes (r = 0.329, P = 0.000). Patients with normal albumin had a higher chance of survival (odds ratio: 33.1225, 95% confidence interval: 3.415-321.20, P = 0.003).

Conclusion

Pain-reduced oral intake and altered sensorium are common emergency symptoms in oncology palliative care. Mortality is high in these patients. Hyponatraemia, hypoalbuminaemia, and deranged renal functions were commonly seen. Normal sodium and albumin levels were associated with higher chances of survival, and the association was strong for serum albumin levels. This may have prognostic utility.

DIETARY LIFESTYLE, HYPOALBUMINAEMIA AND ANAEMIA AMONG OLDER ADULTS ATTENDING A PRIMARY CARE CLINIC IN NIGERIA: A CROSS-SECTIONAL STUDY

Introduction

Anaemia has been extensively studied in children and women of reproductive age. However, there are few data on anaemia and related conditions in the elderly from developing countries.

Objectives

To determine the prevalence and severity pattern of anaemia, and assess the relationship between dietary lifestyle, hypoalbuminaemia, and anaemia in older persons.

Methodology

A cross-sectional study involving 378 patients aged≥60 years who presented at the General Outpatient Clinic. Dietary lifestyle was assessed using a structured questionnaire. Samples were collected for packed cell volume and serum albumin. Inferential statistical analyses were used to determine the associations between variables.

Results

A total of 348 respondents completed the study. The mean age of respondents was 67.83 ±7.53 years with female (60.9%) predominance. The prevalence of anaemia and hypoalbuminaemia were 42.2% and 17.8% respectively. Hypoalbuminaemia (β=0.335, 95%CI=0.131-0.229, P<0.001), long duration of co-morbidities (β= - 0.179, 95%CI= -0.165-0.047, P<0.001), one full meal/day (β=0.130, 95%CI=0.224-1.879, P=0.013), and low monthly income (β=0.122, 95%CI=0.179-1.543, P=0.026) were the predictors of anaemia among the elderly in this study.

Conclusion

Data on the predictors of anaemia from this study will be useful in developing guidelines and strategies for managing the condition in primary care settings and other similar sites.

Clinical and biochemical understanding of Zinc interaction during liver diseases: A paradigm shift

Zinc (Zn) is an essential and the second most abundant trace element after Iron. It can apply antioxidant, anti-inflammatory, and anti-apoptotic activity. It is assumed to be indispensable for cell division, cellular differentiation and cell signalling. Zinc is essential for proper liver function which is also the site of its metabolism. Depleted Zn concentrations have been observed in both acute and chronic hepatic diseases. It is reported that Zn deficiency or abnormal Zn metabolism during majority of liver diseases is attributed to deficient dietary intake of Zn, augmented disposal of Zn in the urine, activation of certain Zn transporters, and expression of hepatic metallothionein. Undoubtedly, Zn is involved in generating many diseases but how and whether it plays role from acute to fulminant stage of all chronic liver diseases remains to be cleared. Here, we will discuss the role of Zn in development of different diseases specifically the involvement of Zn to understand the aetiology and intricate mechanism of dynamic liver diseases.

Predictors of Post-Chemoradiotherapy Pulmonary Complication in Locally Advanced Non-Small Cell Lung Cancer

Purpose

We investigated the clinical effects and predictive factors of severe post-chemoradiotherapy pulmonary complications (PCPC) in locally advanced non-small cell lung cancer (LA-NSCLC).

Materials and Methods

Medical records of 317 patients who underwent definitive concurrent chemoradiation (CCRT) for LA-NSCLC were reviewed retrospectively. PCPC was defined as an event of admission or emergency department visit for acute or subacute pulmonary inflammatory complications, including pneumonitis and pneumonia, within 6 months after CCRT initiation. Patient characteristics, baseline lung function tests, radiation dosimetric parameters, and laboratory tests were analysed to investigate their association with PCPC. Prognostic endpoints were disease progression rate (DPR) and overall survival (OS).

