Bicavitary effusion in cats: retrospective analysis of signalment, clinical investigations, diagnosis and outcome

OBJECTIVES

The aim of this study was to describe the clinical and diagnostic findings and outcome of cats with bicavitary effusion presenting to a referral centre.

METHODS

Medical records of cats presenting with bicavitary effusion were identified and their history, physical examination findings, clinicopathological data, diagnostic imaging findings, aetiology of bicavitary effusions (cardiac disease, neoplasia, infectious disease, sterile inflammatory disease, severe hypoalbuminaemia, trauma, coagulopathy or 'open' if no definitive diagnosis was reached) and outcome were recorded. Cox regression analysis was performed to identify independent predictors of death in cats with bicavitary effusion. Kaplan-Meier curves were generated for survival analysis.

RESULTS

In total, 103 cats with bicavitary effusion were included. Neoplasia and cardiac disease were the most common aetiologies of bicavitary effusion, in 21 (20.4%) and 20 (19.4%) cats, respectively, followed by infectious disease (n = 11, 10.7%), trauma (n = 13, 12.6%), hypoalbuminaemia (n = 6, 5.8%), sterile inflammatory disease (n = 4, 3.9%) and coagulopathy (n = 1, 1.0%). The median survival time for all cats with bicavitary effusion was 3 days. Cats with a neoplastic aetiology had a 2.03 times greater risk of death compared with cats in which no diagnosis was achieved. Neoplasia (P = 0.030) and pedigree breed status (P = 0.016) were independent predictors of death in the multivariable Cox regression model.

CONCLUSIONS AND RELEVANCE

This study highlights that bicavitary effusions in cats generally carry a guarded to poor prognosis, particularly if neoplasia is the underlying aetiology or if the cat is a pedigree breed. Cardiac disease appeared to be associated with a better prognosis, suggesting that assessment for congestive heart failure should be considered early when evaluating cats with bicavitary effusion. The prognosis for cats with feline infectious peritonitis is likely to be markedly improved by the advent of novel antiviral drugs, compared with the historical cohort of cats presented here.

The prognostic-nutritional index in HPV-negative head and neck squamous cell carcinoma treated with upfront surgery: a multi-institutional series

Objectives

To evaluate the prognostic value of pre-treatment prognostic-nutritional index (PNI) in patients with HPV-negative head and neck squamous cell carcinoma (HNSCC).

Methods

A multi-institutional retrospective series of HPV-negative, Stages II-IVB, HNSCCs treated with upfront surgery was evaluated. Correlation of pre-operative blood markers and PNI with 5-year overall (OS) and relapse-free (RFS) survival was tested using linear and restricted cubic spline models, as appropriate. The independent prognostic effect of patient-related features was assessed with multivariable models.

Results

The analysis was conducted on 542 patients. PNI ≥ 49.6 (HR = 0.52; 95% CI, 0.37-0.74) and Neutrophil-to-Lymphocyte Ratio (NLR) > 4.2 (HR = 1.58; 95% CI, 1.06-2.35) confirmed to be independent prognosticators of OS, whereas only PNI ≥ 49.6 (HR = 0.44; 95% CI, 0.29-0.66) was independently associated with RFS. Among pre-operative blood parameters, only higher values of albuninaemia and lymphocyte count (> 1.08 x 10³/microL), and undetectable basophile count (= 0 10³/microL) were independently associated with better OS and RFS.

Conclusions

PNI represents a reliable prognostic tool providing an independent measure of pre-operative immuno-metabolic performance. Its validity is supported by the independent prognostic role of albuminaemia and lymphocyte count, from which it is derived.

