Hypoalbuminemia and long-term survival after coronary artery bypass: a propensity score analysis

Immunonutrition in ERAS Protocol for Patients with Gynecologic Cancer: A Narrative Review of the Literature

In-hospital patients who are in the gynecologic oncology setting often suffer from malnutrition, which is one of the primary problems, the rate of which reportedly ranges from 28% to 70%. Malnutrition is a significant risk factor for immunosuppression, negatively impacting immune response and postoperative recovery capacity. At the time of the surgeries, due to their wide scope and aggressive treatments such as chemotherapy and radiotherapy, the situation becomes more serious. Those micronutrients taking part in immunonutrition, namely, arginine, omega-3 fatty acids, nucleotides, and antioxidants, have the potential to prevent inflammation, protect against infections, and promote healing after the surgery. Research has shown that immunonutrition can lower the risk of postoperative infection, promote the normal healing of wounds, and reduce the hospital stays of patients, as well as support malnutrition status during chemotherapy. This review is based on a literature search conducted in Medline, Scopus, Clinicaltrials.gov, Cochrane CENTRAL, and Google Scholar, with the last search date being November 2024. Some studies. found that perioperative immunonutrition decreases wound infections and affects some immune indexes in gynecologic oncology patients positively. However, factors such as non-compliant patients, high costs, and non-standard formulations can deter its wider use. Patient adherence drops postoperatively mainly due to nausea and decreased appetite, whereas the cost of enriched formulations acts as an economic barrier. Postoperative compliance drops from ~78% prior to surgery to ~28% due to nausea, anorexia, and chemotherapy. Additionally, cost remains a constraining factor since special formulas are 2-4 times that of normal nutrition. While immunonutrition reduces hospital stay (by ~2-3 days) and infection rate (by 25-40%), access is hindered by prohibitive initial costs and lack of insurance coverage. Approaches such as subsidized schemes, enhanced palatability, and cost-benefit analyses are required to increase adoption. In addition, the lack of standardized protocols makes the clinical community hesitant to adopt this approach. Immunonutrition is, despite these problems, still hoped to be the new adjunct to gynecologic oncology patients. In future studies, it is imperative to pay attention to the best formulations that produce the best outcomes and evaluate and implement guidelines that are based on evidence. Together, with these improvements, immunonutrition could very well be an integral part of perioperative care thus completing the process by which patients in intense treatments are benefited not only via treatment but also via quality of life.

Machine Learning Models With Prognostic Implications for Predicting Gastrointestinal Bleeding After Coronary Artery Bypass Grafting and Guiding Personalized Medicine: Multicenter Cohort Study

BACKGROUND

Gastrointestinal bleeding is a serious adverse event of coronary artery bypass grafting and lacks tailored risk assessment tools for personalized prevention.

OBJECTIVE

This study aims to develop and validate predictive models to assess the risk of gastrointestinal bleeding after coronary artery bypass grafting (GIBCG) and to guide personalized prevention.

METHODS

Participants were recruited from 4 medical centers, including a prospective cohort and the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. From an initial cohort of 18,938 patients, 16,440 were included in the final analysis after applying the exclusion criteria. Thirty combinations of machine learning algorithms were compared, and the optimal model was selected based on integrated performance metrics, including the area under the receiver operating characteristic curve (AUROC) and the Brier score. This model was then developed into a web-based risk prediction calculator. The Shapley Additive Explanations method was used to provide both global and local explanations for the predictions.

RESULTS

The model was developed using data from 3 centers and a prospective cohort (n=13,399) and validated on the Drum Tower cohort (n=2745) and the MIMIC cohort (n=296). The optimal model, based on 15 easily accessible admission features, demonstrated an AUROC of 0.8482 (95% CI 0.8328-0.8618) in the derivation cohort. In external validation, the AUROC was 0.8513 (95% CI 0.8221-0.8782) for the Drum Tower cohort and 0.7811 (95% CI 0.7275-0.8343) for the MIMIC cohort. The analysis indicated that high-risk patients identified by the model had a significantly increased mortality risk (odds ratio 2.98, 95% CI 1.784-4.978; P<.001). For these high-risk populations, preoperative use of proton pump inhibitors was an independent protective factor against the occurrence of GIBCG. By contrast, dual antiplatelet therapy and oral anticoagulants were identified as independent risk factors. However, in low-risk populations, the use of proton pump inhibitors (χ21=0.13, P=.72), dual antiplatelet therapy (χ21=0.38, P=.54), and oral anticoagulants (χ21=0.15, P=.69) were not significantly associated with the occurrence of GIBCG.

CONCLUSIONS

Our machine learning model accurately identified patients at high risk of GIBCG, who had a poor prognosis. This approach can aid in early risk stratification and personalized prevention.

TRIAL REGISTRATION

Chinese Clinical Registry Center ChiCTR2400086050; http://www.chictr.org.cn/showproj.html?proj=226129.

The Potential Role of Albumin in Reducing Cardiac Surgery-Associated Acute Kidney Injury: A Randomized Controlled Trial

OBJECTIVES

Cardiac surgery-associated acute kidney injury (CSA-AKI) is a common complication with high morbidity and mortality. This study was designed to determine whether adding human albumin to the cardiopulmonary bypass (CPB) priming solution reduces the incidence of CSA-AKI.

DESIGN

A double-blind, randomized controlled trial (RCT) involving 248 patients scheduled for cardiac surgery with CPB.

SETTING

A single-center tertiary university hospital.

PARTICIPANTS

Adults with a baseline estimated glomerular filtration rate (eGFR) of ≥60 mL/min/1.73 m2 and left ventricular ejection fraction ≥40%.

INTERVENTIONS

Patients were randomized to receive either a crystalloid priming solution (Plasma-Lyte) plus 4% albumin (intervention group, n = 126) or a crystalloid solution alone (control group, n = 122) for CPB.

MEASUREMENTS AND MAIN RESULTS

Data analyses were performed using the Chi-square test and Student's t-test, or their nonparametric equivalent. The primary outcome was the incidence of CSA-AKI, as defined by the Kidney Disease Improving Global Outcomes criteria, within 5 days postoperatively. Both cohorts were comparable in baseline and perioperative characteristics, including preoperative albumin levels. The incidence of CSA-AKI was 29.3% (n = 37) in the intervention group compared with 31.2% (n = 38) in the control group (odds ratio: 0.91, 95% confidence interval: 0.53-1.58). The observed difference in CSA-AKI incidence between the groups was not statistically significant. A post-hoc subgroup analysis of patients with a baseline eGFR of 60 to 70 mL/min/1.73 m² indicated a trend toward a reduced incidence of CSA-AKI in the intervention group compared with the control group (35.7% v 57.6%; odds ratio: 0.41, 95% confidence interval: 0.16-1.03). This trend was not observed in patients with an eGFR greater than 70 mL/min/1.73 m². No significant differences were observed between groups for the need for inotropes or vasoconstrictors, incidence of cardiogenic or distributive shock, bleeding, need for transfusion, or use of nephrotoxic drugs.

CONCLUSIONS

Adding albumin to the CPB priming solution did not decrease the incidence of CSA-AKI in patients with normal preoperative renal function. These findings suggest that albumin might benefit patients with impaired renal function, warranting further investigation.

Moving beyond frailty: Obesity paradox persists in lung resection

BACKGROUND

The apparent protective effect of high body mass index on postoperative outcomes, termed the "obesity paradox," has been postulated to reflect the relative frailty of patients without obesity. We wanted to examine the independent association between body mass index and outcomes after anatomic lung resection.

METHODS

All adults undergoing elective lung resection for cancer were identified in the 2012-2020 National Surgical Quality Improvement Program. The modified Frailty Index quantified degree of patient frailty. Malnutrition was defined as a preoperative serum albumin <3.5g/dL. Multivariable regressions were used to examine the independent association of body mass index and major adverse events, analyzed as a composite of 30-day mortality, postoperative complications, and unplanned reoperation.

RESULTS

Of an estimated 20,099 patients meeting study criteria, 6,424 (32.0%) had obesity. Relative to others, patients with obesity were significantly younger (49.3 vs 50.3 years), more commonly White (78.1 vs 74.9%), and more frequently frail (modified Frailty Index >1: 35.7 vs 22.5%, all P < .001). There was no significant difference in malnutrition rates (7.6 vs 8.4%, P = .05) or extent of resection between groups. After adjustment, obesity was associated with decreased odds of major adverse events (adjusted odds ratio 0.86, 95% confidence interval 0.78-0.94).

