Baseline Hypoalbuminemia Research Articles

Serum Albumin for Short-Term Poor Prognosis in Patients With Acute Pulmonary Embolism: A Clinical Study Based on a Database.

The relationship between serum albumin (ALB) and short-term prognosis in patients with acute pulmonary embolism (APE) remains unclear. We investigated the predictive value of ALB for short-term prognosis in APE patients using our hospital pulmonary embolism (PE) database (384 patients consecutively collected). Logistic regression analysis and nomograms were applied to construct the predictive model, and validation was assessed. A total of 340 APE patients were included, with a 30-day all-cause mortality rate of 8.5%. The incidence of hypoalbuminemia was 15.9%. The odds ratio (OR) for short-term mortality in patients with high ALB was 0.89 (0.886, 95% CI: 0.812-0.967). Additionally, we created a nomogram for individualized mortality risk prediction. Receiver operating characteristic (ROC) curve analysis showed that the diagnostic area under the curve (AUC) of ALB was 0.758 (95% CI 0.683-0.833), and the best cut-off value was 33.85g/L. Optimal simplified Pulmonary Embolism Severity Index (sPESI) (ALB combined sPESI) AUC was 0.835 (95% CI 0.775-0.896). Baseline hypoalbuminemia may be an independent prognostic indicator of short-term mortality in patients with APE.

The Prevalence and Risk Factors of Acute Kidney Injury during Colistin Therapy: A Retrospective Cohort Study from Lebanon.

The current study aimed to determine the prevalence, risk factors, and stages of severity of acute kidney injury (AKI) caused by colistimethate sodium (CMS) treatment in patients diagnosed with systemic antibiotic-resistant Gram-negative bacterial infections. The predictors of all-cause mortality in this patient population were also examined. This retrospective cohort study included patients who were admitted to a university-affiliated hospital and acute tertiary care referral center in Beirut, Lebanon between January 2015 and December 2018 and underwent CMS treatment for a period of 48 h or more. The study sample included 298 adult patients, of which 46.3% (n = 138/298) developed AKI (assessed using the Kidney Disease Improving Global Outcomes (KDIGO) criteria). Of these, 37.7% (n = 51/138) were diagnosed with stage 1 AKI, 23.9% with stage 2 (n = 33/138), and 38.4% with stage 3 (n = 53/138). Nephrotoxicity was reversed in 87.5% of AKI patients who survived until hospital discharge. Independent risk factors for AKI included patient age ≥ 75 years (aOR = 1.854; 95% CI: 1.060-3.241; p-value = 0.03); underlying chronic kidney disease (aOR = 4.849; 95% CI: 2.618-9.264; p-value < 0.0001); and concomitant use of vasopressors (aOR = 4.305; 95% CI: 2.517-7.456; p-value < 0.0001). Multivariate analysis showed that the predictors of severe AKI (stage 2 or 3) included baseline hypoalbuminemia (aOR = 2.542; 95% CI: 1.000-6.564; p-value = 0.05); concomitant use of vasopressors (aOR = 6.396; 95% CI: 2.741-15.87; p-value < 0.0001); and CMS days of therapy (DOT) prior to development of AKI ≥ 7 days (aOR = 4.728; 95% CI: 2.069-11.60; p-value < 0.0001). All-cause mortality was recorded in 51.3% of patients (n = 153/298), and this was significantly higher in patients with AKI (76.8%; n = 106/138) compared to those without (29.4%; n = 47/160; OR = 7.964; 95% CI: 4.727-13.417; p-value < 0.0001). Independent predictors of all-cause mortality included a baseline Charlson comorbidity index score ≥5 (aOR = 4.514; 95% CI: 2.443-8.530; p-value < 0.0001); concomitant use of vasopressors (aOR = 7.76; 95% CI: 4.238-14.56; p-value < 0.0001); and CMS-induced AKI (aOR = 4.117; 95% CI: 2.231-7.695; p-value < 0.0001). The findings of this study suggest that old age, history of chronic kidney disease, and concomitant vasopressor treatment are all independent predictors of CMS-induced AKI. The risk of developing severe AKI significantly increases with CMS DOT. Understanding the risk factors of nephrotoxicity is essential for improving prognosis and treatment outcomes.

Severe hypertension development significantly improves progression-free survival in regorafenib treatment for metastatic colorectal cancer.