The recommended dosage regimen for caspofungin in patients with higher body weight or hypoalbuminaemia will result in low exposure: Five years of data based on a population pharmacokinetic model and Monte-Carlo simulations

Background: To develop a population pharmacokinetic (PPK) model for caspofungin, identify parameters influencing caspofungin pharmacokinetics, and assess the required probability of target attainment (PTA) and cumulative fraction of response (CFR) for various dosing regimens of caspofungin in all patients and intensive care unit (ICU)-subgroup patients. Method: The general PPK model was developed based on data sets from all patients (299 patients). A ICU-subgroup PPK model based on data sets from 136 patients was then analyzed. The effects of demographics, clinical data, laboratory data, and concomitant medications were tested. Monte-Carlo simulations (MCS) were used to evaluate the effectiveness of different caspofungin dosage regimens. Results: One-compartment model best described the data of all patients and ICU patients. Clearances (CL) were 0.32 L/h and 0.40 L/h and volumes of distribution (V) were 13.31 L and 10.20 L for the general and ICU-subgroup PPK models, respectively. In the general model, CL and V were significantly associated with albumin (ALB) concentration and body weight (WT). In the ICU-subgroup model, CL was associated with WT. The simulated exposure in ICU patients was lower than that in all patients (p < 0.05). MCS indicated that higher caspofungin maintenance doses of 70-150 mg may achieve target CFR of >90% for patients with higher WT (>70 kg) or with C. albicans or C. parapsilosis infections, and especially for ICU patients with hypoalbuminaemia. Conclusion: The PPK model and MCS presented in the study demonstrated that the recommended dosage regimen for caspofungin in patients with higher body weight or hypoalbuminaemia will result in low exposure.

Pseudo-pheochromocytoma due to obstructive sleep apnea: a case report

SUMMARY

Obstructive sleep apnea (OSA) is a condition of intermittent nocturnal upper airway obstruction. OSA increases sympathetic drive which may result in clinical and biochemical features suggestive of pheochromocytoma. We present the case of a 65-year-old male with a 2.9-cm left adrenal incidentaloma on CT, hypertension, symptoms of headache, anxiety and diaphoresis, and persistently elevated 24-h urine norepinephrine (initially 818 nmol/day (89-470)) and normetanephrine (initially 11.2 µmol/day (0.6-2.7)). He was started on prazosin and underwent left adrenalectomy. Pathology revealed an adrenal corticoadenoma with no evidence of pheochromocytoma. Over the next 2 years, urine norepinephrine and normetanephrine remained significantly elevated with no MIBG avid disease. Years later, he was diagnosed with severe OSA and treated with continuous positive airway pressure. Urine testing done once OSA was well controlled revealed complete normalization of urine norepinephrine and normetanephrine with substantial symptom improvement. It was concluded that the patient never had a pheochromocytoma but rather an adrenal adenoma with biochemistry and symptoms suggestive of pheochromocytoma due to untreated severe OSA. Pseudo-pheochromocytoma is a rare presentation of OSA and should be considered on the differential of elevated urine catecholamines and metanephrines in the right clinical setting.

LEARNING POINTS

Obstructive sleep apnea (OSA) is a common condition among adults. OSA may rarely present as pseudo-pheochromocytoma with symptoms of pallor, palpitations, perspiration, headache, or anxiety. OSA should be considered on the differential of elevated urine catecholamines and metanephrines, especially in patients with negative metaiodobenzylguanidine (MIBG) scan results.

Hypoalbuminaemia and One-Year Mortality in Haemodialysis Patients with Heart Failure: A Cohort Analysis

INTRODUCTION

The prevalence of chronic kidney disease (CKD) and heart failure (HF) has been rising over the past decade, with a prevalence close to 40%. Cardiovascular disease and malnutrition are common comorbidities and known risk factors for mortality in haemodialysis (HD) patients. We aimed to evaluate the one-year mortality rate after dialysis induction, and the impact of serum albumin levels on survival outcomes, in patients with CKD and HF.

METHODS

This was a retrospective analysis of patients with CKD and HF who underwent chronic HD between January 2016 and December 2019 in a tertiary-care Portuguese hospital. Variables were submitted to univariate and multivariate analysis to determine factors predictive of one-mortality after HD start.