CONCLUSION

The present findings uphold the canonical obesity paradox in anatomic lung resection, despite adjustment for frailty and malnutrition. Further studies are warranted to characterize the nature of this association; however, our results may inform efforts to optimize risk stratification and patient selection for surgical intervention.

Optimizing Nutritional Status of Patients Prior to Major Surgical Intervention

In patients undergoing elective cardiovascular and thoracic surgery, malnutrition and the deterioration of nutritional status are associated with negative outcomes. Recognition of the contributory factors and the complications stemming from surgical stress is important for the prevention and management of these patients. We have reviewed the literature available and focused on the nutritional and metabolic aspects affecting surgical patients, with emphasis on the recommendations of enhanced recovery protocols. The implementation of enhanced recovery protocols and nutritional support guidelines focusing on the surgical patient as part of a multidisciplinary approach would improve the nutritional status of surgical patients at risk for negative outcomes.

Preoperative hypoalbuminemia in patients undergoing cardiac surgery: a meta-analysis

The preoperative serum albumin level has been shown to be associated with adverse postoperative complications, meaning that hypoalbuminemia may also be a risk factor. We performed a meta-analysis to evaluate the association of serum albumin levels with survival and complication rates after cardiac surgery. Relevant articles were identified through seven databases. Twenty studies with 22553 patients (hypoalbuminemia group, n = 9903; normal group, n = 12650) who underwent cardiac surgery met the inclusion criteria after screening. The primary outcomes were that hypoalbuminemia was significantly correlated with serious long-term all-cause mortality (hazard ratio [HR]: 1.95 [1.54-2.48]; P < 0.00001) and increased mortality (risk ratio [RR] = 1.91 [1.61-2.27], P < 0.00001). Hypoalbuminemic patients with cardiopathy were more likely to suffer postoperative complications (bleeding, infections, renal injury, and others) than those whose serum albumin levels were normal. Furthermore, hypoalbuminemia increased the time in the intensive-care unit (ICU) (mean difference [MD] = 1.18 [0.49-1.87], P = 0.0008), length of hospital stay (LOS) (MD = 3.34, 95% CI: 1.88-4.80, P < 0.00001), and cardiopulmonary bypass time (CPB) (MD = 12.40 [1.13-23.66], P = 0.03). Hypoalbuminemia in patients undergoing cardiac surgery appears to have a poor all-cause mortality or increased risk of complications. Adjusted perioperative serum albumin levels and treatment strategies for this high-risk population have the potential to improve the survival.

Elevated Blood Urea Nitrogen to Serum Albumin Ratio Is an Adverse Prognostic Predictor for Patients Undergoing Cardiac Surgery

Background

Elevated blood urea nitrogen (BUN) and reduced albumin have been prominently correlated with unfavorable outcomes in patients with cardiovascular diseases. However, whether combination BUN and albumin levels could predict the adverse outcomes of cardiac surgery patients remains to be confirmed. Here, we investigated the prognostic effect of the preoperative BUN to serum albumin ratio (BAR) in cardiac surgery patients.

Methods

Data were obtained from the Medical Information Mart for Intensive Care (MIMIC) III and eICU databases and classified into a training cohort and validation cohort. The BAR (mg/g) was calculated by initial BUN (mg/dl)/serum albumin (g/dl). The primary outcome was in-hospital mortality. Secondary outcomes were 1-year mortality, prolonged length at intensive care unit, and duration of hospital stay. The associations of BAR with outcomes were explored by multivariate regression analysis and subgroup analyses. Then, C statistics were performed to assess the added prognostic impact of BAR beyond a baseline risk model.

Results

Patients with in-hospital death had significantly higher levels of BAR. Multivariate regression analysis identified BAR, as a categorical or continuous variable, as an independent factor for adverse outcomes of cardiac surgery (all p < 0.05). Subgroup analyses demonstrated a significant relationship between elevated BAR and in-hospital mortality in different subclasses. The addition of BAR to a baseline model provided additional prognostic information benefits for assessing primary outcome. Results were concordant in the external validation cohort.

Conclusions

Increased preoperative BAR is a potent predictor of unfavorable outcomes in patients undergoing cardiac surgery.

Association Between Preoperative Fibrinogen-to-Albumin Ratio and All-Cause Mortality After Off-Pump Coronary Artery Bypass Grafting: A Retrospective Observational Study

BACKGROUND

The fibrinogen-to-albumin ratio (FAR) is a recently introduced prognostic marker for patients with coronary artery disease. The present study investigated whether the FAR is associated with clinical outcome after off-pump coronary artery bypass grafting (OPCAB).

METHODS

We retrospectively reviewed 1759 patients who underwent OPCAB (median duration of follow-up, 46 months). To evaluate the association between FAR and mortality in OPCAB patients, time-dependent coefficient Cox regression analyses were used to assess the association between FAR and all-cause mortality.

RESULTS

In multivariable time-dependent coefficient Cox regression analyses, preoperative FAR was an independent risk factor for all-cause mortality after OPCAB (adjusted hazard ratio, 1.051; 95% confidence interval, 1.021-1.082). In the restricted cubic spline function curve of the multivariable-adjusted relationship between the preoperative FARs, a linear increase in the relative hazard for all-cause mortality was observed as the FAR increased (P = .001).

CONCLUSIONS

A higher FAR is associated with increased all-cause mortality after OPCAB. The preoperative FAR could be a prognostic factor for predicting higher mortality after OPCAB.

Mercaptoalbumin Is Associated with Graft Patency in Patients Undergoing Coronary Artery Bypass Grafting

Coronary artery bypass graft (CABG) surgery still represents the gold standard for patients with complex multivessel coronary artery disease. However, graft occlusion still occurs in a significant proportion of CABG conduits, and oxidative stress is currently considered to be a potential contributor. Human serum albumin (HSA) represents the main antioxidant in plasma through its reduced amino acid Cys34, which can efficiently scavenge several oxidants. In a nested case–control study including 36 patients with occluded grafts and 38 age- and sex-matched patients without occlusion, we assessed the levels of the native mercaptoalbumin (HSA-SH) and oxidized thiolated form of albumin (Thio-HSA) in relation with graft occlusion within 5 years after CABG. We found that the plasma level of preoperative HSA-SH was significantly lower in patients with occluded graft at 5 years follow-up than in patients with graft patency. Furthermore, low HSA-SH remained independently associated with graft occlusion even after adjusting for preoperative D-dimer, a well-known marker of activated coagulation recently found to be associated with graft occlusion. In conclusion, the preoperative level of HSA-SH is independently associated with graft occlusion in CABG and represents a measurable and potentially druggable predictor.

Enhanced recovery after surgery multimodality pain regimen performs similar to PRN narcotics on outcomes and pain control after cardiac surgery: A quality improvement project

BACKGROUND

While enhanced recovery after surgery (ERAS) pathways have been successfully applied for cardiac surgery, there has been limited research directly comparing ERAS protocols to ad hoc narcotic use after surgery. We hypothesized that a standardized ERAS protocol would provide similar pain management and psychoemotional outcomes while decreasing the use of opioids in the hospital and after discharge.

METHODS

As part of a 7-month quality improvement project, cardiac surgery patients on a fast-tracked to extubate pathway were assigned pro re nata (PRN) narcotic pain management for 3 months (n = 49). After a 1-month ERAS protocol optimization period, a separate group of patients were given the ERAS protocol (n = 34). Clinical outcomes were gathered, and participants completed a quality of recovery survey that allowed for the assessment of pain and symptom control at four-time points after surgery.

RESULTS

Among 83 participants, 66% were male and the mean age was 53 years. There were no differences in patient characteristics between PRN and ERAS groups (all p > .244). There were no differences between ERAS and PRN groups for surgery characteristics (all p > .060), inpatient outcomes (all p > .658), or after-discharge outcomes (all p > .397). Furthermore, across all time-point comparisons, there were no supported differences in patient-reported outcome and pain control between the ERAS and PRN narcotic groups (all p > .075).

CONCLUSIONS

An ERAS protocol demonstrated similar patient outcomes and pain control to traditional opioid use for postoperative cardiac surgery patients. Further research is recommended to further confirm the results of this study.

Nontumor related risk score: A new tool to improve prediction of prognosis after hepatectomy for colorectal liver metastases

BACKGROUND

Prognostic stratification of patients with colorectal cancer liver metastasis based solely on tumor-related factors has only moderate discriminatory ability. We hypothesized that the inclusion of nontumor related factors can improve prediction of long-term prognosis of patients with colorectal cancer liver metastasis.