Results

PCPC was reported in 53 (16.7%) patients. The OS of patients with PCPC was significantly worse (35.0% in 2 years) than that of patients without PCPC (67.0% in 2 years, p<0.001). However, 2-year DPRs were 77.0% and 70.7% in patients with and without PCPC, respectively, which were not significantly different (p=0.087). In multivariate logistic regression, PCPC was independently associated with grade≥1 hypoalbuminaemia during CCRT (odds ratio [OR] 5.670, 95% confidence interval [CI] 2.487-13.40, p<0.001), lower diffusing capacity of carbon monoxide (DLCO) (per ml/min/mmHg, OR 0.855, 95% CI 0.743-0.974, p=0.022), and higher lung V5 (per 10%, OR 1.872, 95% CI 1.336-2.699, p<0.001).

Conclusion

PCPC might be a clinical endpoint to evaluate complications and predict the survival of patients subjected to CCRT for LA-NSCLC. Hypoalbuminaemia, DLCO, and lung V5 might predict PCPC in LA-NSCLC.

Hypoalbuminaemia in orthopaedic trauma patients in a rural hospital in South Africa

BACKGROUND

The deleterious effects of hypoalbuminaemia in the peri-operative period are well documented. We aimed to review serum albumin levels in a cohort of orthopaedic trauma patients to determine the prevalence of hypoalbuminaemia. Secondarily, we aimed to identify factors associated with an increased risk of hypoalbuminaemia.

METHODS

A retrospective cross-sectional study was performed of data collected prospectively at a regional hospital serving primarily a rural population in South Africa.

RESULTS

Two hundred ninety-five patients were included in the study. Twenty-nine per cent of the cohort was found to have hypoalbuminaemia. Femur neck fractures (p < 0.001), intertrochanteric fractures (p = 0.004), tibial plateau fractures (p = 0.034) and polytrauma (p = 0.013) were associated with hypoalbuminaemia. The mean albumin level was lower in HIV-positive patients when compared to HIV-negative patients (35.7 g/L vs 37.5 g/L, p = 0.007). The presence of comorbidities other than HIV, like diabetes mellitus (p = 0.001), previous pulmonary tuberculosis (p = 0.034) and chronic renal failure (p = 0.007) was associated with hypoalbuminaemia.

CONCLUSION

In this cohort of orthopaedic trauma patients from rural South Africa, we found a 29% prevalence of hypoalbuminaemia at the time of presentation. High-risk subgroups include patients with pre-existing comorbidities and increased age, as well as patients presenting with polytrauma, femoral neck, intertrochanteric femur or tibial plateau fractures.

Prognostic significance of albumin levels prior to treatment in patients with head and neck squamous cell carcinoma

INTRODUCTION AND OBJECTIVES

Pre-treatment albumin levels have been shown to have prognostic capacity in oncological patients. The aim of this study is to analyse the relationship between albumin levels and prognosis in patients with head and neck squamous cell carcinoma (HNSCC).

METHODS

We performed a retrospective study in a cohort of 741 patients with HNSCC and a plasmatic albumin testing within the 4weeks prior to the start of treatment. The relationship between disease-specific survival and plasma albumin levels was analysed by a recursive partitioning analysis.

RESULTS

Albumin levels showed a directly proportional and statistically significant association with disease-specific survival. According to the results of the recursive partitioning analysis, the cut-off points with a higher prognostic capacity were 37.5g/L and 46.1g/L. Taking patients with albumin levels >46.1g/L as the benchmark, patients with albumin levels between 37.5-46.1g/L had a 1.44 times higher risk of disease-specific death (95%CI: .95-2.19, P=.081), and patients with levels <37.5g/L had a 3.19 times higher risk (95%CI: 2.01-5.04, P=.0001). The differences in survival based on albumin levels were only seen in patients with advanced stage tumours (stagesIII-IV).