Regorafenib is the first multikinase inhibitor used for metastatic colorectal cancer (mCRC) treatment. Reports regarding other multikinase inhibitors have suggested that the development of hypertension is associated with improved clinical benefits. We aimed to reveal the relationship between the development of severe hypertension and regorafenib efficacy in an mCRC real-world setting. Patients with mCRC (n = 100) who received regorafenib were assessed retrospectively. The primary endpoint was a comparison of progression-free survival (PFS) between patients with and without ≥ grade 3 hypertension. The secondary endpoints were overall survival (OS), disease control rate (DCR), and adverse effects. Patients developing ≥ grade 3 hypertension accounted for 30%, and obtained significantly longer PFS than control patients (median PFS of 53 and 56days, 95% confidence interval [CI] of 46-144 and 49-63days, respectively; P = 0.04). In contrast, OS and DCR were not statistically different between the groups (P = 0.13 and P = 0.46, respectively). The incidence and severity of adverse effects were not significantly different, except for hypertension. Treatment interruption was significantly more frequent in patients with hypertension (P = 0.04). Multivariate Cox hazard analysis suggested that the development of ≥ grade 3 severe hypertension was an independent factor for improved PFS (adjusted hazard ratio 0.57, 95% CI 0.35-0.93; P = 0.02). In contrast, baseline hypoalbuminemia was associated with a worse PFS (1.85, 1.14-3.01; P = 0.01). We have revealed that patients who develop severe hypertension after regorafenib treatment for mCRC have improved PFS. Management of hypertension is important for effective treatment with less burden; therefore, further evaluation is needed.

Expert Consensus on the Use of Human Serum Albumin in Adult Cardiac Surgery.

Expert Consensus on the Use of Human Serum Albumin in Adult Cardiac Surgery.

Management of Adverse Events in Early Clinical Trials by Advanced Practice Providers in the Outpatient Setting: The University of Texas MD Anderson Cancer Center Experience.

Background:Advanced practice providers (APPs) play important roles in enrolling, educating, and caring for patients in clinical trials. However, much remains unknown about the role of APPs in managing adverse events (AEs) in early (phase I to II) clinical trials. In this study, we assessed the outpatient management of grade 3 to 4 AEs by APPs in early trials and characterized the workflow of our APP Phase I to II Fast Track (FT) Clinic.Patients and Methods:We retrospectively reviewed records of patients with advanced or metastatic solid tumors enrolled in phase I to II clinical trials who were seen by APPs from September 2017 to August 2018 in the APP phase I to II FT clinic in the Department of Investigational Cancer Therapeutics.Results:A total of 808 patients enrolled in 159 clinical trials were seen in 2,697 visits (median 3 visits per patient; range 1–28) by 10 APPs. Treatment was interrupted in 6.9% of visits, and grade 3 to 4 AEs were seen in 5.4% of visits; however, patients from 1.4% of visits were sent to the emergency center (EC) and/or admitted. Patients referred to the EC and/or admitted were more likely to have baseline hypoalbuminemia, high lactate dehydrogenase, and poor Eastern Cooperative Oncology Group performance status (i.e., ECOG > 1; p < .001). There were no associations between EC referral and gender, APP years of experience, or type of treatment.Conclusions:The APP Phase I to II FT Clinic has an important role in the management of AEs by APPs in early clinical trials in the outpatient setting, potentially avoiding EC visits and admissions.

Prognostic Values of Inflammatory Indexes and Clinical Factors in Patients with Epidermal Growth Factor Receptor Mutations in Lung Adenocarcinoma and Treated with Tyrosine Kinase Inhibitors.