METHODS

Nontumor related laboratory markers were assessed utilizing a training cohort from 2 U.S. institutions (n = 1,205). Factors independently associated with prognosis were used to develop a nontumor related prognostic score. The discriminatory ability, assessed by Harrell's C-statistics (C-index) and net reclassification improvement, was validated and compared with 3 commonly used tumor-related clinical risk scores: Fong clinical risk scores, m-clinical risk scores, and Genetic and Morphological Evaluation (GAME) score in an external validation cohort from 5 Asian (n = 1,307) and 3 European (n = 1,058) institutions. The discriminatory ability of nontumor related prognostic score combined with each of these 3 tumor-related prognostic scores was also estimated.

RESULTS

Alkaline phosphatase (hazard ratio 1.43; 95% confidence interval, 1.11-1.84), albumin (hazard ratio 0.71; 95% confidence interval, 0.57-0.89), and mean corpuscular volume (hazard ratio 19.0, per log unit; 95% confidence interval, 4.79-75.0) were each independently associated with increased risk of death after resection of colorectal cancer liver metastasis (all P < .05). In turn, alkaline phosphatase, albumin, and mean corpuscular volume were combined to form a nontumor related prognostic score (2.942 × mean corpuscular volume + 0.399 × alkaline phosphatase-0.339 × albumin-12) × 10 (median, 16; range, 1-30). The nontumor related prognostic score had good-to-modest discriminatory ability in the external cohort (C-index = 0.58), which was comparable to the 3 established tumor-related prognostic scores (C-index: Fong clinical risk scores, 0.53, m-clinical risk scores, 0.55, GAME, 0.58). The addition of the nontumor related prognostic score to the tumor-related prognostic scores enhanced the discriminatory ability in the entire study cohort (C-index: nontumor related score+Fong, 0.60, nontumor related score+m-clinical risk scores, 0.61, nontumor related score+GAME, 0.64), as well reclassification improvement (42.5, 42.7%, and 21.2%, respectively).

CONCLUSION

Nontumor related prognostic information may help improve the prognostic stratification of patients after resection of colorectal cancer liver metastasis. The nontumor related prognostic score may be combined with tumor-related prognostic tools to enhance prognostic stratification of patients with colorectal cancer liver metastasis.

Evaluation of Prognostic Factors in Anti-MDA5 Antibody-Positive Patients in Chongqing, China: A Retrospective Study

Objective

The aim of our study was to elucidate the potential prognostic factors in anti-melanoma differentiation-associated gene 5 (anti-MDA5)-positive patients.

Methods

We divided anti-MDA5-positive patients into death and survival groups. The differences in clinical characteristics were analyzed.

Results

A total of 56 cases were included. The death group comprised 10 (17.9%) cases, and the survival group comprised 46 (82.1%) cases. Median age of the death group was greater than the survival group, 59.50 years vs 39.25 years, p<0.05. The death group had lower lymphocyte count and albumin and higher erythrocyte sedimentation rate, ferritin and lactate dehydrogenase initially (p<0.05, respectively). Ground-glass opacity on chest computed tomography was found more often in the death group (p<0.05), in which there was an absence of honey-combed shadow initially. The diagnosis of interstitial pneumonia with autoimmune features was higher in the death group than the survival group (70% vs 13%, p<0.05). The median dose of maximum daily methylprednisolone in the death group (160 mg/d) was higher than that in the survival group (48 mg/d) (p<0.05).

Conclusion

Advanced age, low lymphocyte count and albumin, and increased levels of inflammatory markers may portend poor prognosis in anti-MDA5-positive patients. Extra-large doses of glucocorticoid may have no additional benefit in these patients.

Prognostic impact of malnutrition in elderly patients with acute myocardial infarction

We aimed to investigate the prevalence and the prognostic impact of malnutrition using the geriatric nutritional risk index (GNRI) in elderly patients with acute myocardial infarction (AMI). We investigated 130 consecutive patients aged ≥ 75 years who were discharged following successful primary coronary intervention between March 2009 and December 2016. The mean age of the patients was 81.5 ± 5.0 years, and 55.4% of them were male. At discharge, the patients' nutritional statuses were evaluated using the GNRI, which were calculated as follows: 14.89 × serum albumin (g/dL) + 41.7 × body mass index/22. The patients were divided into two groups, a low GNRI group (GNRI < 92) with nutrition-related risk and a high GNRI group (GNRI ≥ 92) without nutrition-related risk. The mean GNRI score of all patients was 95.2 ± 11.0, and 46 patients (35.4%) had a low GNRI score. During the mean follow-up of 1030 ± 850 days, the all-cause mortality was significantly higher in the low GNRI group than in the high GNRI group (32.6% vs. 13.1%, p < 0.001), while the event rates of AMI recurrence and hospitalization due to heart failure did not differ significantly between the two groups. Multivariate Cox proportional analysis revealed that low GNRI was a modest but independent predictor of mortality (hazard ratio, 0.94; 95% confidence interval 0.90-0.98; p = 0.01). Among elderly patients with AMI, malnutrition assessed using the GNRI was often encountered and was an independent predictor of long-term mortality.

Albumin in adult cardiac surgery: a narrative review

PURPOSE

Intravascular fluids are a necessary and universal component of cardiac surgical patient care. Both crystalloids and colloids are used to maintain or restore circulating plasma volume and ensure adequate organ perfusion. In Canada, human albumin solution (5% or 25% concentration) is a colloid commonly used for this purpose. In this narrative review, we discuss albumin supply in Canada, explore the perceived advantages of albumin, and describe the clinical literature supporting and refuting albumin use over other fluids in the adult cardiac surgical population.

SOURCE

We conducted a targeted search of PubMed, Embase, Medline, Web of Science, ProQuest Dissertations and Theses Global, the Cochrane Central Register of Controlled trials, and the Cochrane Database of Systematic Reviews. Search terms included albumin, colloid, cardiac surgery, bleeding, hemorrhage, transfusion, and cardiopulmonary bypass.

PRINCIPAL FINDINGS

Albumin is produced from fractionated human plasma and imported into Canada from international suppliers at a cost of approximately $21 million CAD per annum. While it is widely used in cardiac surgical patients across the country, it is approximately 30-times more expensive than equivalent doses of balanced crystalloid solutions, with wide inter-institutional variability in use and no clear association with improved outcomes. There is a general lack of high-quality evidence for the superiority of albumin over crystalloids in this patient population, and conflicting evidence regarding safety.

CONCLUSIONS

In cardiac surgical patients, albumin is widely utilized despite a lack of high- quality evidence supporting its efficacy or safety. A well-designed randomized controlled trial is needed to clarify the role of albumin in cardiac surgical patients.

Perioperative hypoalbuminemia is a risk factor for wound complications following posterior lumbar interbody fusion

Background

Although serum albumin levels are increasingly used as an indicator of nutritional status in the clinic, the relationship between perioperative hypoalbuminemia and wound complications after posterior lumbar interbody fusion in the treatment of lumbar degenerative disease remains ambiguous. The aim of this study was to evaluate perioperative serum albumin in relation to postoperative wound complications after posterior lumbar interbody fusion in the treatment of single-segment lumbar degenerative disease.

Material and methods

We reviewed patients who underwent single-segment posterior lumbar interbody fusion surgery from December 2014 to April 2017 in the Department of Orthopedics at the First Affiliated Hospital of Chongqing Medical University. Perioperative (preoperative and early postoperative) serum albumin levels were assessed in all patients and were used to quantify nutritional status. We divided the patients into a surgical wound dehiscence (SWD) group and a normal wound healing group and into a surgical site infection (SSI) group and a non-SSI group. To evaluate the relationship between perioperative serum albumin level and postoperative wound complications, we conducted univariate and multiple logistic regression analyses.

Results

A total of 554 patients were enrolled in the study. The univariate and multiple logistic regression analysis of these differences showed that preoperative serum albumin < 3.5 g/dl (P = 0.001) and postoperative serum albumin < 3.0 g/dl (P = 0.001) were significantly correlated to SWD. There were also significant differences between the SSI groups in terms of preoperative serum albumin < 3.5 g/dl (P = 0.001) and chronic steroid use (P = 0.003). Additionally, the increased hospitalization costs (P < 0.001) and length of hospitalization (P < 0.001) were statistically significant for patients with perioperative hypoalbuminemia.