RESULTS

In total, 204 patients were analysed (mean age 75.1 ± 10.3 years). Within the first year of HD start, 28.7% of patients died. These patients were significantly older [79.8 ± 7.2 versus 72.9 ± 10.9 years, p < 0.001; OR 1.08 (1.04-1.13), p < 0.001] and had a higher mean Charlson Index [9.0 ± 1.8 versus 8.3 ± 2.0, p = 0.015; OR 1.22 (1.04-1.44), p = 0.017], lower serum creatinine [5.1 ± 1.6 mg/dL versus 5.8 ± 2.0 mg/dL; p = 0.021; OR 0.80 (0.65-0.97), p = 0.022], lower albumin levels [3.1 ± 0.6 g/dL versus 3.4 ± 0.6 g/dL, p < 0.001; OR 0.38 (0.22-0.66), p = 0.001] and started haemodialysis with a central venous catheter more frequently [80.4% versus 66.2%, p = 0.050]. Multivariate analysis identified older age [aOR 1.07 (1.03-1.12), p = 0.002], lower serum creatinine [aOR 0.80 (0.64-0.99), p = 0.049] and lower serum albumin [aOR 0.41 (0.22-0.75), p = 0.004] as predictors of one-year mortality.

CONCLUSION

In our cohort, older age, lower serum creatinine and lower serum albumin were independent risk factors for one-year mortality, highlighting the prognostic importance of malnutrition in patients starting chronic HD.

Hypoalbuminemia in COVID-19: assessing the hypothesis for underlying pulmonary capillary leakage

BACKGROUND

Since the first observations of patients with COVID-19, significant hypoalbuminaemia was detected. Its causes have not been investigated yet.

OBJECTIVE

We hypothesized that pulmonary capillary leakage affects the severity of respiratory failure, causing a shift of fluids and proteins through the epithelial-endothelial barrier.

METHODS

One hundred seventy-four COVID-19 patients with respiratory symptoms, 92 admitted to the intermediate medicine ward (IMW) and 82 to the intensive care unit (ICU) at Luigi Sacco Hospital in Milan, were studied.

RESULTS

Baseline characteristics at admission were considered. Proteins, interleukin 8 (IL-8) and interleukin 10 (IL-10) in bronchoalveolar lavage fluid (BALF) were analysed in 26 ICU patients. In addition, ten autopsy ultrastructural lung studies were performed in patients with COVID-19 and compared with postmortem findings in a control group (bacterial pneumonia-ARDS and H1N1-ARDS). ICU patients had lower serum albumin than IMW patients [20 (18-23) vs 28 (24-33) g L^-1 , P < 0.001]. Serum albumin was lower in more compromised groups (lower PaO₂ -to-FiO₂ ratio and worst chest X-ray findings) and was associated with 30 days of probability of survival. Protein concentration was correlated with IL-8 and IL-10 levels in BALF. Electron microscopy examinations of eight out of ten COVID-19 lung tissues showed loosening of junctional complexes, quantitatively more pronounced than in controls, and direct viral infection of type 2 pneumocytes and endothelial cells.

CONCLUSION

Hypoalbuminaemia may serve as severity marker of epithelial-endothelial damage in patients with COVID-19. There are clues that pulmonary capillary leak syndrome plays a key role in the pathogenesis of COVID-19 and might be a potential therapeutic target.

Monitoring for valproate and phenytoin toxicity in hypoalbuminaemia: A retrospective cohort study

AIMS

Equations to calculate albumin-adjusted total concentrations have been validated to correlate with measured free concentrations for both phenytoin and valproate, but there is a lack of data to assess correlation with clinical outcomes. We aimed to assess the association of hypoalbuminaemia and albumin-adjusted total concentrations with concentration-dependent toxicity for phenytoin and valproate and review the impact on management decisions following concentration monitoring in hypoalbuminaemia.

METHODS

Patients undergoing concentration monitoring for phenytoin or valproate between January and December 2018 were included. Patients were identified using a centralised laboratory database with data extracted from medical records.

