Initial Serum Albumin Levels Research Articles

Clinical characteristics of acute hepatitis A complicated by acute kidney injury

The incidence of acute viral hepatitis A (AHA) in Korea is increasing rapidly. Additionally, we are encountering more cases with acute kidney injury (AKI), which was once regarded as a rare complication of AHA. Thus, we investigated recent aspects of the incidence and clinical characteristics of AHA complicated by AKI. Patients diagnosed with AHA at 2 referral hospitals in Seoul during the period January 2006 to December 2009 were enrolled. Of 1025 patients, 71 (6.9%) had AKI. The incidence of AKI was 3.1% in 2006, 6.0% in 2007, 8.9% in 2008, and 6.9% in 2009. Patients with AKI were predominantly male, heavy alcohol drinkers, and smokers, and also had a higher rate of underlying hypertension than patients without AKI. At admission, patients with AKI had significantly higher white blood cell counts, prolonged prothrombin times, and elevated liver enzymes, including total and direct bilirubin, gamma-glutamyltransferase, and C-reactive protein. Additionally, patients with AKI had a higher peak total bilirubin level and lower initial serum albumin level than patients without AKI. Although most patients with AHA complicated by AKI recover with conservative treatment, we should pay particular attention to patients who have risk factors for AKI.

Early Start of Hemodialysis May Be Harmful

A dramatic increase in the "early start" of dialysis with an estimated glomerular filtration rate (eGFR) at least 10 mL/min/1.73 m(2) has occurred in the United States since at least 1996. Several recent studies have reported a comorbidity-adjusted survival disadvantage of early start of dialysis. The current study examines a relatively "healthy" dialysis cohort to minimize confounding issues and determine whether early initiation of hemodialysis is associated with a survival benefit or harm. We examined demographics, year of dialysis initiation, primary etiology of renal failure, and body mass index, hemoglobin, and serum albumin levels in 81,176 nondiabetic, 20- to 64-year-old, in-center incident hemodialysis patients with no reported comorbidity besides hypertension. We compared survival, using a piecewise proportional hazards model to estimate covariate-adjusted mortality hazard ratios (HRs) for eGFR at the time of initiation of dialysis. We also performed time-dependent adjusted analysis stratified by initial serum albumin levels lower than 2.5 g/dL, 2.5 to 3.49 g/dL, and 3.5 g/dL or higher (the "healthiest" group [HG]). Unadjusted 1-year mortality by eGFR ranged from 6.8% in the reference group (eGFR <5.0 mL/min/1.73 m(2)) to 20.1% in the highest eGFR group (≥15.0 mL/min/1.73 m(2)). Compared with the reference group, the HR for the HG was 1.27 (eGFR, 5.0-9.9 mL/min/1.73 m(2)), 1.53 (eGFR, 10.0-14.9 mL/min/1.73 m(2)), and 2.18 (eGFR ≥15.0 mL/min/1.73 m(2)) and ranged from 1.50 to 3.53 mL/min/1.73 m(2) in the first year of dialysis for the early-start group. The increased HR during hemodialysis associated with early start in the healthiest group of patients undergoing dialysis indicates that early start of dialysis may be harmful.

Influence of ketoanalogs supplementation on the progression in chronic kidney disease patients who had training on low‐protein diet

A low-protein diet (LPD) is a conservative treatment in patients with chronic kidney disease (CKD) to improve uremic symptoms and slow the progression of renal dysfunction. However, the deleterious effects of protein restriction on nutritional status have raised concern. We investigated whether ketoanalogs supplementation in CKD patients who had training on LPD retards the progression of CKD and maintains nutritional status. Data were collected retrospectively from 120 consecutive patients in the CKD stages III and IV. Firstly all patients were restricted to LPD alone for 6 months (LPD alone), and then ketoanalogs of essential amino acids (KA) were supplemented for 6 months. The adequate LPD had not achieved in both periods. The declining slopes of glomerular filtration rate (GFR) during the LPD + KA period were significantly lower than those during the LPD alone period. This improvement in GFR was apparent in both subjects with diabetics and non-diabetic patients. Mean serum total cholesterol levels decreased in LPD + KA compared with LPD alone period. However, serum albumin levels did not change. Responders showed a higher prevalence of diabetes and higher serum albumin levels during the LPD alone period. Multivariate analysis revealed that responsiveness to LPD + KA was independently related to diabetes (p = 0.006) and high serum albumin levels (p = 0.011) in the LPD alone period. KA supplementation on over LPD delayed the progression of CKD without deteriorating nutritional status, and initial serum albumin levels could be an independent factor.