Conclusions

For patients who underwent single-segment posterior lumbar interbody fusion surgery, we need to pay more attention to perioperative hypoalbuminemia and chronic steroid use, which are more likely to be associated with increased wound complications, hospitalization costs, and length of hospitalization after surgery. Adequate assessment and management of these risk factors will help reduce wound complications and hospital stays for surgical patients and will save medical costs.

Serum albumin and cardiovascular disease: State-of-the-art review

Cardiovascular disease is the leading cause of death worldwide. Conceptually, endothelial dysfunction, inflammatory conditions and oxidative stress are at the forefront of the onset and development of most cardiovascular diseases, particularly coronary artery disease and heart failure. Serum albumin has many physiological properties, including in particular antioxidant, anti-inflammatory, anticoagulant and anti-platelet aggregation activity. It also plays an essential role in the exchange of fluids across the capillary membrane. Hypoalbuminemia is a powerful prognostic marker in the general population as well as in many disease states. In the more specific context of cardiovascular disease, low serum albumin is independently associated with the development of various deleterious conditions such as coronary artery disease, heart failure, atrial fibrillation, stroke and venous thromboembolism. Low serum albumin has also emerged as a potent prognostic parameter in patients with cardiovascular disease regardless of usual prognostic markers. Remarkably, its potent prognostic value persists after adjusting for causative confounders such as malnutrition and inflammation. This prognostic value probably refers primarily to the syndrome of malnutrition-inflammation and the severity of comorbidities. Nevertheless, several recent meta-analyses strongly support the hypothesis that hypoalbuminemia may act as an unrecognized, potentially modifiable risk factor contributing to the emergence and progression of cardiovascular disease, primarily by exacerbating oxidative stress, inflammation and platelet aggregation, and by favouring peripheral congestion and pulmonary edema. Currently, it is unknown whether prevention and correction of low serum albumin offers a benefit to patients with or at risk for cardiovascular disease, and further studies are critically needed in this setting.

The Utility of Albumin Level as a Marker of Postoperative Course in Infants Undergoing Repair of Congenital Heart Disease

We sought to examine the role of preoperative and 2nd postoperative day albumin levels as predictors for postoperative course in infants undergoing repair of congenital heart disease. This retrospective, single-center, observational study comprised consecutive infants younger than 1 year who had undergone repair of tetralogy of Fallot, ventricular septal defect, complete atrioventricular canal or transposition of the great arteries over a 25 months period. We correlated preoperative and postoperative day (POD) #2 albumin level to vaso-inotropic score (VIS) and intensive care unit (ICU) length of stay (LOS) as markers for degree and duration of postoperative cardiac support. A composite outcome was defined as maximal vaso-inotropic score of > 10 and ICU LOS > 96 h. Preoperative albumin level negatively correlated with VIS and ICU LOS. Compared to preoperative albumin level of > 4 g/dL, the relative risk of meeting composite criteria was 1.5 for preoperative albumin of 3.1-4 g/dL and 2.6 for preoperative albumin ≤ 3 g/dL. Compared to POD#2 albumin level > 3 g/dL, the relative risk of meeting composite criteria was 1.8 for albumin of 2.6-3 g/dL, and 2.5 for albumin ≤ 2.5 g/dL. In summary, we found that preoperative and POD#2 albumin levels predicted prolonged and complicated postoperative course. These finding may help clinicians to inform the patient's parents, early in the ICU hospitalization, as to the predicted risks and difficulties of their infant's postoperative course.

The influence of postoperative albumin levels on the outcome of cardiac surgery

BACKGROUND

The prognostic role of low postoperative serum albumin levels (SAL) after cardiac surgery (CS) remains unclear in patients with normal preoperative SAL. Our aim was to evaluate the influence of SAL on the outcome of CS.

METHODS

Prospective observational study. Patients undergoing CS with normal preoperative SAL and nutritional status were included and classified into different subgroups based on SAL at 24 h after CS. We assessed outcomes (i.e., in-hospital mortality, postoperative complications and long-term survival) and results were analyzed among the different subgroups of SAL.

RESULTS

We included 2818 patients. Mean age was 64.5 ± 11.6 years and body mass index 28.0 ± 4.3Kg·m^- 2. 5.8%(n = 162) of the patients had normal SAL levels(≥35 g·L^- 1), 32.8%(n = 924) low deficit (30-34.9 g·L^- 1), 44.3%(n = 1249) moderate deficit (25-29.9 g·L^- 1), and 17.1%(n = 483) severe deficit(< 25 g·L^- 1). Higher SAL after CS was associated with reduced in-hospital (OR:0.84;95% CI:0.80-0.84; P = 0.007) and long-term mortality (HR:0.85;95% CI:0.82-0.87;P < 0.001). Subgroups of patients with lower SAL showed worst long-term survival (5-year mortality:94.3% normal subgroup, 87.4% low, 83.1% moderate and 72.4% severe;P < 0.001). Multivariable analysis showed higher in-hospital mortality, sepsis, hemorrhage related complications, and ICU stay in subgroups of patients with lower SAL. Predictors of moderate and severe hypoalbuminemia were preoperative chronic kidney disease, previous CS, and longer cardiopulmonary bypass time.

CONCLUSIONS

The presence of postoperative hypoalbuminemia after CS is frequent and the degree of hypoalbuminemia may be associated with worst outcomes, even in the long-term scenario.

Meta-Analysis of the Impact of Pre-Procedural Serum Albumin on Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement

Pre-procedural serum albumin's impact on prognosis after transcatheter aortic valve replacement (TAVR) has been studied. Literature on the prognostic role of serum albumin in the survival of patients undergoing TAVR shows conflicting results. This meta-analysis was conducted to evaluate the impact of pre-procedural serum albumin on outcomes after TAVR. A comprehensive literature search of EMBASE, MEDLINE, and the Cochrane Library was undertaken through July 2019. The primary end points were 30-day and one-year all-cause mortality after TAVR. Risk ratios (HRs) and 95% confidence intervals (CIs) were calculated using the random-effect model. Ten eligible studies with 8,236 patients were analyzed. Of the 8,236 patients undergoing TAVR, with a mean age of 83 years, 48.8% were men and were categorized into two groups according to low and normal serum albumin (cut-off value: 3.5 or 4 g/dL). Overall, low albumin was significantly associated with an approximately two-fold increase in 30-day all-cause mortality (HR, 2.09; 95% CI, 1.53-2.86) and a 61% increase risk for one-year mortality (HR, 1.61; 95% CI, 1.31-1.98) in patients after TAVR. Sensitivity analyses showed the results to be robust. The association of low albumin level with an increase in one-year mortality risk was not modified by study design, albumin cut-off value, Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM), and study quality. In conclusion, low albumin levels were associated with poor prognosis in patients after TAVR. Pre-procedural albumin can be used as a simple tool related to prognosis after TAVR.

Is Hypoalbuminemia a Predictor for Acute Kidney Injury after Coronary Bypass Grafting in Diabetes Mellitus Patients?

Objective

Acute kidney injury (AKI) is one of the most important complications after coronary artery bypass grafting (CABG) procedure. Serum albumin, which is an acute phase reactant, is suggested to be associated with AKI development subsequent to various surgical procedures. In this study, we research the relation between preoperative serum albumin levels and postoperative AKI development in diabetes mellitus (DM) patients undergoing isolated CABG.

Methods

We included a total of 634 diabetic patients undergoing CABG (60.5±9.1 years, 65.1% male) into this study, which was performed between September 2009 and January 2014 in a single center. The relation between preoperative serum albumin levels and postoperative AKI development was observed. AKI was evaluated and diagnosed using the Kidney Disease: Improving Global Outcomes (KDIGO) classification.

Results

AKI was diagnosed in 230 (36.3%) patients. Multiple logistic regression analysis was performed to determine the independent predictors of AKI development. Proteinuria (odds ratio [OR] and 95% confidence interval [CI], 1.066 [1.002-1.135]; P=0.043) and low preoperative serum albumin levels (OR and 95% CI, 0.453 [0.216-0.947]; P=0.035) were found to be independent predictors of AKI. According to the receiver operating characteristic curve analysis, albumin level <3mg/dL (area under the curve: 0.621 [0.572-0.669], P<0.001) had 83% sensitivity and 10% specificity on predicting the development of AKI.