This study aimed to access the predictive value of inflammatory indices and clinical factors in toxicity and survival in patients with epidermal growth factor receptor (EGFR)-mutated lung adenocarcinoma receiving first-line tyrosine kinase inhibitor (TKI)-treatment. A total of 259 patients with stage IIIB–IV lung adenocarcinoma and actionable EGFR mutation who received first-line TKI treatment between 2008 and 2020 were retrospectively enrolled and analyzed. The prognostic factors of TKI-related toxicity, overall survival (OS), and progression-free survival (PFS) were identified by using logistic regression analysis and Cox proportional hazards models. Pre-TKI high platelet-to-lymphocyte ratio (PLR) was associated with post-TKI anemia. Hypoalbuminemia was associated with acneiform rash. Elderly age (≥70 years) and lower body mass index (<18.5 kg/m2) were also associated with hypoalbuminemia. Elderly age, stage IV, EGFR-mutated with L858R and uncommon mutations, and neutrophil-to-lymphocyte ratio were found to be independent prognostic factors for PFS, while elderly age, uncommon EGFR-related mutations, and lymphocyte-to-monocyte ratio were found to be independent prognostic factors for OS. A useful prognostic scoring tool for improving the survival risk stratification of patients was established by incorporating the above essential factors. Baseline hypoalbuminemia and PLR could be crucial clinical assessment factors when initiating TKI therapy. In addition, the optimization of individualized treatment strategies for these patients may be assisted by using the risk-scoring model.

Negative anti-phospholipase A2 receptor antibody status at three months predicts remission in primary membranous nephropathy

Background The value of anti-phospholipase A2 receptor antibody (anti-PLA2R ab) monitoring at 3 months after diagnosis in membranous nephropathy (MN) remains uncertain. Methods We retrospectively examined the outcome on 1 August 2020 of 59 adult patients (age 54 (44, 68) years, 69% male, SCr 1.0 (0.9, 1.3) mg/dL) diagnosed with MN (kidney biopsy, positive serum anti-PLA2R ab). The outcomes were: kidney survival; partial and/or complete remission. Results Most of the studied patients (97%) received immunosuppression, cyclophosphamide regimens were the most frequent (87%), followed by cyclosporine (10%). The median time to remission was 12.0 months and the cumulative remission rates were 34% at 6, 54% at 12, and 73% at 24 months. Forty (69%) patients had negative anti-PLA2R ab at 3 months, they had similar age, serum creatinine, albumin, proteinuria, and treatment with the group with positive ab at 3 months. In the Cox proportional hazard model, three months anti-PLA2R ab negativization (HR 0.4 (95%CI 0.1, 0.9)) was an independent predictor for remission, while baseline hypoalbuminemia (HR 3.0 (95%CI 1.5, 5.7)) was associated with absence of remission. Six (10%) patients died, mostly due to cardiovascular disease and infections. A total of five (9%) patients started dialysis. Mean kidney survival time was 50.3 months and there was no survival difference in relation to baseline anti-PLA2R ab titer (p .09) or 3 months negativization (p .8). Conclusions Three months anti-PLA2R ab negativization seems to be a late predictor of remission, and lower serum albumin at diagnosis is an early marker for remission absence. Abbreviations: anti-P LA2R ab, anti-phospholipase A2 receptor antibody; eGFR, estimated glomerular filtration rate; ESKD, end stage kidney disease; MN, membranous nephropathy; NELL-1, neural epidermal growth factor-like 1 protein; RAAS: renin–angiotensin–aldosterone system; RBC: red blood cells; RRT, renal replacement therapy; T HSD7A, thrombospondin type-1 domain containing 7A

Impact of Weight Loss on Patients with Locally Advanced Esophageal and Esophagogastric Junction Cancers Treated with Chemoradiotherapy

Introduction:Malnutrition and weight loss are commonly observed in patient with esophageal and esophagogastric junction (EGJ) cancers. Chemoradiotherapy (CRT) is a mainstay of treatment for locally advanced esophageal and EGJ cancers. Impact of weight loss on patients with treated with CRT was not well studied. Methods:Patients with locally advanced esophageal and EGJ cancer who received CRT were identified in our institutional database and allocated into low (LWL) and high (HWL) weight loss groups. HWL was defined as weight loss >5% of baseline during CRT. Results: A total of 167 patients were underwent definitive (n=89) or preoperative (n=78) CRT, respectively. HWL was observed in 46% and 55% of patients treated with definitive and preoperative CRT, respectively. Cisplatin/5FU regimen used during CRT was a significant predictive factor for weight loss in multivariate analysis (OR 2.07, 95% CI 1.09–3.94; p=0.026). In the definitive CRT group, patients in the HWL group experienced significantly worse overall survival than those in the LWL group (1.2 years vs 1.95 years; p=0.003). Multivariate analysis revealed that baseline albumin (>3.0 g/dL) was significantly associated with longer OS of definitive CRT patients (HR 2.15, 95% CI 1.1-4.19; p=0.024). Tolerability and toxicities during CRT were not statistically different between groups. Conclusion:Significant weight loss during CRT was frequently observed in patients with locally advanced esophageal and EGJ cancers. Baseline hypoalbuminemia was an independent prognostic factor for OS in patients treated with definitive CRT. Nutritional support before and during treatment should be considered to potentially improve patients’ outcomes.