US Highlights

In a new analysis of the saline versus albumin fluid evaluation (SAFE) study, the investigators examined (doi: 10.1136/bmj.38985.398704.7C) clinical outcomes of over 6000 Australian patients in intensive care who had been randomized to receive either saline or albumin for their fluid resuscitation. Whether their initial serum albumin levels were high or low, there was no difference in mortality, length of stay, or other outcome variables between the two groups. In an accompanying editorial (doi: 10.1136/bmj.39029.490081.80), J L Vincent points out that the SAFE study was undertaken to establish not whether albumin was better than saline, but whether it was as safe, which it was. He argues that no one would use albumin for all patients needing fluids and advocates a trial comparing albumin and saline in ICU patients who are at increased risk of complications. Can increased physical activity reduce weight in preschool children? John Reilly et al performed a randomized controlled trial (doi: 10.1136/bmj.38979.623773.55) in 36 Scottish preschools with 545 children. Half the schools received a physical activity intervention consisting of three 30 minute physical education classes, classroom posters, and home resource packs. The other half served as controls. At six and 12 months, there was no difference between the BMI scores in the two groups of children, although the intervention group children had better movement skills. Antronette Yancey writes in an editorial (doi: 10.1136/bmj.39021.605683.BE) that this result is unsurprising given the “dose” of the intervention and the fact that it was probably applied inconsistently in real world settings. Correct implementation of programs, as well as increased comprehensiveness, are probably needed to show a change in children's weights. Finally, this week's issue has an ethical debate (doi: 10.1136/bmj.38950.645799.55) about whether it can ever be ethical to withhold prenatal testing. The case in point involves a fetus at risk for the gene for Huntington's disease, which is detectable in utero. The disease is universally fatal but does not appear until young adulthood. Some ethical guidelines call for providing prenatal diagnosis only if the parents are planning to abort a fetus that is found to be affected. Martin Delatycki argues that it is appropriate to withhold the test if the parents are not planning an abortion on the grounds of autonomy—otherwise they will be denying their future child the right to determine when and if he learns his diagnosis. Rony Duncan and Bennett Foddy disagree, citing several arguments: in the first trimester, the fetus is part of the mother's body and she should not be denied knowledge about her own body; a couple can never “know” with 100% certainty whether or not they will abort a fetus; and no one should be placed in the untenable position of having to lie to obtain a medical diagnostic test. As genetic medicine becomes more widespread, dilemmas such as this will likely increase.

Albumin at the start of peritoneal dialysis predicts the development of peritonitis

Background: Both peritonitis and serum albumin level are associated with morbidity and mortality in peritoneal dialysis (PD) patients. Severe cases of peritonitis result in hypoalbuminemia. However, it is not clear whether hypoalbuminemia predicts the development of peritonitis. Methods: We performed a retrospective analysis of a prospectively collected database from six centers in western Pennsylvania and West Virginia. Incident PD patients with a Charlson Comorbidity Index (CCI) score at the start of PD therapy and serum albumin level measured within 30 days of initiation were selected. Poisson regression was used to analyze predictors of peritonitis. Results: Three hundred ninety-three patients had a CCI score and serum albumin level measured at the start of PD therapy. Overall peritonitis rate was 0.65 episodes/dialysis-year. Significant univariate predictors were albumin level (rate ratio [RR], 0.79 per 1-g/dL [10-g/L] increase; 95% confidence interval [CI], 0.65 to 0.95; P = 0.015), male sex (P = 0.003), and being dialyzed in the Veterans Administration (RR, 1.97; 95% CI, 1.48 to 2.62; P < 0.001) or other center (RR, 1.68; 95% CI, 1.92 to 5.62; P < 0.001). Although CCI score correlated inversely with albumin level (r = −0.305; P < 0.001), CCI score was only marginally predictive of peritonitis (P = 0.068). In multivariate analysis, predictors were albumin level (RR, 0.74; 95% CI, 0.31 to 1.75; P = 0.002) and race (RR, 1.36; P = 0.024). Patients with an initial serum albumin level less than 2.9 g/dL (29 g/L) had a peritonitis rate of 1.5 episodes/dialysis-year compared with 0.6 episodes/dialysis-year for patients with an initial serum albumin level of 2.9 g/dL or greater (P < 0.001). Conclusion: Hypoalbuminemia at the start of PD therapy is an independent predictor of subsequent peritonitis. Intervention studies to decrease peritonitis risk in this high-risk subset of patients are needed. Am J Kidney Dis 41:664-669. © 2003 by the National Kidney Foundation, Inc.