Conclusion

We observed that a preoperative low serum albumin level was associated with postoperative AKI development in patients with DM who underwent isolated CABG procedure. We emphasize that this adjustable albumin level should be considered before the operation since it is an easy and clinically implementable management for the prevention of AKI development.

The predictive value of the prognostic nutritional index for postoperative acute kidney injury in patients undergoing on-pump coronary bypass surgery

BACKGROUND

We aimed to investigate the predictive value of the prognostic nutritional index (PNI) regarding the development of acute kidney injury (AKI) after elective coronary artery bypass grafting (CABG).

METHODS

A total of 336 consecutive patients with normal serum creatinine levels undergoing CABG were enrolled in this retrospective study. AKI was defined as meeting Acute Kidney Injury Network (AKIN) criteria based on the occurrence of creatinine changes within the first 48 h after CABG surgery. The patients were grouped according to whether they developed AKI or not into an AKI (-) and an AKI (+) group.

RESULTS

AKI developed in 88 (26.2%) of all patients. The PNI was independently predictive of AKI (OR: 0.829, 95% CI: 0.783-0.877, p <  0.001). Moreover, C-reactive protein (CRP), a history of diabetes mellitus, and positive inotropric usage were independent risk factors for AKI in the multivariate logistic regression analysis. The area under the curve (AUC) of the multivariable model, including positive inotrope support, a history of diabetes mellitus, and CRP, was 0.693 (95% CI: 0.626-0.760, p <  0.001) in predicting AKIN. When the PNI was added to the multivariable model, the AUC was 0.819 (95% CI, 0.762-0.865, z = 3.777, difference p = 0.0002). Also, the addition of the PNI to the multivariable model was associated with a significant net reclassification improvement estimated at 88.2% (p <  0.001) and an integrated discrimination improvement of 0.22 (p <  0.001).

CONCLUSIONS

Our study demonstrated that decreasing the PNI could be associated with the development of AKI after coronary artery bypass surgery.

Predictors of Increased Length of Hospital Stay in Patients with Severe Cardiomyopathy Undergoing Coronary Artery Bypass Grafting

OBJECTIVE

Predictors of operative outcome in patients with severely depressed left ventricular ejection fraction (LVEF) undergoing coronary artery bypass grafting (CABG) remain poorly defined. This study aims to identify preoperative variables that are associated with increased postoperative length of hospital stay or operative mortality in this patient population.

DESIGN

Retrospective study.

SETTING

Single tertiary care university hospital.

PARTICIPANTS

Patients undergoing isolated CABG between January 2012 and March 2017 with an LVEF ≤ 25%.

INTERVENTIONS

Isolated CABG.

MEASUREMENTS AND MAIN RESULTS

Primary endpoint was a composite of prolonged length of stay, defined as postoperative length of stay >7 days or operative mortality. Of the 201 patients, 99 (49.3%) met the primary endpoint. Patient comorbidities, clinical presentation, presence of Q-waves on electrocardiogram, and echocardiographic parameters including ventricular dimensions and right heart dysfunction were not associated with the primary endpoint. On multivariable analysis, patients who were not on preoperative beta-blockers, patients with preoperative albumin of <3.5 g/dL, and higher Society of Thoracic Surgeons Predicted Risk of Mortality score were associated with increased prolonged length of stay or death.

CONCLUSIONS

More than half of patients with severely depressed LVEF undergoing isolated CABG are able to be discharged within 7 days postoperatively. The absence of preoperative beta-blockers, low preoperative albumin levels, and higher Society of Thoracic Surgeons Predicted Risk of Mortality score are associated with more complicated or slower postoperative recovery after CABG in this patient population.

[Association of hypoalbuminemia with acute kidney injury in children after cardiac surgery]

OBJECTIVE

To study whether hypoalbuminemia after pediatric cardiopulmonary bypass (CPB) for cardiac surgery is a risk factor for postoperative acute kidney injury (AKI).

METHODS

A retrospective analysis was performed on the clinical data of 1 110 children who underwent CPB surgery between 2012 and 2016. According to the minimum serum albumin within 48 hours postoperatively, these patients were divided into hypoalbuminemia group (≤35 g/L) and normal albumin group (>35 g/L). The two groups were compared in terms of perioperative data and the incidence of AKI. Furthermore, the incidence of AKI was compared again after propensity score matching for the unbalanced factors during the perioperative period. The perioperative risk factors for postoperative AKI were analyzed by logistic regression.

RESULTS

The overall incidence rate of postoperative AKI was 13.78% (153/1 110), and the mortality rate was 2.52% (28/1 110). The mortality rate of children with AKI was 13.1% (20/153). The patients with hypoalbuminemia after surgery (≤35 g/L) accounted for 44.50% (494/1 110). Before and after propensity score matching, the hypoalbuminemia group had a significantly higher incidence of AKI than the normal albumin group (P<0.05). The children with AKI had a significantly lower serum albumin level after surgery than those without AKI (P<0.05). The multivariate logistic regression analysis showed albumin ≤35 g/L was one of the independent risk factors for postoperative AKI.

CONCLUSIONS

Albumin ≤35 g/L within 48 hours postoperatively is an independent risk factor for postoperative AKI in children after CPB surgery.

[Serum albumin and cardiovascular diseases: A comprehensive review of the literature]

Cardiovascular diseases are the leading cause of death worldwide. Conceptually, endothelial dysfunction, inflammatory status and oxidative stress are at the forefront in the onset and development of most cardiovascular diseases, particularly coronary artery disease and heart failure. Serum albumin, the most abundant plasma protein, has many physiological properties, including anti-inflammatory, antioxidant and antiplatelet aggregation activity. It also plays an essential role in the fluid exchange across the capillary membrane. Definite evidence is that hypo-albuminemia is a powerful prognostic marker in the general population as well as in many pathological settings. In the more specific context of cardiovascular diseases, serum albumin is independently associated with the development of a variety of deleterious conditions such as coronary artery disease, heart failure, atrial fibrillation and stroke. Serum albumin has also emerged as a powerful prognostic parameter in patients with coronary artery disease, heart failure, congenital heart disease, infective endocarditis, cardiovascular surgery and stroke, regardless of usual prognostic markers. This prognostic value probably refers mainly to the malnutrition-inflammation syndrome and the severity of comorbidities. Nevertheless, hypo-albuminemia may act as an unknown and modifiable risk factor that contributes to the emergence and the pejorative evolution of cardiovascular diseases, mainly by exacerbation of inflammation, oxidative stress and platelet aggregation, and by pulmonary and myocardial edema. This article provides an overview of the physiological properties of serum albumin, the prevalence, causes, prognostic value and potential contribution to the emergence and aggravation of cardiovascular disease of hypoalbuminemia, as well as its clinical implications.

Effect of Malnutrition on Radical Nephroureterectomy Morbidity and Mortality: Opportunity for Preoperative Optimization

INTRODUCTION

Nutritional status has been increasingly recognized as an important predictor of prognosis and surgical outcomes for cancer patients. We evaluated the effect of preoperative malnutrition on the development of surgical complications and mortality after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC).

MATERIALS AND METHODS

Using data from the American College of Surgeons National Surgical Quality Improvement Program, we evaluated the association of poor nutritional status with 30-day postoperative complications and overall mortality after RNU from 2005 to 2015. The preoperative variables suggestive of poor nutritional status included hypoalbuminemia (< 3.5 g/dL), weight loss within 6 months before surgery (> 10%), and a low body mass index.

RESULTS

A total of 1200 patients were identified who had undergone RNU for UTUC. The overall complication rate was 20.5% (n = 246), and mortality rate was 1.75% (n = 21). On univariate analysis, patients who experienced a postoperative complication were more likely to have hypoalbuminemia (25.0% vs. 11.4%; P < .001) and weight loss (3.7% vs. 1.0%; P = .003). After controlling for baseline characteristics and comorbidities, hypoalbuminemia was found to be a significant independent predictor of postoperative complications (odds ratio, 2.09; 95% confidence interval, 1.29-3.38; P = .003). Hypoalbuminemia was also a significant independent predictor of mortality (odds ratio, 4.31; 95% confidence interval, 1.45-12.79; P = .008) on multivariable regression analysis.

CONCLUSION

Our results have shown that hypoalbuminemia is a significant predictor of surgical complications and mortality after RNU for UTUC. This finding supports the importance of patients' preoperative nutritional status in this population and suggests that effective nutritional interventions in the preoperative setting could improve patient outcomes.