CONCLUSION

Pre-treatment plasmatic albumin is an independent prognostic factor for patients with advanced stage HNSCC (III-IV), 37.5g/L being the cut-off point with the highest prognostic capacity.

Switch from tablet levothyroxine to oral solution resolved reduced absorption by intestinal parasitosis

Reduced intestinal absorption of levothyroxine (LT4) is the most common cause of failure to achieve an adequate therapeutic target in hypothyroid patients under replacement therapy. We present the case of a 63-year-old woman with autoimmune hypothyroidism previously well-replaced with tablet LT4 who became unexpectedly no more euthyroid. At presentation, the patient reported the onset of acute gastrointestinal symptoms characterized by nausea, loss of appetite, flatulence, abdominal cramps and diarrhea, associated with increase of thyrotropin levels (TSH: 11 mIU/mL). Suspecting a malabsorption disease, a thyroxine solid-to-liquid formulation switch, at the same daily dose, was adopted to reach an optimal therapeutic target despite the gastrointestinal symptoms persistence. Oral LT4 solution normalized thyroid hormones. Further investigations diagnosed giardiasis, and antibiotic therapy was prescribed. This case report is compatible with a malabsorption syndrome caused by an intestinal parasite (Giardia lamblia). The reduced absorption of levothyroxine was resolved by LT4 oral solution. Learning points: The failure to adequately control hypothyroidism with oral levothyroxine is a common clinical problem. Before increasing levothyroxine dose in a patient with hypothyroidism previously well-controlled with LT4 tablets but no more in appropriate therapeutic target, we suggest to investigate non adhesion to LT4 therapy, drug or food interference with levothyroxine absorption, intestinal infection, inflammatory intestinal disease, celiac disease, lactose intolerance, short bowel syndrome after intestinal or bariatric surgery, hepatic cirrhosis and congestive heart failure. LT4 oral solution has a better absorptive profile than the tablet. In hypothyroid patients affected by malabsorption syndrome, switch of replacement therapy from tablet to liquid LT4 should be tested before increasing the dose of LT4.

Retinal and choroidal thickness in paediatric patients with hypoalbuminaemia caused by nephrotic syndrome

BACKGROUND

A study was conducted to evaluate the choroidal thickness (CT) and retinal thickness (RT) in paediatric patients with hypoalbuminaemia caused by nephrotic syndrome (NS). We also studied the correlation between the subfoveal choroidal thickness (SFCT) and serum protein concentration.

METHODS

This was a cross-sectional study. Fifty-one paediatric patients with hypoalbuminaemia caused by NS and 41 normal subjects were included in the study. Enhanced depth imaging optical coherence tomography (EDI-OCT) was performed to measure the RT and CT. The RT and CT were measured manually at intervals of 0.5 mm along a horizontal line through the macular fovea between 2.5 mm nasal and 2.5 mm temporal to the fovea. Clinical data including measurements of serum proteins were obtained.

RESULTS

The mean RTs at the T2.5, T2, N1.5, N2, and N2.5 locations and the average macular horizontal RT were slightly greater in the NS group than those in the control group. The mean CTs at all locations were significantly greater in the NS group than those in the control group; the difference was most significant at the fovea (373.8 ± 74.9 μm vs. 280.2 ± 57.1; p < 0.001). The SFCT in patients with NS was correlated with age (r = - 0.307, p = 0.003), body height (r = - 0.320, p = 0.022), body weight (r = - 0.343, p = 0.014), axial length (AL, r = - 0.237, p = 0.023), total protein (TP, r = - 0.302, p = 0.031), albumin (ALB, r = - 0.285, p = 0.042), prealbumin (PA, r = - 0.303, p = 0.033) and 24-h urine volume (UV, r = - 0.298, p = 0.034). Multiple linear regression analysis showed that the TP concentration and body weight had the highest correlation with the SFCT (R2 = 0.220, p < 0.05).