Respiratory Failure and Sepsis Are the Major Causes of ICU Admissions and Mortality in Survivors of Lung Transplants

To identify outcome predictors and prognostic factors in long-term survivors (> 30 days post-transplant) of single-lung and double-lung transplants on readmission to the medical ICU (MICU). Retrospective study. MICU of the Cleveland Clinic Foundation, a lung transplantation center. As of August 2000, 210 lung transplantations have been performed at our institution. The records of 33 lung transplant recipients who required readmission to the MICU after the initial 30-day post-transplant period over a 4-year period from August 16, 1996 to August 15, 2000 were reviewed. Thirty-three patients had a total of 46 MICU readmissions. Twenty-seven MICU admissions (59%) were due to respiratory deterioration with mechanical ventilation (10 deaths), and 16 MICU admissions (35%) were due to the systemic inflammatory response syndrome (SIRS; 8 deaths). The MICU mortality rate was 37% per admission in our group of patients. A preadmission diagnosis of bronchiolitis obliterans syndrome was observed in 7 of 14 nonsurvivors (50%) and in 5 of 25 patients (20%) surviving to hospital discharge. Respiratory failure and SIRS are the predominant causes of MICU readmissions and are frequent causes of death. APACHE (acute physiology and chronic health evaluation) III scores, nonpulmonary organ system dysfunction, initial serum albumin level, and duration of mechanical ventilation are important prognostic factors.

Impact of Burn Size and Initial Serum Albumin Level on Acute Renal Failure Occurring in Major Burn

Background: Acute renal failure (ARF) is not a rare occurrence in severe burns and is an important complication leading to an increase in mortality. The severity of the burn is largely determined by the burn size, and severe burns are likely to cause enough loss of extracellular fluid and albumin from plasma volume to produce shock and hypoalbuminemia. Hypothesis: We hypothesized that initial serum albumin level may be useful as an indicator of prognosis and severity of injury in burned patients. Methods: The clinical characteristics of 147 adult patients with second- and third-degree burns covering 30% or more of their body surface area were analyzed retrospectively. Logistic regression was used to estimate the relative risks of ARF and mortality associated with the larger burn size and the lower serum albumin level at admission. Results: Mean burned body surface was 60.0 ± 21.8% (range 30–100%). Twenty-eight (19.0%) out of 147 patients experienced ARF, defined as a serum creatinine ≧2 mg/dl, during the admission. The patients with ARF had larger burn size (79.5 ± 15.4 vs. 55.3 ± 20.5%, p < 0.0001) and lower serum albumin concentration at admission (1.92 ± 0.66 vs. 2.48 ± 0.82 g/dl, p < 0.0005) compared with those without ARF. All patients with ARF expired, whereas 29.4% (35/119) of the patients without ARF died. The burn size ≧65% was associated with a risk of ARF that was 9.9 times and with a risk of death that was 14.2 times as high as that for the burn size <65%. The initial serum albumin level <2.5 g/dl was associated with a risk of death that was 2.7 times as high as that for the initial serum albumin level ≧2.5 g/dl. Conclusions: When major burns are complicated by ARF, the mortality rate increases significantly. Burn size is an independent predictor of ARF occurring in major burns. Initially depressed serum albumin level is associated with an increase in mortality in the major burn patients.

