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Background Intradialytic hypotension (IDH) is a frequent complication of intermittent hemodialysis (IHD), occurring from 15 to 50% of ambulatory sessions, and is more frequent among hospitalized patients with hypoalbuminemia. IDH limits adequate fluid removal and increases the risk for vascular access thrombosis, early hemodialysis (HD) termination, and mortality. Albumin infusion before and during therapy has been used for treating IDH with the varying results. We evaluated the efficacy of albumin infusion in preventing IDH during IHD in hypoalbuminemic inpatients. Methods A randomized, crossover trial was performed in 65 AKI or ESKD patients with hypoalbuminemia (albumin < 3 g/dl) who required HD during hospitalization. Patients were randomized to receive 100 ml of either 0.9%sodium chloride or 25% albumin intravenously at the initiation of each dialysis. These two solutions were alternated for up to six sessions. Patients' vital signs and ultrafiltration removal rate were recorded every 15 to 30 min during dialysis. IDH was assessed by different definitions reported in the literature. All symptoms associated with a noted hypotensive event as well as interventions during the dialysis were recorded. Results Sixty-five patients were submitted to 249 sessions; the mean age was 58 ( ±  12), and 46 (70%) were male with a mean weight of 76 ( ±  18) kg. The presence of IDH was lower during albumin sessions based on all definitions. The hypotension risk was significantly decreased based on the Kidney Disease Outcomes Quality Initiative definition; (15% with NS vs. 7% with albumin, p  = 0.002). The lowest intradialytic SBP was significantly worse in patients who received 0.9% sodium chloride than albumin (NS 83 vs. albumin 90 mmHg, p  = 0.035). Overall ultrafiltration rate was significantly higher in the albumin therapies [NS − 8.25 ml/kg/h (− 11.18 5.80) vs. 8.27 ml/kg/h (− 12.22 to 5.53) with albumin, p  = 0.011]. Conclusion In hypoalbuminemic patients who need HD, albumin administration before the dialysis results in fewer episodes of hypotension and improves fluid removal. Albumin infusion may be of benefit to improve the safety of HD and achievement of fluid balance in these high-risk patients. ClinicalTrials.gov Identifier : NCT04522635

Background Risk stratification is recommended as the key step to prevent contrast-associated acute kidney injury (CA-AKI) among at-risk patients following coronary angiography (CAG) and/or percutaneous coronary intervention (PCI). Patients with hypoalbuminemia are prone to CA-AKI and do not have their own risk stratification tool. Therefore, this study developed and validated a new model for predicting CA-AKI among hypoalbuminemia patients CAG/PCI. Methods 1272 patients with hypoalbuminemia receiving CAG/PCI were enrolled and randomly allocated (2:1 ratio) into the development cohort ( n  = 848) and the validation cohort ( n  = 424). CA-AKI was defined as an increase of ≥0.3 mg/dL or 50% in serum creatinine (SCr) compared to baseline in the 48 to 72 h after CAG/PCI. A prediction model was established with independent predictors according to stepwise logistic regression, showing as a nomogram. The discrimination of the new model was evaluated by the area under the curve (AUC) and was compared to the classic Mehran CA-AKI model. The Hosmer-Lemeshow test was conducted to assess the calibration of our model. Results Overall, 8.4% (71/848) patients of the development group and 11.2% (48/424) patients of the validation group experienced CA-AKI. A new nomogram included estimated glomerular filtration rate (eGFR), serum albumin (ALB), age and the use of intra-aortic balloon pump (IABP); showed better predictive ability than the Mehran score (C-index 0.756 vs. 0.693, p  = 0.02); and had good calibration (Hosmer–Lemeshow test p  = 0.187). Conclusions We developed a simple model for predicting CA-AKI among patients with hypoalbuminemia undergoing CAG/PCI, but our findings need validating externally. Trial registration http://www.ClinicalTrials.gov NCT01400295 , retrospectively registered 21 July 2011.