CONCLUSIONS

The macular RT is slightly increased and the macular CT is significantly increased in paediatric patients with hypoalbuminaemia caused by NS, indicating fluid accumulation in the retina and choroid. There is a negative correlation between the SFCT and serum TP concentration. Thus, the serum TP concentration is an important indicator of CT in patients with hypoalbuminaemia.

A pharmacokinetic case study of intravenous posaconazole in a critically ill patient with hypoalbuminaemia receiving continuous venovenous haemodiafiltration

This article reports a pharmacokinetic case study of intravenous posaconazole in a 49-year-old male patient with intra-abdominal sepsis and hypoalbuminaemia receiving continuous venovenous haemodiafiltration. Concentration-time data following 300 mg intravenous posaconazole was analysed using a population pharmacokinetics approach. The 300-mg intravenous dose appears to be adequate for the treatment of yeast infections; however, for the treatment of invasive aspergillosis in isolated cases of critically ill patients with hypoalbuminaemia, the current dosing may not achieve desired exposure, although steady state exposure data are needed.

Hypoalbuminaemia-a marker of malnutrition and predictor of postoperative complications and mortality after hip fractures

OBJECTIVE

Our aim was to determine the effect of hypoalbuminaemia as a marker of malnutrition on the 30-day postoperative complication rate and mortality in patients receiving surgical treatment for hip fractures using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

METHODS

We analyzed all patients admitted with hip fractures receiving surgical treatment from 2011 to 2013. Patients were dichotomized based on their albumin levels; hypoalbuminaemia (albumin <3.5g/dL), and nonhypoalbuminaemia (albumin >3.5g/dL). Patient demographics, postoperative complications, and length of stay were analysed. Logistic regression analysis was conducted to assess the ability of albumin level for predicting postoperative complications, length of stay, and mortality.

RESULTS

A total of 10,117 patients with hip fractures were identified with 5414 patients with normal albumin levels, and 4703 with low albumin. Multivariate analysis showed that when controlling for comorbidities; hypoalbuminaemia alone was a predictor of postoperative complications (death, unplanned intubation, being on a ventilator >48h, sepsis, and blood transfusion), and increased length of stay (6.90±7.23 versus 8.44±8.70, CI 0.64-1.20, P<0.001).

CONCLUSION

Hypoalbuminaemia alone can predict postoperative outcomes in patients with hip fractures. Furthermore, patients with hypoalbuminaemia had a longer hospital length of stay. Further studies are needed to assess whether nutritional support can improve postoperative complications in patients with hypoalbuminaemia.

Are Albumin Levels a Good Predictor of Mortality in Elderly Patients with Neck of Femur Fractures?

BACKGROUND

Neck of femur (NOF) fractures are associated with significant morbidity and mortality in elderly people with multiple co-morbidities; making management of this patient subgroup challenging. Predictors of an increase in morbidity and mortality would therefore provide a useful framework for the assessment and management of this demographic. Within the current literature, hypoalbuminaemia (<35g/dl) has been highlighted as being a good biochemical predictor of short-term mortality (<12 months). Our aims were to assess whether there was an association between low albumin levels and mortality and whether the severity adversely affects outcomes.

MATERIALS AND METHODS

Patients admitted to our large district hospital between January 2011 and December 2012 who had sustained a NOF fracture, were over 65 years old and had a pre-operative albumin level were included. This retrospective, longitudinal, observational study concluded in July 2014. Demographic and pre-operative function and albumin data was collated retrospectively. An association with mortality was made.

RESULTS

471 patients had usable data. Mean pre-operative albumin level was 29.5g/dl (SD 6.22g/dl) in patients who died and 32.8g/dl (SD 6.43g/dl) in patients who survived during the study period. Pre-operative albumin level was significantly associated with survival (hazard ratio 0.957: 95% CI (0.937, 0.978); p<0.001). Thus, a reduction of 1g/dl in pre-operative albumin is associated with an increased hazard of death of 4.3%.