RESULTS

Total phenytoin concentrations were measured for 144 patients, with hypoalbuminaemia (≤30 g L^-1 ) recorded in 59 (41%) patients. Albumin-adjusted phenytoin concentration >20 mg L^-1 was associated with increased neurological adverse effects (77% vs. 43%, P < .001). On logistic regression, higher albumin-adjusted phenytoin concentration was an independent risk factor for neurotoxicity (OR 1.06, 95% CI 1.01-1.12, P = .011). Total valproate concentrations were measured for 383 patients, with hypoalbuminaemia (≤30 g L^-1 ) noted in 53 (14%) patients. For the valproate cohort, hypoalbuminaemia (42% vs. 28%, P = .039) and albumin-adjusted valproate concentration >100 mg L^-1 (49% vs. 23%, P < .001) were both associated with increased neurotoxicity. On multiple logistic-regression, valproate daily dose (aOR = 1.01, 95% CI 1.00-1.02, P = .006) and albumin-adjusted valproate concentration (aOR 1.01, 95% CI 1.00-1.02, P = .033) were independent risk factors for neurotoxicity after accounting for confounders.

CONCLUSION

While measuring free drug concentrations in hypoalbuminaemia would be ideal, the adjustment equations can help identify vulnerable patients needing further assessment of potential concentration-dependent toxicity.

Advances in the Starling Principle and Microvascular Fluid Exchange; Consequences and Implications for Fluid Therapy

Ernest Starling first presented a hypothesis about the absorption of tissue fluid to the plasma within tissue capillaries in 1896. In this Chapter we trace the evolution of Starling's hypothesis to a principle and an equation, and then look in more detail at the extension of the Starling principle in recent years. In 2012 Thomas Woodcock and his son proposed that experience and experimental observations surrounding clinical practices involving the administration of intravenous fluids were better explained by the revised Starling principle. In particular, the revised or extended Starling principle can explain why crystalloid resuscitation from the abrupt physiologic insult of hypovolaemia is much more effective than the pre-revision Starling principle had led clinicians to expect. The authors of this chapter have since combined their science and clinical expertise to offer clinicians a better basis for their practice of rational fluid therapy.

A case series of confusional states and other neurotoxic effects caused by ertapenem

Ten cases of ertapenem neurotoxicity, mainly confusional states, are described, some of them with fatal outcomes. The majority of patients (90%) had a creatinine clearance (CrCl) < 50 mL/min/1.73m² at some point during treatment and hypoalbuminaemia was always present when ertapenem treatment was started. The pharmacokinetic and pharmacodynamic properties of this carbapenem could favour a different profile, and approved doses can be excessive in some patients with moderate renal failure (CrCl 31-59 mL/min/1.73 m² ). It may be necessary to re-evaluate renal function during treatment and adjust doses or reconsider the adequacy of treatment based on clinical judgement, especially if relevant changes in the CrCl occur (i.e. a reduction to ≤30 mL/min/1.73 m² ) or unexplained behavioural disorders are detected. The onset of the symptoms of ertapenem neurotoxicity can be insidious and go unnoticed, and so a knowledge and early suspicion of confusional states are important to improve the patient prognosis.

A retrospective test for a possible relationship between linezolid-induced thrombocytopenia and hyponatraemia

WHAT IS KNOWN AND OBJECTIVE

Thrombocytopenia is one of the typical adverse events caused by linezolid (LZD). Recently, some cases of severe hyponatraemia occurring while receiving LZD have been reported. This study investigated a possible relationship between LZD-induced hyponatraemia and thrombocytopenia and identified the risk factors for hyponatraemia and/or thrombocytopenia.

METHODS

In this retrospective, single-centre, observational cohort study, 63 hospitalized patients aged over 18 years who received intravenous injection of LZD for more than seven consecutive days in Oita University Hospital between April 2015 and March 2018 were analysed.