Longitudinal Analysis of the Utility of Liver Biochemistry as Prognostic Markers in Hospitalized Patients With Corona Virus Disease 2019.

The association of liver biochemistry with clinical outcomes of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection is currently unclear, and the utility of longitudinally measured liver biochemistry as prognostic markers for mortality is unknown. We aimed to determine whether abnormal liver biochemistry, assessed at baseline and at repeat measures over time, was associated with death in hospitalized patients with COVID‐19 compared to those without COVID‐19, in a United Kingdom population. We extracted routinely collected clinical data from a large teaching hospital in the United Kingdom, matching 585 hospitalized patients who were SARS‐CoV‐2 real‐time reverse transcription‐polymerase chain reaction (RT‐PCR) positive to 1,165 hospitalized patients who were RT‐PCR negative for age, sex, ethnicity, and preexisting comorbidities. A total of 26.8% (157/585) of patients with COVID‐19 died compared to 11.9% (139/1,165) in the group without COVID‐19 (P < 0.001). At presentation, a significantly higher proportion of the group with COVID‐19 had elevated alanine aminotransferase (20.7% vs. 14.6%, P = 0.004) and hypoalbuminemia (58.7% vs. 35.0%, P < 0.001) compared to the group without COVID‐19. Within the group with COVID‐19, those with hypoalbuminemia at presentation had 1.83‐fold increased hazards of death compared to those with normal albumin (adjusted hazard ratio [HR], 1.83; 95% confidence interval [CI], 1.25‐2.67), while the hazard of death was ~4‐fold higher in those aged ≥75 years (adjusted HR, 3.96; 95% CI, 2.59‐6.04) and ~3‐fold higher in those with preexisting liver disease (adjusted HR, 3.37; 95% CI, 1.58‐7.16). In the group with COVID‐19, alkaline phosphatase (ALP) increased (R = 0.192, P < 0.0001) and albumin declined (R = −0.123, P = 0.0004) over time in patients who died. Conclusion: In this United Kingdom population, liver biochemistry is commonly deranged in patients with COVID‐19. Baseline hypoalbuminemia and rising ALP over time could be prognostic markers for death, but investigation of larger cohorts is required to develop a better understanding of the relationship between liver biochemistry and disease outcome.

Real-World Performance of High-Flux Dialyzers in Patients With Hypoalbuminemia.

There is little research on factors that influence the choice of dialyzer in patients undergoing hemodialysis. In patients at risk for poorer outcomes, including those with hypoalbuminemia, understanding how this choice impacts clinical parameters could inform patient management. The objective of this real-world analysis was to evaluate the use and performance of four single-use (i.e., nonreuse [NR]), high-flux Optiflux dialyzers with varying surface areas (F160NR [1.5 m2], F180NR [1.7 m2], F200NR [1.9 m2], and F250NR [2.5 m2]) in patients (N = 271) with baseline hypoalbuminemia (≤3.5 g/dl) receiving hemodialysis at a medium-sized dialysis organization. Thrice weekly, in-center dialysis was delivered for 6 months without adjustments to the hemodialysis prescription. Larger dialyzers were more frequently used in men, patients with higher body mass indices, and those with diabetes. Increases in serum albumin from baseline (month 1) to month 6 (p < 0.05) were observed with all dialyzer sizes. A mean increase in hemoglobin of 0.31 g/dl was also observed (p < 0.001). Among patients exhibiting increased serum albumin levels (n = 177), reductions in the neutrophil-to-lymphocyte ratio, a marker of inflammation, were observed (mean: 0.90; p < 0.001). These results support the use of high-flux dialyzers in patients with hypoalbuminemia.

