Young Investigator: Hypoalbuminemia as Risk Factor for Thromboembolic Events in Hospitalized Inflammatory Bowel Disease Patients: An Observational and Retrospective Analysis

Abstract

BACKGROUND: Inflammatory bowel diseases (IBD) are chronic entities characterized by local and systemic inflammation that predominantly affects the gastrointestinal tract and may be associated with numerous extraintestinal manifestations including thrombosis. The association between IBD and thromboembolic events (TEE) was first described in 1936 in a study involving more than 1000 patients with IBD followed at the Mayo Clinic. TEE were found in 1.2% of the cases. Since then, several studies have demonstrated such association. The incidence of TEE in patients with IBD ranges from 1.2-6.7%, increasing to 39% in post mortem. Such events occur mostly at a time when IBD is active and (or) with complications such as stenosis, fistulas and abscesses. The aim of this study was to identify the prevalence of TEE in hospitalized IBD patients and find risk factors for its occurrence. METHODS: This was a retrospective single-center longitudinal study carried out by reviewing the medical records of patients with IBD from the gastroenterology and colorectal surgery units at the University of Campinas, Brazil, between 2004 and 2014. Patients hospitalized for more than 48 hours, due to active IBD and who did not use prophylaxis for TEE during hospitalization, were included. Patients with hematopoietic systemic diseases or with coagulopathies, using anticoagulant medications up to 30 days before admission and pregnant women were excluded. Patients were allocated in two groups: those with TEE up to 30 days or at the time of hospitalization (TEE-group) and patients without TEE (control-group). Clinical characteristics (disease duration, medical therapy, extra-intestinal manifestations, disease activity) and laboratorial characteristics (complete blood count, CRP, ESR, albumin, pre albumin, coagulogram) of the patients were evaluated. RESULTS: 45 patients, 23 (51.1%) female were evaluated. 32 patients (71.1%) had Crohn's disease (CD) and 13 (28.9%) ulcerative colitis (UC). At the time of admission, 24.4% of the patients were off treatment due to the recent diagnosis. Only 4.4% of the patients were active smokers and 8.9% were previous smokers. 56.5% of the women used hormonal contraceptive methods. The mean biochemical factors related to the nutritional aspect (albumin and pre-albumin) were reduced (albumin: 3.07±0.94g/dL, pre-albumin: 16.79±10.8mg/dL). Both mean serum albumin and pre-albumin levels were lower in CD (albumin: 2.9±0.93g/dL, pre-albumin: 12.37±8.9mg/dL). The prevalence of TEE, 30 days before or during hospitalization, was 17.7%(n=8), 12.5% in CD and 30.7% in UC. There was no difference between the gender. Patients with TEE presented depletion of the anthropometric status, BMI= 17.6±3.26Kg/m2 in relation to the control group 23.2±3.7Kg/m2. In TEE group, mean serum albumin was 2.06±0.62g/dL vs 3.3±0.85g/dL in the control group. In univariate analysis, only hypoalbuminemia was considered a risk factor for TEE. Individuals with hypoalbuminemia (values below 2.62g/dL) had a 14.8 fold higher chance of developing any TEE (P<0.001). CONCLUSION(S): TEE were identified in 17.7% of admitted IBD patients. Albumin levels were significantly lower in individuals with TEE. Hypoalbuminemia was a risk factor for the development of TEE in IBD. Serum albumin dosage is a simple and accessible test that can be used in the risk stratification of active IBD patients.