Albumin in nephrotic syndrome and oedematous malnutrition

Abstract

Malcolm Coulthard is a paediatric nephrologist with experience in the care of children with the rare, lethal condition, Finnish congenital nephrotic syndrome. If not transplanted, these children have a tortuous clinical course with progressive inanition and high mortality. He argues a commonality of the pathophysiological process with the relatively common childhood syndrome oedematous malnutrition (kwashiorkor). From that he concludes the justification for similar treatment with intravenous infusion of albumin to correct the plasma oncotic pressure in the expectation of effective mobilization of oedema fluid and correction of the condition. 1 He has re-analyzed data presented in a paper from 1980 in which it was shown that, in oedematous, severely malnourished children, clinical improvement could be achieved using an approach which did not place emphasis on the need for early correction of a low plasma albumin concentration. 2 Coulthard argues that his re-analysis shows that there was an important change in the concentration of albumin, questions the ability to measure albumin with assurance and argues for a trial of therapy with intravenous albumin. The presentation is theoretical and no new data or direct experience are presented. Michael Golden is a physician who has thought deeply about the cause of oedematous malnutrition and has had very wide experience in its characterization and management. He presents a portfolio of evidence around the complexity of the aetiopathophysiology of the condition, illustrating wider factors beyond plasma albumin concentration which might need to be taken into consideration in its successful management. 3 He draws on his own and other historical experience to emphasise the dangers of simple extrapolation of the treatment for one clinical syndrome to another. Both authors raise important points around the limitations of our understanding of the aetiology and treatment of oedema in malnourished individuals. The implications of their suggestions have to be placed in historical context and within a wider framework around the clinical care of children with complicated problems and serious ill-health, especially those with severe malnutrition. Historically, severe malnutrition in childhood has had a mortality rate as high as 50%. 4,5 Despite the development of guidelines for its treatment by the World Health Organization (WHO) in 1981, 6 the fatality rate remained high, even in centres where there was considerable experience of its management. 7 This review used the WHO guidelines of 1981 as a reference against which to assess the practice adopted for the care of severely malnourished children in a wide range of centres across the world. The approaches to care indicated a range of practices, which very frequently did not meet the standards of better practice offered in the guidelines. Furthermore, this indicated that available evidence had not been used to improve care in many centres around the world and that the formal guidance on better practice had not been widely adopted. This led to a revision of the WHO guidelines in 1998, published in 1999, 8 which provided a ten-point structured approach to care. 9 The careful and considered application of these guidelines in resource-poor settings has been associated with significant improvements in case fatality in children with severe malnutrition. 10‐12 These benefits are seen whether or not oedema is present, but the presence of oedema does indicate a risk of a worse prognosis. The extrapolation of these principles of care under appropriate circumstances to communitybased management of severe acute malnutrition 13,14 has enabled significant progress towards achievement of the Millennium Development Goals, contributing substantially to reductions in under-5 mortality rates. 15 It has been shown that a lack of effect in the application of the guidelines is more likely to be associated with poor adoption and application rather than a fundamental fault in the guidelines