Prognostic factors with the use of the transjugular intrahepatic portosystemic shunt for bleeding varices.

To evaluate the outcome of patients undergoing the transjugular intrahepatic portosystemic shunt (TIPS) procedure for bleeding esophageal varices and to outline the factors affecting outcome. Uncontrolled, nonrandomized, retrospective study. A 320-bed university-associated urban emergency adult hospital. Thirty-three patients undergoing TIPS procedures for bleeding esophageal varices with at least 18 months of follow-up. Five patients (15%) had Child class B disease and 28 (85%) had Child class C disease. The mean transfusion requirements were 12.6 U of red blood cells, 18 U of fresh-frozen plasma, and 7 U of platelets. The mean portosystemic gradients before and after the initial TIPS procedure were 18 and 7 mm Hg, respectively. The incidence, time and causes of death, and recurrent variceal hemorrhage were correlated with various clinical and laboratory factors. By 18 months after the TIPS procedure, 16 patients (48%) died of rebleeding or hepatic failure. Subsequent upper gastrointestinal tract bleeding occurred in 14 patients (42%). Of 8 in whom occlusion or stenosis of the TIPS was promptly corrected, all 8 survived. Of 6 in whom occlusion or stenosis of the TIPS was not corrected, 5 (83%) died. Laboratory values (mean +/- SD) predictive of death before 18 months (compared with those of patients alive at 18 months) included a low initial serum albumin level (22 +/- 4 vs 29 +/- 5 g/L; P < .001); an increased initial total bilirubin level (68 +/- 75 vs 34 +/- 20 mumol/L [4.0 +/- 4.4 vs 2.0 +/- 1.2 mg/dL]; P = .001), and an elevated prothrombin time after attempts at correction (18.0 +/- 3.4 vs 14.6 +/- 1.2 seconds; P < .001). The TIPS procedure in patients with Child class C alcoholic cirrhosis was associated with a high incidence of death or rebleeding within 18 months. Prompt correction of TIPS abnormalities in patients with rebleeding increased survival. The albumin, bilirubin, and prothrombin time values obtained before performance of the TIPS procedure were predictive of outcome.

The efficacy number as a predictor of morbidity and mortality in peritoneal dialysis patients.

The efficacy number has been proposed as a predictor of clinical outcome in patients on chronic ambulatory peritoneal dialysis (CAPD). The usefulness of this parameter in a large group of CAPD patients was analyzed. Forty-five patients who have received chronic CAPD therapy for at least 1 yr were included in the study. The efficacy number was compared with outcome as defined by mortality and days of hospitalization. Other demographic and laboratory parameters, including gender; race; presence of diabetes; serum albumin, serum creatinine, and BUN levels; and measures of peritoneal transport, including dialysate-to-plasma creatinine and dialysate-to-plasma urea ratios, were also assessed for their role in predicting outcome. Laboratory values were obtained at the initiation of CAPD and at 12 months after the start of CAPD. By univariate analysis, a low 12-month serum albumin level was the best predictor of mortality (P < 0.005), followed by a high 12-month efficacy number (P < 0.05). After adjusting for age and the presence of diabetes, these two variables remained the best predictors of mortality (P < 0.08 and < 0.09, respectively). A low initial serum albumin level was also a strong predictor of mortality (P < 0.09). By univariate analysis, the best predictor of hospitalization was a low serum albumin level obtained either initially or at 12 months (P < 0.005 for both time periods). After adjusting for age and the presence of diabetes, the 12-month serum albumin level remained a significant predictor of hospitalization (P < 0.03), whereas efficacy number was not a strong predictor (P = 0.27).(ABSTRACT TRUNCATED AT 250 WORDS)