RESULTS

Thrombocytopenia occurred in 25 (39.7%) patients and hyponatraemia in 11 (17.5%) patients. Seven of 11 patients with hyponatraemia had concurrent thrombocytopenia. Although both serum sodium level and platelet count declined in most patients who developed hyponatraemia, no significant association between thrombocytopenia and hyponatraemia was found. Creatinine clearance level (Ccr) was significantly lower not only in the thrombocytopenia (vs no-thrombocytopenia) but also in the hyponatraemia group (vs no-hyponatraemia group). Univariate and multivariate logistic regression analyses identified different risk factors for thrombocytopenia and/or hyponatraemia (thrombocytopenia: Ccr and administration period; hyponatraemia: serum albumin; thrombocytopenia and hyponatraemia: administration period and serum albumin).

WHAT IS NEW AND CONCLUSION

In conclusion, this study found no significant relationship between LZD-induced thrombocytopenia and hyponatraemia and identified some possible risk factors associated with onset of the two adverse events. These require further validation.

Human albumin solutions in intensive care: A review

Albumin plays a key role in the critically ill patient acting as a prognostic marker and as a therapy in the form of human albumin solutions. However, the use of human albumin solution has varied over time with notable differences between health systems. Whilst its use is widely accepted for some clinical indications, its role has not always been clear in the critically ill and has been found to be harmful in some cohorts. Numerous studies have showed conflicting results and critical care clinicians have not always been guided by robust evidence. Nonetheless, at present the use of human albumin solution appears to be increasing again in the United Kingdom. Below, we discuss the latest evidence base for its use in critically ill patients.

Prescribing high-quality peritoneal dialysis: Moving beyond urea clearance

Urea removal in peritoneal dialysis (PD) has been a primary measure of dialysis adequacy, but its utility remains limited due to its poor correlation with the clearance of other important uraemic retention solutes and the low certainty of evidence relating peritoneal urea clearance and survival of individuals doing PD. Indeed, clearances of other uraemic solutes, electrolyte imbalances, hypoalbuminaemia and nutritional status, may provide a more holistic measure of dialysis adequacy when evaluating individuals on PD in addition to focusing on person-centred outcomes. Here, we review the history of the urea and creatinine-centric approach to dialysis adequacy and explore the potential importance of other uraemic retention solutes, electrolyte disturbances, phosphorus control, peritoneal protein losses and hypoalbuminaemia, as well as nutritional management to promote a broader multidimensional concept of clearance for PD.

Preoperative Serum Albumin Level As A Predictor Of Postoperative Pneumonia After Femoral Neck Fracture Surgery In A Geriatric Population

Purpose

Femoral neck fracture usually occurs in the geriatric population. Postoperative pneumonia (POP) is known to be devastated, and it is the most frequent complication among patients receiving surgical treatment for femoral neck fractures. However, whether patients who have hypoalbuminaemia are susceptible to the development of POP is a serious concern, although it has not been investigated. We attempted to investigate the association between newly developed POP and hypoalbuminaemia and to identify whether hypoalbuminaemia is an independent risk factor for POP after femoral neck fracture in geriatric population.

Patients and methods

We retrospectively reviewed the records from the first 30 days after surgery of patients who were ≥65 years of age and who had a femoral neck fracture treated with surgery between January 2018 and December 2018 at the Honghui Hospital, Xi’an Jiaotong University. Patients were divided into two groups based on whether they did or did not experience POP, and their clinical characteristics were compared. Binomial logistic regression was used to identify potential risk factors of POP by analysing demographic factors, preoperative comorbidities, laboratory results, and surgical factors.

Results

A total of 720 patients were included in the analysis, and 54 patients experienced POP. The incidence of POP after surgical treatment for a femoral neck fracture in this geriatric population was 7.5%. In addition, patients with POP had significantly longer hospital stays than patients without POP. The binary logistic regression analysis revealed that preoperative hypoalbuminaemia [odds ratio =5.187, 95% confidence interval (CI): 2.561–10.506, P<0.0001], COPD (OR =3.819, 95% CI: 1.247–11.701, P=0.019), prior stroke (OR =3.107, 95% CI: 1.470–6.568, P=0.003) and the time from injury to surgery (OR =1.076, 95% CI: 1.034–1.119, P<0.0001) were predominant and independent risk factors associated with POP after femoral neck fracture in this geriatric population.