Analysis of Outcomes of the Nutritional Status in Patients Qualified for Aortic Valve Replacement in Comparison to Healthy Elderly

Severe aortic stenosis (AS) is associated with the reduction of muscle mass and may be associated with deterioration of nutritional status. Furthermore, malnourished cardiac patients are characterized by a higher risk of postoperative complications and mortality. The aim of this study was the evaluation and comparison of nutritional status, appetite and body composition in older people with severe aortic stenosis before aortic valve replacement and healthy elderly volunteers. One hundred and one patients, aged >65 years old with severe AS were included in the study. Nutritional status was assessed. Body composition was estimated using bioelectrical impedance analysis. Concentrations of albumin, prealbumin, triglycerides, total cholesterol and C-reactive protein were measured, and a complete blood count was done. About 40% of AS patients were at risk of malnutrition. They had decreased hand grip strength and they lost more body mass than the control group. Malnourished AS patients were older, had lower body mass indexes (BMIs) and lower aortic valve areas in comparison to well-nourished patients. Older AS patients, like their peers, show excessive body mass and, at the same time, the features of malnutrition. They have additional factors such as unintentional weight lost and decreased muscle strength which may be associated with worse outcomes.

Hypoalbuminemia and Clinical Outcomes: What is the Mechanism behind the Relationship?

Albumin has a number of important physiologic functions, which include maintaining oncotic pressure, transporting various agents (fatty acids, bile acids, cholesterol, metal ions, and drugs), scavenging free oxygen radicals, acting as an antioxidant, and exerting an antiplatelet effect. Hypoalbuminemia in adults, defined by an intravascular albumin level of <3.5 g/dL, is associated with poor postoperative outcomes in patients undergoing surgical intervention. Although the relationship of hypoalbuminemia and poor surgical outcome has been known for many years, the pathophysiology behind the relationship is unclear. Three theoretical constructs might explain this relationship. First, albumin might serve as a nutritional marker, such that hypoalbuminemia represents poor nutritional status in patients who go on to experience poor postoperative outcomes. Second, albumin has its own pharmacologic characteristics as an antioxidant or transporter, and therefore, the lack of albumin might result in a deficiency of those functions, resulting in poor postoperative outcomes. Or third, albumin is known to be a negative acute phase protein, and as such hypoalbuminemia might represent an increased inflammatory status of the patient, potentially leading to poor outcomes. A thorough review of the literature reveals the fallacy of these arguments and fails to show a direct cause and effect between low albumin levels per se and adverse outcomes. Interventions designed solely to correct preoperative hypoalbuminemia, in particular intravenous albumin infusion, do little to change the patient's course of hospitalization. While surgeons may use albumin levels on admission for their prognostic value, they should avoid therapeutic strategies whose main endpoint is correction of this abnormality.

Bronchopleural Fistula After Pneumonectomy: Risk Factors and Management, Focusing on Open-Window Thoracostomy

We evaluated principal risk factors and different therapeutic approaches for post-pneumonectomy bronchopleural fistula (BPF), focusing on open-window thoracostomy (OWT). We retrospectively reviewed all patients treated by pneumonectomy for lung cancer from 1999 to 2014; we evaluated preoperative, operative, and postoperative data; time between operation; and fistula formation, size, treatment, and predicting factors of BPF. Cumulative incidence curves for the development of BPF were drawn according to the Kaplan-Meier method. Differences between groups were assessed with the log rank test. Multivariable Cox proportional hazards regression analysis was used to assess the independent risk factors for BPF. P values <0.05 were considered significant. BPF occurred in 60 of 733 patients (8.2%). Bronchial suture with Stapler (EndoGia) (P = 0.02), right side (P = 0.003), and low preoperative albumin levels (< 3.5 g/dL) (P = 0.02) were independent predicting factors of fistula. Early BPF was treated by thoracotomic (12) or thoracoscopic (2) debridement of necrotic tissue and BPF surgical repair. Late BPF was treated by bronchoscopic application of fibrin glue (3) or endobronchial stent (1), chest tube and cavity irrigation by povidone-iodine (15). OWT was performed in 27 patients, followed by muscle flap interposition in 7 of these 27. The survival time of patients after the treatment of BPF was 29.0 months. The overall survival of patients treated by OWT was 50% at 2 years and 27 (8%) at 4 years. Correct management of BPF depends on several factors. In case of failure of different initial therapeutic approaches, we could consider OWT, followed by myoplasty.

WITHDRAWN: Bronchopleural fistula after pneumonectomy: Risk factors and management, focusing on open window thoracostomy

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Prognostic value of hypoalbuminemia for adverse outcomes in patients with rheumatic heart disease undergoing valve replacement surgery

High-risk patients with rheumatic heart disease (RHD) who were undergoing valve replacement surgery (VRS) were not identified entirely. This study included 1782 consecutive patients with RHD who were undergoing VRS to explore the relationship between hypoalbuminemia and adverse outcomes and to confirm whether hypoalbuminemia plays a role in risk evaluation. A total of 27.3% of the RHD patients had hypoalbuminemia. In-hospital deaths were significantly higher in the hypoalbuminemic group than in the non-hypoalbuminemic group (6.6% vs 3.1%, P = 0.001). Hypoalbuminemia was an independent predictor of in-hospital death (OR = 1.89, P = 0.014), even after adjusting for the Euro score. The addition of hypoalbuminemia to Euro score enhanced net reclassification improvement (0.346 for in-hospital death, P = 0.004; 0.306 for 1-year death, p = 0.005). A Kaplan-Meier curve analysis revealed that the cumulative rate of 1-year mortality after the operation was higher in patients with a new Euro score ≥6. These findings indicated that hypoalbuminemia was an independent risk factor for in-hospital and 1-year mortality after VRS in patients with RHD, which might have additive prognostic value to Euro score.

Preoperative hypoalbuminemia is associated with poor clinical outcomes after open and endovascular abdominal aortic aneurysm repair

OBJECTIVE

The effect of preoperative malnutrition on outcomes in patients undergoing major vascular surgery is unclear. We investigated the effects of preoperative hypoalbuminemia, a marker for malnutrition, on outcomes after open abdominal aortic aneurysm repair (OAR) and endovascular abdominal aortic aneurysm repair (EVAR).

METHODS

Patients undergoing OAR or EVAR were identified in the 2005 to 2012 American College of Surgeons National Surgical Quality Improvement Program database and stratified into three groups: normal albumin (serum albumin >3.5 g/dL), moderate hypoalbuminemia (2.8-3.5 g/dL), and severe hypoalbuminemia (<2.8 g/dL). Multivariable analyses were performed to assess the association of preoperative hypoalbuminemia with 30-day morbidity and mortality.

RESULTS

We identified 15,002 patients with a recorded preoperative serum albumin who underwent OAR (n = 4956) or EVAR (n = 10,046). Patients in both cohorts with hypoalbuminemia had a higher burden of comorbidity. In OAR patients, multivariable analyses demonstrated that moderate hypoalbuminemia was associated with an increased risk of 30-day mortality (odds ratio [OR], 1.32; 95% confidence interval [CI], 1.02-1.70) and postoperative length of stay (LOS; means ratio [MR], 1.10; 95% CI, 1.04-1.16), whereas severe hypoalbuminemia was associated with increased 30-day mortality (OR, 1.92; 95% CI, 1.37-2.70), reoperation ≤30 days (OR, 1.80; 95% CI, 1.32-2.48), pulmonary complications (OR, 1.40; 95% CI, 1.06-1.86), and postoperative LOS (MR, 1.33; 95% CI, 1.21-1.45). In EVAR patients, moderate hypoalbuminemia was associated with an increased risk of 30-day mortality (OR, 1.90; 95% CI, 1.38-2.62), pulmonary complications (OR, 1.61; 95% CI, 1.26-2.04), reoperation ≤30 days (OR, 1.39; 95% CI, 1.12-1.74), and postoperative LOS (MR, 1.23; 95% CI, 1.18-1.29), whereas severe hypoalbuminemia was associated with increased 30-day mortality (OR, 2.98; 95% CI, 1.96-4.53), pulmonary complications (OR, 1.88; 95% CI, 1.32-2.67), reoperation ≤30 days (OR, 1.54; 95% CI, 1.08-2.19), and postoperative LOS (MR, 1.52; 95% CI, 1.40-1.65).

CONCLUSIONS

Preoperative hypoalbuminemia is associated with increased postoperative morbidity and mortality in a severity-dependent manner among patients undergoing OAR or EVAR. Evaluation and optimization of nutritional status should be performed preoperatively in this high-risk population.