Impact of tuberculosis in children with idiopathic nephrotic syndrome

Forty black South African children (mean age 4.7 +/- 2.6 years) with idiopathic nephrotic syndrome due to focal glomerulosclerosis (FSGS) were evaluated. Tuberculosis (TB) was found in 37.5% of children with FSGS (FSGS-TB) compared with 6% of a comparable group with minimal lesion nephrotic syndrome. No significant differences were found in the initial mean serum albumin, cholesterol, triglyceride and creatinine levels in FSGS-TB compared with children with glomerulosclerosis but without TB (FSGS-nonTB). The mean serum levels of C4, IgA and IgM were increased by 30%, 25% and 23%, respectively in children with FSGS-TB compared with FSGS-nonTB. Initial estimated creatinine clearance was similar in the two groups, but after a mean follow-up of 2.4 years, the mean estimated creatinine clearance of children with FSGS-TB was significantly reduced by 46% from the initial value, but remained stable in the FSGS-nonTB group. FSGS-TB children also had significantly increased requirements for renal replacement therapy compared with children with FSGS-nonTB. We conclude that TB infection is commonly associated with FSGS in black South African children; this may have deleterious effects on renal function.

Management of acute cholangitis and the impact of endoscopic sphincterotomy.

Ninety-four patients admitted to Leicester Hospitals with acute cholangitis since 1977 were reviewed to coincide with the availability of endoscopic sphincterotomy (ES). Thirty-four were men and sixty were women, their mean age was 69.7 years and the median hospital stay was 20 days. There were 15 deaths (16 per cent) by 30 days in patients with significantly lower initial serum albumin levels (P less than 0.005) and significantly higher serum urea levels (P less than 0.05) than survivors. Eighty-two patients had common bile duct (CBD) calculi of whom 71 underwent early decompression of the biliary tree either surgically (28) or by ES(43). Early surgical decompression was associated with a significantly higher 30 day mortality (6/28) than early ES (2/43) (P less than 0.02) despite the fact that patients undergoing early ES were significantly older (P less than 0.02) and had significantly more medical risk factors (P less than 0.05). Of the 43 patients undergoing early ES 7 had had a previous cholecystectomy, 13 underwent subsequent elective cholecystectomy with no mortality and the remaining 23 had the gallbladder left in situ because of advanced age (mean age 79 years) and frailty. Only 2 of the 23 have since required cholecystectomy. We suggest that patients with acute cholangitis who do not rapidly respond to conservative treatment should undergo early ES with early surgery reserved for those who do not improve following ES. Elective cholecystectomy following successful ES can often be avoided in the elderly and frail.

The clinical spectrum of light chain myeloma: A study of 35 patients with special reference to the occurrence of amyloidosis

During a 40 month interval, 35 patients were seen with a plasma cell dyscrasia in which the only detectable monoclonal immunoglobulin abnormality consisted of excess production of either type kappa or type lambda light chains (Bence Jones protein). This group constituted 17.3 per cent of the total number of patients with plasma cell dyscrasias and 25.7 per cent of the patients with myeloma identified during the same period. Variable initial clinical presentation, the absence of a typical monoclonal serum spike and the unreliability of commonly used urine protein tests made recognition of the disorder difficult in many patients. Sulfosalicylic acid and p-toluene sulfonic acid proved valuable in screening for urine protein. Definition of “proteinuria” by quantitative, electrophoretic and immunochemical studies was essential for diagnosis. Bence Jones proteinemia was present in 80 per cent of the patients; panhypogammaglobulinemia and lytic bone lesions were demonstrable in more than 60 per cent. Although no specific morphologic abnormality of marrow plasma cells was evident by light microscopy, the absence of rouleau on peripheral blood smear was a helpful diagnostic clue. Although patients with lambda light chains presented with more Bence Jones proteinuria, this did not correlate with the severity of initial renal functional impairment or with survival when compared to patients with kappa light chains. No other clinical or laboratory observation differentiated the groups with kappa light chains from those with lambda light chains. Amyloid was identified in seven patients. Their course was dominated by the features of primary systemic amyloidosis instead of the usual findings of classic myeloma. Patients with amyloidosis had lower initial serum albumin levels, fewer lytic bone lesions and reduced survival compared to patients without amyloidosis.