CONCLUSIONS

Early identification of patients with hypoalbuminaemia on admission with a venous blood sample and timely input from orthogeriatrians could optimise these patients pre- and post-operatively. This may enable rates of morbidity and mortality to fall. Hypoalbuminaemia may be a reasonable predictor of shorter-term mortality in this patient subgroup. However, this may reflect existing co-morbidities rather than an isolated cause. This study supports an association between hypoalbuminaemia and poorer outcome for patients with NOF fractures.

Determinants of gentamicin concentrations in critically ill patients: a population pharmacokinetic analysis

When treating critically ill patients with gentamicin for severe infection, peak concentrations (C_max) determine clinical efficacy and trough concentrations (C_min) determine toxicity. Despite administration of body weight-standardised starting doses, a wide range of C_max is generally observed. Furthermore, in therapeutic drug monitoring, several measures of renal function are used to predict appropriate C_min and gentamicin dosing intervals, but the most accurate predictor is not known. This study aimed to quantify the impact of several patient parameters on gentamicin C_max values and to determine which measure of renal function best predicts gentamicin clearance (CL). Clinical data and serum gentamicin levels were retrospectively collected from all critically ill patients treated with gentamicin at our intensive care unit between 1 January and 30 June 2011. Data were analysed using non-linear mixed-effects modelling (NONMEM v.7.1.2). A two-compartmental model was developed based on 303 gentamicin concentration-time data from 44 critically ill patients. Serum albumin levels explained 25% of interindividual variability in the volume of distribution (V_d). Creatinine clearance calculated from the creatinine concentration in a 6-h urine portion (CalcCL_Cr) resulted in acceptable estimation of gentamicin CL, whilst serum creatinine (SCr) and creatinine clearance estimated by the Cockcroft-Gault formula (CGCL_Cr) overestimated gentamicin CL and therefore underestimated C_min. In conclusion, low albumin concentrations resulted in a larger V_d and lower C_max of gentamicin. These results suggest that use of a higher gentamicin starting dose in critically ill patients with hypoalbuminaemia may prevent underdosing. Urinary CalcCL_Cr is a better predictor of C_min than SCr or CGCL_Cr.

Association between unexplained hypoalbuminaemia and new cancer diagnoses in UK primary care patients

BACKGROUND

The association between hypoalbuminaemia and a new diagnosis of cancer is as yet unknown.

OBJECTIVE

This study aimed to assess whether unexplained hypoalbuminaemia was associated with an increased risk of subsequent new cancer diagnosis within the next 12 months.

METHODS

A cohort study was performed using a large UK database of adult primary care patients. Patients with a serum albumin test, either low or normal, were followed for 12 months for a new diagnosis of non-skin cancer. Logistic regression was used to assess for relationships between hypoalbuminaemia and cancer diagnoses.

RESULTS

A total of 100 122 participants had at least one albumin test result. Of these, 5753 (5.75%) had a result <35g/l, of whom 1634 developed cancer within 12 months. Of the 94 116 patients with normal albumin values, 13 906 developed cancer. Hypoalbuminaemia was associated with an increased risk of subsequent cancer diagnosis within 12 months (odds ratio [OR]: 2.29; 95% confidence interval [CI]: 2.15-2.43). This association was smaller in magnitude after controlling for other conditions known to affect albumin levels (OR: 1.29; 95% CI: 1.12-1.49).

CONCLUSIONS

Low albumin levels were associated with an increased risk of cancer. This finding needs to be confirmed in other primary care populations.

Hypoalbuminaemia in haemodialysis patients at Parirenyatwa group of hospitals and Chitungwiza central hospital

Introduction

Haemodialysis is one of the widely used methods in end stage renal disease. However it has a negative impact on the quality of life of the renal patients. Hypoalbuminaemia occur in haemodialysis patients and it correlates strongly with mortality and morbidity. We sought out to determine the prevalence of hypoalbuminaemia among haemodialysis patients at Parirenyatwa group of hospitals and Chitungwiza central hospital.