The association of hypoalbuminemia with early perioperative outcomes - A comprehensive assessment across 16 major procedures

BACKGROUND

Poor nutritional status is thought to influence peri- and postoperative outcomes. We assessed the association of hypoalbuminemia, a surrogate for poor nutritional status, with perioperative outcomes in patients undergoing one of 16 major surgical procedures.

METHODS

Patients undergoing one of 16 major surgeries were identified using the ACS-NSQIP (2005-2011). Risk-adjusted logistic regression models examined the association of hypoalbuminemia on perioperative outcomes.

RESULTS

Overall, 204,819 complete cases were identified, of whom 25.4% underwent major cardiovascular, 19.0% orthopedic and 55.6% oncologic surgery. Patients with hypoalbuminemia had significantly higher rates of complications, reoperations, readmissions, prolonged length-of-stay and mortality (all p < 0.001). After adjustment, hypoalbuminemia was an independent predictor of overall complications in 12 of the procedures examined and 30-day mortality in 11 of the procedures. Individual perioperative complication profile varied widely among procedures.

CONCLUSIONS

Hypoalbuminemia exerts significant impact on perioperative outcomes. Its effect is procedure-specific and thus warrants targeted management strategies to improve surgical outcomes. In the absence of clear recommendations, our findings invite surgeons to assess preoperative albumin levels and to manage nutritional status accordingly.

Outcomes and long-term survival of coronary artery surgery: The controversial role of opium as risk marker

AIM

To study survival in isolated coronary artery bypass graft (CABG) patients and to evaluate the impact of preoperative chronic opium consumption on long-term outcome.

METHODS

Cohort of 566 isolated CABG patients as Tehran Heart Center cardiac output measurement was conducted. Daily evaluation until discharge as well as 4- and 12-mo and 6.5-year follow-up information for survival status were fulfilled for all patients. Long-term 6.5-year overall and opium-stratified survival, adjusted survival curves based on opium consumption as well as possible predictors of all-cause mortality using multiple cox regression were determined by statistical analysis.

RESULTS

Six point five-year overall survival was 91.8%; 86.6% in opium consumers and 92.7% in non-opium consumers (P = 0.035). Patients with positive history of opium consumption significantly tended to have lower ejection fraction (EF), higher creatinine level and higher prevalence of myocardial infarction. Multiple predictors of all-cause mortality included age, body mass index, EF, diabetes mellitus and cerebrovascular accident. The hazard ratio (HR) of 2.09 for the risk of mortality in opium addicted patients with a borderline P value (P = 0.052) was calculated in this model. Further adjustment with stratification based on smoking and opium addiction reduced the HR to 1.20 (P = 0.355).

CONCLUSION

Simultaneous impact of smoking as a confounding variable in most of the patients prevents from definitive judgment on the role of opium as an independent contributing factor in worse long-term survival of CABG patients in addition to advanced age, low EF, diabetes mellitus and cerebrovascular accident. Meanwhile, our findings do not confirm any cardio protective role for opium to improve outcome in coronary patients with the history of smoking. Further studies are needed to clarify pure effect of opium and warrant the aforementioned findings.

Influence of undernutrition at admission on clinical outcomes in patients with acute myocardial infarction

BACKGROUND

Although the effect of overweight or obesity on clinical outcomes in patients with acute myocardial infarction (MI) has been reported, the effect of undernutrition is not as well understood. Therefore, we investigated whether acute MI patients frequently present with undernutrition, and whether this influences poor clinical outcomes.

METHODS AND RESULTS

Using the Korea Acute Myocardial Infarction Registry database, we screened initial data on acute MI patients admitted within 48h of symptom onset to a tertiary university hospital between November 1, 2011 and May 31, 2015. We then assessed nutritional status at admission, using the Geriatric Nutritional Risk Index (GNRI). Of a total of 2251 patients, there were 1585 (70.4%) men, and mean age was 65.0±12.8 years. Based on GNRI score, undernutrition at admission was present in 409 (18.2%) patients. Multiple logistic regression analysis found undernutrition to be an independent factor influencing post-MI complications [odds ratio (OR), 2.13; 95% confidence interval (CI), 1.61-2.84; p<0.001], after adjusting for age, sex, hypertension, diabetes, hyperlipidemia, previous stroke, smoking, diagnosis, number of involved vessel lesions, Killip class, atrial fibrillation, baseline blood pressure, hemoglobin, creatine kinase-MB, creatinine, performance of percutaneous coronary intervention, reperfusion time, recanalization, and use of antithrombotics. Undernutrition was also an important factor influencing in-hospital death (OR, 2.48; 95% CI, 1.55-3.95; p<0.001), after adjusting for all potential factors by univariate analysis.

CONCLUSIONS

Nutritional status is a significant prognostic factor in clinical outcomes after MI during hospitalization. Therefore, nutritional assessment and intervention, especially for undernourished MI patients, should be considered.

Effect of Preoperative Albumin Levels on Outcomes in Patients Undergoing Left Ventricular Device Implantation

Hypoalbuminemia is a well-known predictor of morbidity and mortality in cardiac surgery. Our aim was to establish the impact of serum albumin on outcomes after left ventricular assist device (LVAD) implantation. This was a single-institution retrospective review, including all patients who underwent LVAD implantation between March 2006 and June 2014. Two hundred patients were included in the analysis. Mean serum albumin was 3.27 ± 0.47 g/dl, with 7% in the low albumin group (<2.5 mg/dl), 67.5% in the mid-range (2.5-3.5 mg/dl), and 25.5% in the normal albumin groups (> 3.5 mg/dl). Lower albumin was associated with a significant increase in postoperative renal failure (42.9 vs. 16.5 vs. 17.3%; p = 0.05) and prolonged hospitalization (median 28.5 vs. 16 vs. 15.5 days; p = 0.008). Six month, 1 year, and 5 year survival was 79%, 79%, and 49% with low, 84%, 78%, and 51% with mid-range, and 94%, 88%, and 60% with normal albumin, respectively (p = 0.22). Preoperative hypoalbuminemia is associated with postoperative acute renal failure (ARF) and prolonged hospitalization after LVAD implantation, with no effect on overall survival. Hypoalbuminemia is most likely a marker of advanced disease and should not, in itself, be considered a contraindication to LVAD candidacy.

Effect of Exogenous Albumin on the Incidence of Postoperative Acute Kidney Injury in Patients Undergoing Off-pump Coronary Artery Bypass Surgery with a Preoperative Albumin Level of Less Than 4.0 g/dl

Background

Hypoalbuminemia may increase the risk of acute kidney injury (AKI). The authors investigated whether the immediate preoperative administration of 20% albumin solution affects the incidence of AKI after off-pump coronary artery bypass surgery.

Methods

In this prospective, single-center, randomized, parallel-arm double-blind trial, 220 patients with preoperative serum albumin levels less than 4.0 g/dl were administered 100, 200, or 300 ml of 20% human albumin according to the preoperative serum albumin level (3.5 to 3.9, 3.0 to 3.4, or less than 3.0 g/dl, respectively) or with an equal volume of saline before surgery. The primary outcome measure was AKI incidence after surgery. Postoperative AKI was defined by maximal AKI Network criteria based on creatinine changes.

Results

Patient characteristics and perioperative data except urine output during surgery were similar between the two groups studied, the albumin group and the control group. Urine output (median [interquartile range]) during surgery was higher in the albumin group (550 ml [315 to 980]) than in the control group (370 ml [230 to 670]; P = 0.006). The incidence of postoperative AKI in the albumin group was lower than that in the control group (14 [13.7%] vs. 26 [25.7%]; P = 0.048). There were no significant between-group differences in severe AKI, including renal replacement therapy, 30-day mortality, and other clinical outcomes. There were no significant adverse events.

Conclusion

Administration of 20% exogenous albumin immediately before surgery increases urine output during surgery and reduces the risk of AKI after off-pump coronary artery bypass surgery in patients with a preoperative serum albumin level of less than 4.0 g/dl.

Preoperative prealbumin level as a risk factor for surgical site infection following elective spine surgery

Background:

Nutritional status is a critical factor in patient outcomes in a variety of medical contexts. In the surgical fields, there is substantial evidence suggesting that clinical outcomes including infection risk and surgical efficacy may be affected by preoperative nutritional status. The purpose of this study is to evaluate preoperative serum prealbumin levels, the currently preferred serum biomarker of nutritional deficiency, in relation to the risk of developing a surgical site infection.