Peritoneal transport status and first episode of peritonitis: a large cohort study

Background Peritonitis is one of the most serious complications of peritoneal dialysis (PD). This study aimed to explore the relationship between peritoneal transport status and the first episode of peritonitis, as well as the prognosis of patients undergoing continuous ambulatory peritoneal dialysis (CAPD). Method A retrospective cohort study was conducted, analyzing data of CAPD patients from 1st January 2009, to 31st December 2017. Baseline data within 3 months after PD catheter placement was recorded. Cox multivariate regression analysis was performed to determine the risk factors for the first episode of peritonitis, technique failure and overall mortality. Results A total of 591 patients were included in our analysis, with a mean follow-up visit of 49 months (range: 27–75months). There were 174 (29.4%) patients who had experienced at least one episode of peritonitis. Multivariate Cox regression analysis revealed that a higher peritoneal transport status (high and high-average) (HR 1.872, 95%CI 1.349–2.599, p = 0.006) and hypoalbuminemia (HR 0.932,95% CI 0.896, 0.969, p = 0.004) were independent risk factors for the occurrence of the first episode of peritonitis. In addition, factors including gender (male) (HR 1.409, 95%CI 1.103, 1.800, p = 0.010), low serum albumin (HR 0.965, 95%CI 0.938, 0.993, p = 0.015) and the place of residence (rural) (HR 1.324, 95%CI 1.037, 1.691, p = 0.024) were independent predictors of technique failure. Furthermore, low serum albumin levels (HR 0.938, 95%CI 0.895, 0.984, p = 0.008) and age (>65years) (HR 1.059, 95%CI 1.042, 1.076, p < 0.001) were significantly associated with the risk of overall mortality of PD patients. Conclusions Baseline hypoalbuminemia and a higher peritoneal transport status are risk factors for the first episode of peritonitis. Factors including male gender, hypoalbuminemia, and residing in rural areas are associated with technique failure, while hypoalbuminemia and age (>65years) are predictors of the overall mortality in PD patients. Nevertheless, the peritoneal transport status does not predict technique failure or overall mortality of PD patients.

Perioperative improvement in serum albumin level in patients with left ventricular assist device.

The negative impact of baseline hypoalbuminemia on clinical outcome following left ventricular assist device (LVAD) implantation is well known. However, the implications of perioperative change in serum albumin levels on post-LVAD outcomes remain uninvestigated. Among consecutive patients with baseline serum albumin <3.5 g/dl who received durable LVAD implantation between April 2014 and August 2017 and were followed for 1 year, the impact of perioperative change in serum albumin level from baseline to 3 months post-LVAD on the incidence of adverse events was investigated. Sixty-eight patients (median 60 years and 69% male) were included. Serum albumin change was an independent predictor of the occurrence of adverse events with an adjusted hazard ratio of 0.32 (95% confidence interval, 0.13-0.78) and a cutoff change of 0.7 g/dl. Those with albumin increase >0.7 g/dl had higher 1-year freedom from adverse events (45% vs. 14%, p = .008), dominantly due to lower incidence of death or sepsis compared with those without (p < .05 for both). Among those with baseline hypoalbuminemia, a considerable perioperative increase in serum albumin levels following LVAD implantation was associated with lower mortality and morbidity. The implication of aggressive nutrition intervention on LVAD patients is the next concern.

Predictors and Prognostic Impact of Nutritional Changes After Transcatheter Aortic Valve Replacement

BackgroundLittle is known about changes in nutritional status as an index of frailty on clinical outcomes after transcatheter aortic valve replacement (TAVR). This study aimed to assess the clinical impact of serum albumin changes after TAVR. MethodsChanges in serum albumin levels from baseline to 1 year after TAVR were evaluated in 1524 patients who were classified as having hypoalbuminemia (<3.5 g/dl) and normoalbuminemia (≥3.5 g/dl) at each timepoint. The patients were categorized into 4 groups: NN (baseline normoalbuminemia, 1-year normoalbuminemia: n = 1119), HN (baseline hypoalbuminemia, 1-year normoalbuminemia: n = 202), NH (baseline normoalbuminemia, 1-year hypoalbuminemia: n = 121), and HH (baseline hypoalbuminemia, 1-year hypoalbuminemia: n = 82). We also defined late hypoalbuminemia as hypoalbuminemia identified at the 1-year assessment. Clinical outcomes were compared among 4 groups. Multivariable analysis was driven to assess the variables associated with late hypoalbuminemia and long-term mortality. ResultsThe cumulative 3-year mortality was significantly different among the 4 groups (NN: 11.4%, HN: 10.7%, NH: 25.4%, HH: 44.4%, p < 0.001). Multivariable Cox regression analysis revealed that the NH group had a higher mortality risk (hazard ratio [HR]; 2.80 and 3.53, 95% confidence interval [CI]; 1.71–4.57 and 2.06–6.06, p < 0.001 and p < 0.001, respectively), whereas the HN group had a similar risk (HR; 1.16, 95% CI; 0.66–2.06, p = 0.61) compared with the NN group. Baseline hypoalbuminemia, low body mass index, liver disease, peripheral artery disease, and hospital readmission within 1 year were predictors of late hypoalbuminemia (all p < 0.05). ConclusionSerial albumin assessment may identify poor prognostic subsets in patients with persistent and late acquired malnutrition after TAVR.