Methods

A questionnaire was administered on haemodialysis patients at Parirenyatwa Group of Hospitals and Chitungwiza Central Hospital who consented to participate in the study. Pre dialysis serum samples collected from the patients were used for albumin analysis. The serum from the patients was analysed for serum albumin levels using the Mindray BS120 chemistry analyser using the bromocresol green method.

Results

A total of 60 patients were recruited from the two hospitals. The Mean albumin concentration for the entire group was 33.6g/L SD (6.1 g/L). The mean albumin in males was 33.6 g/L, SD (5.9) and in female 33.6, SD (6.6 g/L) and this was not statistically significantly different (p = 0.988). The prevalence of hypoalbuminaemia was 76.7%.

Conclusion

Hypoalbuminaemia in 76.7% of haemodialysis patients studied is a cause of concern thus monitoring of haemodialysis patients albumin is necessary since its decreased levels has been associated with increased morbidity and mortality.

Changes in the pharmacokinetics of teicoplanin in patients with hyperglycaemic hypoalbuminaemia: Impact of albumin glycosylation on the binding of teicoplanin to albumin

There is large interindividual variability in serum teicoplanin (TEIC) concentrations after administration of a loading dose, and the factors that influence the pharmacokinetics of TEIC are disputed. The aim of this study was to clarify changes in the pharmacokinetics of TEIC that occur in patients with hyperglycaemia as well as the impact of albumin glycosylation on the pharmacokinetics of TEIC. This study consisted of retrospective and prospective investigations. The pharmacokinetic parameters of TEIC were retrospectively compared between patients receiving TEIC treatment. Ninety-four patients were divided into four groups according to their serum albumin and blood glucose concentrations [(i) hyperglycaemic hypoalbuminaemia (albumin<3.0g/dL) (n=16); (ii) non-hyperglycaemic hypoalbuminaemia (n=29); (iii) hyperglycaemic normoalbuminaemia (albumin≥3.0g/dL) (n=9); and (iv) non-hyperglycaemic normoalbuminaemia (n=40)]. In addition, the concentration of glycosylated albumin was prospectively determined in 28 patients. At 12h after administration of a loading dose, patients with hyperglycaemic hypoalbuminaemia displayed significantly lower serum TEIC concentrations (P<0.05) and higher TEIC volume of distribution (Vd) (P<0.05) than the other three groups, whereas TEIC clearance did not differ significantly among the groups. In addition, the percentage of glycosylated albumin was significantly correlated with the association constant (Ka) of TEIC for albumin (r=0.53, P=0.004) and the Vd (r=0.41, P=0.031). These results suggest that hyperglycaemic hypoalbuminaemia lowers the serum TEIC concentration, which is attributable to the decreased Ka and increased Vd of TEIC by albumin glycosylation.

Albumin concentration significantly impacts on free teicoplanin plasma concentrations in non-critically ill patients with chronic bone sepsis

The impact of decreased serum albumin concentrations on free antibiotic concentrations in non-critically ill patients is poorly described. This study aimed to describe the pharmacokinetics of a high-dose regimen of teicoplanin, a highly protein-bound antibiotic, in non-critically ill patients with hypoalbuminaemia. Ten patients with chronic bone sepsis and decreased serum albumin concentrations (<35 g/L) receiving teicoplanin 12 mg/kg 12-hourly intravenously for 48 h followed by 12 mg/kg once daily were enrolled. Surgical debridement was performed on Day 3. Samples of venous blood were collected pre-infusion and post-infusion during the first 4 days of therapy. Total and free teicoplanin concentrations were assayed using validated chromatographic methods. The median serum albumin concentration for the cohort was 18 (IQR 15-24) g/L. After 48 h, the median (IQR) free trough (fC(min)) and total trough (tC(min)) concentrations were 2.90 (2.67-3.47) mg/L and 15.54 (10.28-19.12) mg/L, respectively, although trough concentrations declined thereafter. Clearance of the free concentrations was significantly high relative to the total fraction at 38.6 (IQR 29.9-47.8) L/h and 7.0 (IQR 6.8-9.8) L/h, respectively (P<0.001). Multiple linear regression analysis demonstrated that whereas total teicoplanin concentration did not impact on free concentrations (P=0.174), albumin concentration did (P<0.001). This study confirms the significant impact of hypoalbuminaemia on free concentrations of teicoplanin in non-critically ill patients, similar to that in critically ill patients. Furthermore, the poor correlation with total teicoplanin concentration suggests that therapeutic drug monitoring of free concentrations should be used in these patients.