Methods:

A retrospective case–control series was conducted comparing prospectively collected preadmission serum prealbumin levels to the risk for surgical site infection following elective spine surgery. The analysis was conducted under an approved institutional quality assurance protocol. Patients were identified by querying the department billing codes for deep wound washouts over a 3-year period. A cohort of 32 patients with preoperative prealbumin levels who underwent spine surgery complicated by postoperative deep tissue infection was identified. This was compared against a case–control cohort of 74 patients who underwent spine surgery and did not experience postoperative infection. Clinical variables included demographic information, body mass index, smoking, diabetes, steroid use, length of the procedure, and length of hospital stay. The data were analyzed using multivariate Cox regression.

Results:

Two variables: Preoperative prealbumin < 20 and diabetes were both statistically significant predictors for the risk of developing a postoperative infection with hazard ratios of 2.12 (95% confidence interval [CI]: 1.03–4.37) and 2.22 (95% CI: 1.04–4.75), respectively.

Conclusions:

Our results reinforce the relationship between preoperative nutritional status and outcomes in elective spine surgery. The data indicate that preoperative prealbumin levels may be useful in risk stratification. Further study is needed to determine whether nutritional supplementation may reduce the risk of infection.

Preoperative hypoalbuminemia is a risk factor for 30-day morbidity after gynecological malignancy surgery

OBJECTIVE

To determine the relationship between preoperative hypoalbuminemia and the development of complications after gynecological cancer surgery, as well as postoperative bowel function and hospital stay.

METHODS

The medical records of 533 patients with gynecological cancer surgery at Konkuk University Hospital between 2005 and 2013 were reviewed. Serum albumin level <3.5 g/dL was defined as hypoalbuminemia. All perioperative complications within 30-days after surgery, time to resumption of normal diet and length of postoperative hospital stay, were analyzed. Regression models were used to assess predictors of postoperative morbidity.

RESULTS

The median age was 49 years (range, 13 to 85 years). Eighty patients (15%) had hypoalbuminemia. Hypoalbuminemic patients had significantly higher consumption of alcohol >2 standard drinks per day, lower American Society of Anesthesiologist score, higher frequency of ascites, and more advanced stage compared with non-hypoalbuminemic patients. Overall complication rate within 30-days after surgery was 20.3% (108 out of 533). Hypoalbuminemic patients were more likely to develop postoperative complications compared to non-hypoalbuminemic patients (34.3% vs. 17.8%, P=0.022), and had significantly longer median time to resumption of normal diet (3.3 [1-6] vs. 2.8 [0-15] days, P=0.005) and length of postoperative hospital stay (0 [7-50] vs. 9 [1-97] days, P=0.014). In multivariate analysis, age >50 (odds ratio [OR], 2.478; 95% confidence interval [CI], 1.310 to 4.686; P=0.005), operation time (OR, 1.006; 95% CI, 1.002 to 1.009; P=0.006), and hypoalbuminemia (OR, 2.367; 95% CI, 1.021 to 5.487; P=0.044) were the significant risk factor for postoperative complications.

CONCLUSION

Preoperative hypoalbuminemia in patients with elective surgery for gynecologic malignancy is an independent predictor of 30-days postoperative complications. Identification of this subset and preoperative optimization of nutritional status may improve surgical outcomes.

Is low serum albumin associated with postoperative complications in patients undergoing cardiac surgery?

A best evidence topic was written according to a structured protocol. The clinical question investigated was: is low serum albumin associated with postoperative complications in patients undergoing cardiac surgery? There were 62 papers retrieved using the reported search strategy. Of these, 12 publications embodied the best evidence to answer this clinical question. The authors, journal, date and country of the publication, patient group investigated, study design, relevant outcomes and results of these papers were tabulated. This paper includes a total of 12 589 patients, and of the papers reviewed, 4 were level 3 and 8 level 4. Each of the publications reviewed and compared either all or some of the following postoperative complications: mortality, postoperative bleeding requiring reoperation, prolonged hospital stay and ventilatory support, infection, liver dysfunction, delirium and acute kidney injury (AKI). Of the studies that examined postoperative mortality, all except for three established a significant multivariate association with low preoperative albumin level. Some scepticism is required in accepting other results that were only present in univariate analysis. While three studies examined multiple levels of serum albumin, most dichotomized the serum albumin levels into normal and abnormal groups. This led to differing classifications of hypoalbuminaemia, ranging from less than 2.5 to 4.0 g/dl. The available evidence, however, suggests that low preoperative serum albumin level in patients undergoing cardiac surgery is associated with the following: (i) increased risk of mortality after surgery and (ii) greater incidence of postoperative morbidity. While the evidence supports the use of preoperative albumin in assessing post-cardiac surgery complications, a specific level of albumin considered to be abnormal cannot be concluded from this review.

Preoperative factors associated with postoperative requirements of renal replacement therapy following cardiac surgery

Renal dysfunction is a major adverse event after cardiovascular surgery. Therefore, the preoperative prediction of which patients will require renal replacement therapy (RRT) after cardiac surgery is an important issue. In the present study, 1,822 consecutive patients who underwent cardiovascular surgery from 2008 and 2013 at a single institution were reviewed. Patients who were already receiving long-term hemodialysis before surgery (n = 134) were excluded. The remaining 1,688 patients were separated into 2 groups: those requiring postoperative RRT and those without RRT requirement. A total of 128 patients (7.6%) required RRT. Patients requiring RRT had greater perioperative blood loss, longer intubation time, and longer hospital stays (p <0.0001 for all). Multivariate analysis revealed that cardiopulmonary bypass use, preoperative body surface area, the left ventricular ejection fraction, serum albumin, and creatinine were independent risk factors for postoperative RRT (odds ratios 2.435, 0.204, 0.976, 0.556, and 5.394, 95% confidence intervals 1.471 to 4.140, 0.054 to 0.841, 0.962 to 1.025, 0.363 to 0.860, and 3.671 to 8.223, respectively, p <0.05 for all). A subgroup of patients with relatively preserved renal function before surgery (creatinine <1.12 mg/dl, a cut-off value for RRT requirement obtained from receiver-operating characteristic curve analysis [area under the curve 0.74748, sensitivity 60.2%, specificity 85.0%]) showed that preoperative serum albumin concentration was most significantly associated with postoperative RRT requirement (odds ratio 0.048, 95% confidence interval 0.023 to 0.095, p <0.0001). In conclusion, cardiopulmonary bypass use, preoperative renal impairment as reflected by elevated creatinine level, small body size, a low left ventricular ejection fraction, and hypoalbuminemia were associated with a requirement for postoperative RRT. In patients with preserved renal function, hypoalbuminemia was most significantly related to requirement for RRT.

Hypoalbuminaemia predicts outcome in adult patients with congenital heart disease

BACKGROUND

In patients with acquired heart failure, hypoalbuminaemia is associated with increased risk of death. The prevalence of hypoproteinaemia and hypoalbuminaemia and their relation to outcome in adult patients with congenital heart disease (ACHD) remains, however, unknown.

METHODS

Data on patients with ACHD who underwent blood testing in our centre within the last 14 years were collected. The relation between laboratory, clinical or demographic parameters at baseline and mortality was assessed using Cox proportional hazards regression analysis.

RESULTS

A total of 2886 patients with ACHD were included. Mean age was 33.3 years (23.6-44.7) and 50.1% patients were men. Median plasma albumin concentration was 41.0 g/L (38.0-44.0), whereas hypoalbuminaemia (<35 g/L) was present in 13.9% of patients. The prevalence of hypoalbuminaemia was significantly higher in patients with great complexity ACHD (18.2%) compared with patients with moderate (11.3%) or simple ACHD lesions (12.1%, p<0.001). During a median follow-up of 5.7 years (3.3-9.6), 327 (11.3%) patients died. On univariable Cox regression analysis, hypoalbuminaemia was a strong predictor of outcome (HR 3.37, 95% CI 2.67 to 4.25, p<0.0001). On multivariable Cox regression, after adjusting for age, sodium and creatinine concentration, liver dysfunction, functional class and disease complexity, hypoalbuminaemia remained a significant predictor of death.

CONCLUSIONS

Hypoalbuminaemia is common in patients with ACHD and is associated with a threefold increased risk of risk of death. Hypoalbuminaemia, therefore, should be included in risk-stratification algorithms as it may assist management decisions and timing of interventions in the growing ACHD population.