Conclusion

The current study revealed that among a geriatric population admitted for femoral neck fracture surgery, preoperative hypoalbuminaemia was a predictor of POP, followed by COPD, prior stroke and the time from injury to surgery. Thus, patients who undergo femoral neck fracture surgery and have preoperative hypoalbuminaemia should receive additional monitoring and perioperative care.

Hypoalbuminaemia and Postoperative Outcomes in Inflammatory Bowel Disease: the NSQIP Surgical Cohort

BACKGROUND

The inflammatory bowel diseases [IBD], including Crohn's disease [CD] and ulcerative colitis [UC], frequently lead to bowel surgery. Hypoalbuminaemia has been shown to be a prognostic factor for outcomes following surgery for other indications, and we sought to determine its role in predicting IBD-related postoperative outcomes.

METHODS

We included patients who underwent IBD-related major abdominal surgery in the American College of Surgeons' National Surgical Quality Improvement Program [ACS-NSQIP] between 2005 and 2012. We assessed the impact of indicators of protein-energy malnutrition [PEM] including hypoalbuminaemia, weight loss, and body mass index on postoperative outcomes.

RESULTS

We identified 10 913 IBD patients [6082 Crohn's disease and 4831 ulcerative colitis] who underwent bowel surgery. The prevalence of modest and severe hypoalbuminaemia was 17% and 24%, respectively; 30-day mortality was higher in Crohn's patients with modest and severe hypoalbuminaemia compared with those with normal albumin levels preoperatively [0.7% vs 0.2%, p <0.05; 2.4% vs 0.2%, p <0.01]. The same was true for patients with UC with modest and severe hypoalbuminaemia [0.9% vs 0.1%, p <0.01; 5.6% vs 0.1%, p <0.01]. Overall infectious complications were more common in the presence of severe hypoalbuminaemia for CD [20% vs 13%, p <0.01]. and UC [28% vs 15%, p <0.01] patients. Last, there were higher rates of extra-intestinal, non-septic complications in both CD and UC patients with hypoalbuminaemia compared with those with normal albumin levels.

CONCLUSIONS

This study suggests that moderate-severe hypoalbuminaemia is associated with worse IBD-related postoperative outcomes and may have a role in preoperative risk stratification.

The Correlation between Preoperative and Postoperative Hypoalbuminaemia and the Development of Acute Kidney Injury with Respect to the KDIGO Criteria in the Hip Fracture Surgery in Elderly Patients

Objective

The aim of the present study was to determine the correlation between preoperative and postoperative hypoalbuminaemia and acute kidney injury (AKI) in the hip fracture surgery in elderly patients.

Methods

A total of 160 patients aged ≥65 years were scanned retrospectively. They were grouped into four as the preoperative albumin level of <3.8, preoperative albumin level of >3.8, postoperative day 2 albumin level of <2.9 and postoperative day 2 albumin level of >2.9. In the beginning and 7 days, age, gender, white blood cell, haemoglobin, haematocrit, glucose, blood urea nitrogen, serum creatinine, albumin values, fever, anaesthesia method, presence of blood transfusion, surgical period, hospitalisation durations and expenses in the postoperative period were recorded for all the patients.

Results

In the study, 92 women and 68 men were scanned. AKI was observed in 28 (17.5%) patients, and 16 (57.1%) patients were determined in stage 1. AKI development in Group 1 and Group 3 was significantly high (p<0.05). Advanced age, multiple drug usage, postoperative glucose level and blood product transfusion during the operation were significantly associated with AKI (p<0.05). The hospitalisation period and cost were high in patients with AKI (p<0.05).