Hypoalbuminaemia is an independent predictor of poor outcome in metastatic Ewing's sarcoma family of tumours: a single institutional experience of 150 cases treated with uniform chemotherapy protocol

AIMS

Data on metastatic Ewing's sarcoma family of tumours (ESFT) with uniform chemotherapy protocol are minimal.

MATERIALS AND METHODS

This was a single institutional patient review of patients treated between June 2003 and November 2011 and evaluated on an intent-to-treat analysis. All patients received uniform chemotherapy: neoadjuvant chemotherapy (NACT), surgery and/or radiotherapy as local treatment followed by adjuvant chemotherapy. Local treatment was offered if the patient achieved a complete response and/or a partial response at both the primary and the metastatic site.

RESULTS

In total, 150/374 (40%) ESFT patients were metastatic, with a median age of 15 years (range: 2-50); a tumour diameter of 10 cm (range: 1.8-26). Most common metastatic sites were lung only (53; 35%), bone only (35; 23%) and combined bone/lung (25; 17%). Twenty patients underwent surgery; 55 patients received radical radiotherapy after NACT. After a median follow-up of 26.1 months (range: 1.6-101.6), 5 year event-free survival (EFS), overall survival and local control rate (LCR) were 9.1 ± 3.3%, 16.9 ± 5.2% and 31.8 ± 7.9%, respectively. Univariate analysis showed serum albumin ≤3.4 g/dl (P < 0.001) to predict inferior EFS. Tumour size >8 cm (P = 0.05), haemoglobin ≤10 g/dl (P = 0.04), hypoalbuminaemia (P = 0.003) and radical radiotherapy as local treatment (P = 0.03) predicted inferior overall survival. No factor significantly predicted LCR, although age ≤15 years (P = 0.08) and radical radiotherapy as local treatment (P = 0.09) had a trend towards inferior LCR. Hypoalbuminaemia was the only prognostic factor to predict EFS on multivariate analysis.

CONCLUSION

This was the largest study of metastatic ESFT from Asia and identified a unique prognostic factor. In view of dismal prognosis with conventional chemotherapy in metastatic ESFT with hypoalbuminaemia, palliative intent therapy may be a potential therapeutic alternative for this subgroup of patients, especially in resource-challenged situations.

Variability in protein binding of teicoplanin and achievement of therapeutic drug monitoring targets in critically ill patients: lessons from the DALI Study

The aims of this study were to describe the variability in protein binding of teicoplanin in critically ill patients as well as the number of patients achieving therapeutic target concentrations. This report is part of the multinational pharmacokinetic DALI Study. Patients were sampled on a single day, with blood samples taken both at the midpoint and the end of the dosing interval. Total and unbound teicoplanin concentrations were assayed using validated chromatographic methods. The lower therapeutic range of teicoplanin was defined as total trough concentrations from 10 to 20 mg/L and the higher range as 10-30 mg/L. Thirteen critically ill patients were available for analysis. The following are the median (interquartile range) total and free concentrations (mg/L): midpoint, total 13.6 (11.2-26.0) and free 1.5 (0.7-2.5); trough, total 11.9 (10.2-22.7) and free 1.8 (0.6-2.6). The percentage free teicoplanin for the mid-dose and trough time points was 6.9% (4.5-15.6%) and 8.2% (5.5-16.4%), respectively. The correlation between total and free antibiotic concentrations was moderate for both the midpoint (ρ = 0.79, P = 0.0021) and trough (ρ = 0.63, P = 0.027). Only 42% and 58% of patients were in the lower and higher therapeutic ranges, respectively. In conclusion, use of standard dosing for teicoplanin leads to inappropriate concentrations in a high proportion of critically ill patients. Variability in teicoplanin protein binding is very high, placing significant doubt on the validity of total concentrations for therapeutic drug monitoring in critically ill patients.