Baseline Hypoalbuminemia Does Not Appear to be an Adverse Prognostic Factor in Patients with Relapse/Refractory B-Cell Lymphomas Treated with Axicabtagene Ciloleucel (axi-cel)

Baseline Hypoalbuminemia Does Not Appear to be an Adverse Prognostic Factor in Patients with Relapse/Refractory B-Cell Lymphomas Treated with Axicabtagene Ciloleucel (axi-cel)

Changes in serum albumin and other nutritional markers when using sucroferric oxyhydroxide as phosphate binder among hemodialysis patients: a historical cohort study

BackgroundElevated serum phosphorus concentrations are common among maintenance hemodialysis patients. Protein is a major source of dietary phosphate, but restriction of protein intake can result in hypoalbuminemia and protein-energy wasting. We hypothesized that sucroferric oxyhydroxide (SO), a potent phosphate binder with a low pill burden, may reduce serum phosphorus levels in hemodialysis patients with hypoalbuminemia without adversely impacting albumin levels or dietary intake of protein.MethodsWe retrospectively examined de-identified data from 79 adult, in-center hemodialysis patients with baseline hypoalbuminemia (≤ 3.5 g/dL) switched to SO as part of routine clinical care for at least 1 year. Temporal changes (3-month intervals from baseline through Q4) in phosphate binder pill burden, serum phosphorous levels, nutritional markers, and equilibrated Kt/V were analyzed. Data from a matched reference group of non-hypoalbuminemic patients (N = 79) switched to SO were also examined.ResultsSO therapy was associated with a mean reduction of 45.7 and 45.1% in daily phosphate binder pill burden, and a mean reduction of 0.4 mg/dL and 0.51 mg/dL in serum phosphorus levels for the hypoalbuminemic and non-hypoalbuminemic patients, respectively. Hypoalbuminemic patients demonstrated significant increases in mean serum albumin levels from 3.50 mg/dL at baseline to 3.69, 3.74, 3.70, and 3.69 mg/dL during Q1 through Q4, respectively (P < 0.0001), whereas serum albumin levels remained unchanged in the non-hypoalbuminemic group.ConclusionsBoth hypoalbuminemic and non-hypoalbuminemic patients switching to SO exhibited significant reductions in serum phosphorus concentrations and daily phosphate binder pill burden. Among hypoalbuminemic patients, the initiation of SO therapy was also associated with increases in serum albumin, suggesting therapy may have allowed patients to increase their dietary intake of protein.

High dose intravenous colistin methanesulfonate therapy is associated with high rates of nephrotoxicity; a prospective cohort study from Saudi Arabia