Conclusion

It was determined that hypoalbuminaemia was associated with AKI development, and preoperative or postoperative hypoalbuminaemia affected AKI development at similar rates. Advanced age, multiple drug usage, postoperative glucose level and blood product transfusion during the operation were associated with AKI.

Peritoneal Protein Clearance Is a Function of Local Inflammation and Membrane Area Whereas Systemic Inflammation and Comorbidity Predict Survival of Incident Peritoneal Dialysis Patients

It is not clear whether the association of increased peritoneal protein clearance (PPCl) with worse survival on peritoneal dialysis (PD) is a consequence of either local or systemic inflammation or indicative of generalized endothelial dysfunction associated with comorbidity. To investigate this we determined the relationship of PPCl to comorbidity, membrane area (equivalent to low molecular weight peritoneal solute transport rate), local and systemic inflammation and hypoalbuminaemia, and for each of these with patient survival. 257 incident patients from three GLOBAL Fluid Study centers were included in this analysis. Clinical profiles were collected at baseline along with a peritoneal equilibration test, 24-h dialysate protein and paired plasma and dialysate cytokine measurements. Although peritoneal protein clearance was associated with increased age and severe comorbidity on univariate analysis, only dialysate IL-6, peritoneal solute transport rate, plasma albumin and cardiac comorbidities (ischaemic heart disease and left ventricular dysfunction) were independent explanatory variables on multivariate analysis. While peritoneal protein clearance and daily peritoneal protein loss were associated with survival in univariate analysis, on multivariate analysis only plasma IL-6, age, residual kidney function, comorbidity, and plasma albumin were independent predictors. Peritoneal protein clearance is primarily a function of peritoneal membrane area and local membrane inflammation. The association with comorbidity and survival is predominantly explained by its inverse relationship to hypoalbuminaemia, especially in diabetics.

Hypoalbuminaemia at admission predicts the poor outcomes in critically ill children

BACKGROUND

Hypoalbuminaemia at admission is a common finding in patients admitted to the Paediatric Intensive Care Unit (PICU) and it is thought that this may predict morbidity and mortality.

METHODS

A retrospective study was conducted in the tertiary hospital. The medical records of critically ill children were reviewed. The data were analyzed for the prevalence of hypoalbuminaemia and outcomes.

RESULTS

Two hundred and two patients were included in the analysis. The incidence of hypoalbuminaemia at admission was 57.9%. These patients had a mortality rate 4 times greater (adjusted odds ratio 3.8; 95% CI: 1.4-10.0), a longer length of PICU stay (8.6 vs. 6.7 days, P = 0.04) and a longer period on a ventilator (5.9 vs. 3.9 days, P = 0.04) than patients with normal albumin levels.

CONCLUSIONS

Hypoalbuminaemia at admission was a predictive factor of poor outcome in critically ill children. It is associated with a higher mortality, a longer length of stay in the PICU, as well as longer ventilator use.

Simple self-report FRAIL scale might be more closely associated with dialysis complications than other frailty screening instruments in rural chronic dialysis patients

AIM

Despite the perceived importance of frailty, few studies focus on its impact on rural patients undergoing chronic dialysis. Comparison of different self-report questionnaires in assessing frailty among these patients has not been attempted before.

METHODS

A prospectively enrolled chronic dialysis cohort from a rural centre was recruited for analysis. Six types of self-report questionnaires were administered to these patients. Clinical and dialysis-related laboratory parameters were collected. Correlation analyses between questionnaire results and dialysis complications were performed, and variables demonstrating significant correlations were entered into multivariate regression models to determine their independent associations.