Pyogenic liver abscess: An audit of 10 years’ experience

AIM: To describe our own experience with pyogenic liver abscesses over the past 10 years and investigate the risk factors associated with failure of initial percutaneous therapy.

METHODS: A retrospective study of records of 63 PLA patients presenting between 1998 and 2008 to Australian tertiary referral centre, were reviewed. Amoebic and hydatid abscesses were excluded. Demographic, clinical, radiological, and microbiological characteristics, as well as surgical/radiological interventions, were recorded.

RESULTS: Sixty-three patients (42 males, 21 females) aged 65 (± 14) years [mean ± (SD)] had prodromal symptoms for a median (interquartile range; IQR) of 7 (5-14) d. Only 59% of patients were febrile at presentation; however, the serum C-reactive protein was elevated in all 47 in whom it was measured. Liver function tests were non-specifically abnormal. 67% of patients had a solitary abscess, while 32% had > 3 abscesses with a median (IQR) diameter of 6.3 (4-9) cm. Causative organisms were: Streptococcus milleri 25%, Klebsiella pneumoniae 21%, and Escherichia coli 16%. A presumptive cryptogenic cause was most common (34%). Four patients died in this series: one from sepsis, two from advanced cancer, and one from acute myocardial infarction. The initial procedure was radiological aspiration ± drainage in 54 and surgery in two patients. 17% underwent surgical management during their hospitalization. Serum hypoalbuminaemia [mean (95% CI): 32 (29-35) g/L vs 28 (25-31) g/L, P = 0.045] on presentation was found to be the only factor related to failure of initial percutaneous therapy on univariate analysis.

CONCLUSION: PLA is a diagnostic challenge, because the presentation of this condition is non-specific. Intravenous antibiotics and radiological drainage in the first instance allows resolution of most PLAs; However, a small proportion of patients still require surgical drainage.

Hypoalbuminaemia--a marker of cardiovascular disease in patients with chronic kidney disease stages II-IV

Cardiovascular disease (CVD) is a major cause of morbidity and mortality in patients with chronic kidney disease (CKD) patients. Serum albumin, a negative acute-phase reactant and marker for underlying inflammation and/or malnutrition, is an independent predictor of CVD and mortality in CKD VI patients. Such an association in patients with less severe CKD is not well established. We conducted a cross sectional study of all CKD II-IV patients attending the nephrology clinic (N=376; mean age: 57+/-17 years; GFR: 47+/-20 mL/min/1.73 m(2); females 48%; blacks 15%; diabetics 27%; hypertensive 79%). Laboratory and clinical data including risk factors and evidence of CVD were obtained at the point of the most recent visit. The association between risk factors and CVD was evaluated by logistic regression. In the simple logistic regression model, age (p<0.0001), sex (P= 0.02), hypertension (P<0.0001), diabetes (P<.0001), dyslipidemia (p=.01), and serum albumin (p<.0001) were found to be statistically significant. Serum albumin was found to be an independent predictor (p=0.04) of CVD by multiple logistic regression analysis using the above risk factor variables.

IN CONCLUSION

a) hypoalbuminaemia is an independent predictor of CVD in early CKD stages; b) hypoalbuminaemia may be used to identify the population at higher risk for CVD.