BackgroundNephrotoxicity is an important adverse effect of colistin methanesulfonate (CMS) therapy. No data exist on rates and risk factors for colistin-related nephrotoxicity in Saudi Arabia (SA). We conducted a prospective cohort study to identify rates and risk factors for CMS nephrotoxicity in our patient population.MethodsWe prospectively included adult patients who received ≥48 hours of intravenous CMS therapy. Pregnant patients and those on renal replacement were excluded. Patients received 9 million units (mU) loading dose followed by 3 mU 8 hourly. In renal impairment, CMS dosing was adjusted according to calculated creatinine clearance (CrCl). Nephrotoxicity was defined as per RIFLE criteria (Risk, Injury, Failure, Loss and End-stage renal disease). Statistical analysis was performed using SPSS version 20.0 (IBM, Armonk, New York, USA). The study was approved by the institution’s Research Ethics Committee.ResultsA total of 67 patients were included in the study. Mean (±standard deviation) age was 57.5 (±24.0) years, Charlson Co-morbidity Score 2.88 (±2.39), CrCl 133.60 (±92.54) mL/min and serum albumin 28.65 (±4.45) g/L. Mean CMS dose was 0.11 (±0.04) mU/kg/day and mean total CMS dose received was 101.21 (±47.37) mU. Fifty-one (76.1%) patients developed RIFLE-defined nephrotoxicity. Mean total CMS dose and duration of therapy before onset of nephrotoxicity were 66.71 (±43.45) mU and 8.70 (±6.70) days, respectively. In bivariate analysis, patients with nephrotoxicity were significantly older (P 0.013) and had lower baseline serum albumin (P 0.008). Multivariate logistic regression identified serum albumin [odds ratio (OR) 0.72; 95% confidence interval (CI) 0.57–0.93; P 0.010] and intensive care admission (OR 16.38; 95% CI 1.37–195.55; P 0.027) as independent risk factors for CMS nephrotoxicity.ConclusionsHigh dose intravenous CMS therapy is associated with high rates of nephrotoxicity in SA. Independent risk factors for colistin nephrotoxicity were baseline hypoalbuminemia and intensive care admission.

The role of palliative chemotherapy in hospitalized patients.

Hospitalized patients with advanced cancer often have a poor performance status, which is considered a relative contraindication to cytotoxic chemotherapy. We investigated outcomes in hospitalized solid tumour oncology patients who received palliative chemotherapy (pct). With ethics approval, we performed a single-institution chart review of all patients hospitalized on our oncology unit who received pct between April 2008 and January 2010. Patient demographics, reasons for admission, cancer type, prior therapy, and administered chemotherapy were recorded. The primary endpoint was median survival from date of inpatient chemotherapy until death or last known follow up. We also investigated place of discharge and whether patients received additional therapy. During the study period, 199 inpatients received pct. Median age was 61 years; 59% of the patients were women. Most had been admitted with dyspnea (31%) or pain (29%) as the dominant symptom. Common cancers represented were breast (23%), small-cell lung cancer (sclc, 22%), non-small-cell lung cancer (nsclc, 16%), and colorectal cancer (9%). Most patients (67%) were receiving first-line chemotherapy. Median overall survival duration was 4.5 months, and the 6-month survival rate was 41%. The longest and shortest survivals were seen in the sclc and nsclc groups (7.3 and 2.5 months respectively). Factors significantly associated with shorter survival were baseline hypoalbuminemia and therapy beyond the first line. In this cohort, 77% of patients were discharged home, and 72% received further chemotherapy. Despite a short median survival, many patients are well enough to be discharged home and to receive further chemotherapy. The development of risk models to predict a higher chance of efficacy will have practical clinical utility.

Risk Factors for High Mesothelial Cell Counts in HIV-negative Patients With Tuberculous Pleural Effusion

Higher mesothelial cell counts (HM) greater than 5% of total cell counts in tuberculous pleural effusions (TBPE) have been described in human immunodeficiency virus (HIV)-infected patients, however the nature and risk factors in HIV-negative patients with TBPE are unknown. The purpose of the study was to characterize the clinical manifestation of HM in HIV-negative patients with TBPE and evaluate the risk factors of developing HM-TBPE. This retrospective study was undertaken in HIV-negative patients with TBPE from the Far Eastern Memorial Hospital Tuberculosis database. The cytologist and examining specialist differentiated and quantified the cell counts. HM-TBPE was defined when more than 5% of total cell counts in the pleural fluid were mesothelial cells. Multivariate analysis was calculated with stepwise logistic regression for HM-TBPE risk factors. Nineteen patients were diagnosed as HM-TBPE, while 30 were diagnosed with lower mesothelial cell counts TBPE (LM-TBPE). Compared with LM-TBPE patients, those with HM-TBPE had significantly decreased hemoglobin and serum albumin levels (p<0.05). Organ dysfunction such as congestive heart failure, liver cirrhosis and renal failure was significantly more common in patients with HM-TBPE (47.4%) than in patients with LM-TBPE (13.3%; p=0.01). Multivariate analysis revealed that independent risk factors for developing HM-TBPE included hypoalbuminemia (odds ratio =1.6; 95% confidence interval = 1.1-13.8) and the presence of organ dysfunction (odds ratio =4.5; 95% confidence interval = 1.4-17.5). Baseline hypoalbuminemia and comorbidities were independent risk factors for development of HM-TBPE in HIV-negative patients. Mesothelial cell counts should not be used alone in the diagnosis of TBPE. An understanding of the organ dysfunction associated with HM-TBPE in HIV-negative patients could avoid delayed diagnosis and treatment of tuberculosis.