RESULTS

Six types of questionnaire (Strawbridge questionnaire, Edmonton Frail Scale, simple FRAIL scale, Groningen Frail Indicator, G8 questionnaire, and Tilburg Frail Indicator) were provided to rural patients undergoing chronic dialysis. Scores from each questionnaire showed significant association with each other, except the G8 questionnaire. Scores from the simple FRAIL scale correlated significantly with age (P = 0.02), female gender (P = 0.03), higher Liu's comorbidity index (P = 0.02), lower serum albumin (P = 0.03) and creatinine levels (P < 0.01), and higher ferritin levels (P = 0.02). The other five questionnaires did not show consistently significant relationships with important dialysis-related complications. Multivariate linear regression analysis identified an independently negative association between serum albumin and the simple FRAIL scale results (P = 0.01).

CONCLUSION

This is the first study establishing the utility of different self-report questionnaires for assessing frailty in chronic dialysis patients. The simple FRAIL scale scores might demonstrate a closer relationship with dialysis-related complications.

Preoperative serum albumin is associated with mortality and complications after radical cystectomy

OBJECTIVE

To determine the association between preoperative serum albumin and mortality and postoperative complications after radical cystectomy (RC) and urinary diversion.

PATIENTS AND METHODS

We conducted a retrospective review of 1097 RCs performed for the treatment of bladder cancer between 1992 and 2005. All data were entered prospectively into a hospital-based complications database. We used multivariable logistic regression to assess the association between preoperative serum albumin and complications and mortality ≤90 days of RC, while controlling for preoperative patient and disease characteristics.

RESULTS

Low preoperative serum albumin was identified in 14% of the cohort. Preoperative serum albumin was a predictor of postoperative complications (adjusted odds ratio [OR] per unit increase in albumin: 0.61, 95% confidence interval [CI] 0.42-0.90) and 90-day mortality (OR 0.33, 95% CI 0.14-0.75) when controlling for sex, race, age-adjusted Charlson score, body mass index, prior history of abdominal surgery, clinical stage, and neoadjuvant chemotherapy. As serum albumin decreased, the risk of complications and mortality increased.

CONCLUSIONS

In addition to age-adjusted Charlson score, low preoperative serum albumin is a significant predictor of complications and mortality after RC. Serum albumin testing can be used to identify individuals at high-risk of morbidity and mortality.

Inflammatory factors for hypoalbuminemia in Japanese peritoneal dialysis patients

AIM

Hypoalbuminaemia is a common complication of peritoneal dialysis (PD), and the leakage of albumin through peritoneal membrane may be a principal reason for hypoalbuminaemia. However, the relationship between peritoneal inflammation, peritoneal transport properties and hypoalbuminaemia has not been fully elucidated.

METHODS

A cross-sectional study was performed on 76 Japanese PD patients who had been using a low-glucose PD solution and icodextrin. Systemic inflammatory markers of C-reactive protein (CRP) and serum interleukin-6 (IL-6), peritoneal effluent markers of dialysate IL-6 and CA125, the dialysate-to-plasma ratio of creatinine (D/Pcr) and the dialysate protein concentration were measured and examined for their relationship with hypoalbuminaemia.

RESULTS

There was a significant positive correlation between serum IL-6 and dialysate IL-6, mean dialysate IL-6 being significantly higher than mean serum IL-6, suggesting that intraperitoneal inflammation was a principal origin of systemic inflammation. Both serum and dialysate IL-6 were significantly correlated with serum albumin (r= -0.25, P<0.05 and r=-0.32, P<0.01, respectively). Dialysate IL-6 was significantly correlated with D/Pcr and the dialysate protein concentration, and there was a significantly positive association between D/Pcr and the dialysate protein concentration. Dialysate CA125, which is argued to be a marker of mesothelial cell mass in this study, was positively correlated with D/Pcr and the dialysate protein concentration. The dialysate protein, dialysate IL-6 and dialysate CA125 all increased according to the peritoneal transport rate defined by D/Pcr. A multiple-regression analysis showed that serum albumin was independently associated with the age, D/Pcr and serum IL-6.

CONCLUSION

Hypoalbuminaemia was attributable to both the increased peritoneal permeability and systemic inflammation, and intraperitoneal inflammation might contribute to developing these complications.