Severity of Hypoalbuminemia Predicts Response to Intradialytic Parenteral Nutrition in Hemodialysis Patients

Intradialytic parenteral nutrition (IDPN) is used infrequently to correct hypoalbuminemia in maintenance hemodialysis (MHD) patients. We hypothesized that the severity of baseline hypoalbuminemia correlates with the success rate of IDPN therapy in MHD patients. In a prospective and contemporary cohort of 196 hypoalbuminemic MHD patients who received IDPN through Pentec Health (Boothwyn, PA), predictors of IDPN response were examined using multivariate logistic regression. Of 196 hypoalbuminemic MHD patients, 134 had severe hypoalbuminemia, defined as a baseline serum albumin level of less than 3.0 g/dL. The average period of IDPN therapy was 5.8 +/- 2.4 months, S.D. The baseline level of serum albumin was lower in MHD patients who responded to IDPN (2.68 +/- 0.47 g/dL, S.D.). A multivariate logistic regression analysis adjusted the associations for age, gender, diabetes, and IDPN time. The presence of severe hypoalbuminemia (serum albumin, <3.0 g/dL) at baseline was associated with a 2.5 times higher chance of responding to IDPN (95% confidence interval, 1.3 to 4.9; P = .006). The same severe hypoalbuminemia was associated with a 3.5 times increased likelihood of serum albumin correction by at least 0.5 g/dL (95% confidence interval, 1.8 to 6.8; P < .001). Improvement of hypoalbuminemia occurs in most hypoalbuminemic MHD patients who receive IDPN therapy. The likelihood and magnitude of the response to IDPN are associated with the severity of baseline hypoalbuminemia. These associations need to be verified in controlled trials.

Clostridium Difficile Associated Diarrhea

Purpose: CDAD is a common nosocomial infection, and a frequent cause of morbidity and mortality among elderly patients. There are three million new inpatient cases of CDAD each year, affecting 10% of patients hospitalized for >2 days (1). In this study, we used simple biochemical tests like blood leucocyte count, serum albumin level and fecal leucocyte test (FLT) to predict prolonged hospitalization and increased mortality in CDAD patients. Methods: A retrospective study was conducted by analysis of the records of all inpatients between March 2003 and April 2006 who had a positive stool immunoassay test for Clostridium. difficile. The normal range for blood leucocyte count was 4.8–10.8 thou/ml, and 3.5–4.8 g/dL for serum albumin. The lower limit for positive FLT was ≥1 WBC/HPF. The patient's demographics, result of FLT, increase or decrease in blood leucocyte count, baseline hypoalbuminemia and drop in serum albumin level during the course of CDAD were recorded. The data was analyzed using paired t test. Results: There were 112 patients (39M; 73F). Mean age was 68.7 yrs (range 23 to 101). Of the 112 patients, 31 (27.7%) expired during the course of CDAD. Drop in serum albumin level and abnormal blood leucocyte count showed a statistically significant association with increased mortality (p-values 0.0017 and 0.0001 respectively). Baseline hypoalbuminemia and positive FLT weren't statistically significant. Of 112 patients, 21 (18.7%) expired before the 4th week. Of the remaining 91 patients, 20 (21.95%) stayed beyond 4 weeks. Drop in serum albumin level and abnormal blood leucocyte showed statistically significant association with prolonged hospitalization (p-values 0.0528 and 0.0188 respectively). Baseline hypoalbuminemia and positive FLT weren't statistically significant. Conclusions: In our study, drop in serum albumin level and abnormal blood leucocyte count were associated with prolonged hospitalization and mortality. The drop in serum albumin level is not only because of co-morbid conditions, CDAD itself associated with protein-losing enteropathy (2). Such patients may warrant more aggressive management of CDAD along with correction of underlying co-morbid conditions and nutritional requirements.