Background Pharmacokinetic studies of cefuroxime by ultra‐performance liquid chromatography tandem mass spectrometry (UPLC‐MS/MS) have been limited to measurements of total concentrations. Here, we developed a robust method for quantifying total and unbound cefuroxime concentrations using UPLC‐MS/MS and ultrafiltration in critically ill patients with hypoalbuminemia and renal failure. Methods Method validation included accuracy, linearity, precision, repeatability, recovery, and limit of quantification (LOQ). Feasibility of the method was performed on samples obtained from randomly selected intensive care unit (ICU) patients. Total and unbound cefuroxime concentrations were quantified using UPLC‐MS/MS. Sampling times were categorized as trough (180‐1 min prior to administration), peak (10‐30 min after administration), mid (30‐360 min after administration), and continuous (sampling during administration). Pharmacokinetic/pharmacodynamic (PK/PD) targets were unbound cefuroxime concentrations above 4 times the minimum inhibitory concentration (32 mg/L). Results Intra‐assay and inter‐assay precision was <3%. Recovery was 99.7%‐100.3%, and LOQ was 0.1 mg/L. We included 11 patients (median age 72 years (range 54‐77). Median albumin serum concentrations and eGFR were 19 g/L (range 11‐40 g/L) and 48 mL/min/1.73 m2 (range 7‐115 mL/min/1.73 m2), respectively. Median trough and mid concentrations of total cefuroxime were 22.27 mg/L (range 5.42‐54.03 mg/L) and 71.49 mg/L (range 53.87‐73.86 mg/L), and median unbound fraction was 75.42% (range 27.36%‐99.75%). Median unbound cefuroxime concentrations were 11.94 mg/L (range 3.85‐32.39 mg/L) (trough) and 55.62 mg/L (range 10.03‐62.62 mg/L) (mid). Conclusion The method is precise and accurate according to ISO 15189 and within the clinical range of cefuroxime (0.5‐100 mg/L). The method was applied in ICU patients and is suitable for TDM on unbound cefuroxime concentrations.

ObjectivesTotal plasma levels of valproic acid (VPA) may mask an increased risk of adverse effects in hypoalbuminaemic patients since, in these patients, the free fraction is higher. The aim of this study is to analyse the relationship between plasma levels of total and free VPA (FVPA) in hypoalbuminaemic patients and define an equation that allows the estimation of FVPA concentration, as well as to validate the obtained equation.MethodsThis is a retrospective observational study conducted between January 2015 and January 2020. Hypoalbuminaemic adult patients with normal renal function were included. Serum VPA levels were determined using an automated enzyme immunoassay technique with a pre-treatment of the sample by ultrafiltration for the quantification of FVPA. Patients’ determinations were randomised into two groups: first, to calculate the FVPA estimation equation (regression group) by multiple linear regression analysis; and second to validate the equation (validation group), calculating the agreement between experimental and estimated FVPA concentrations using Lin’s coefficient and a Bland and Altman analysis.ResultsWe included 51 determinations, corresponding to 33 patients: 26 in the regression group, and 25 in the validation group. The multiple linear regression analysis showed a statistically significant relationship between FVPA concentration (Y), total VPA concentration (X1) and albumin level (X2), explained by the equation Y=11.882 + 0.216*X1–4.722*X2. Pearson’s correlation coefficient was 0.798 (p<0.001). Lin’s coefficient was 0.82 (95% CI 0.63 to 0.92). The Bland and Altman analysis showed a bias of 0.32 mg/L, and the concordance limits were between −3.80 and 4.44.ConclusionsThe calculated equation adequately predicts FVPA concentration, with a high degree of correlation between the variables. Despite Lin’s coefficient outcome, Bland and Altman analysis showed a minimum bias that slightly underestimates FVPA concentration, positioning the calculated equation as a useful and validated estimation tool in hypoalbuminaemic patients with normal renal function.

Background We conducted a randomized, controlled trial to determine whether supplementation with oral branched-chain amino acids (BCAAs) improves serum albumin and clinical outcomes in heart failure (HF) patients with hypoalbuminemia. Methods and results We randomly assigned 18 in-hospital HF patients with serum albumin < 3.5 g/dL to receive oral BCAA granules (LIVACT ® ) for 28 days during their hospital stay or until discharge (BCAA group; N  = 9) or to receive no supplementation (controls; N  = 9), in addition to recommended HF therapy. The primary endpoints were changes from baseline in serum albumin and cardiothoracic ratio (CTR). Sixteen patients completed the study. The mean (± standard deviation) period of BCAA supplementation was 18.4 ± 8.4 days. Serum albumin significantly increased in the BCAA group [mean difference vs baseline, 0.44 g/dL; 95% confidence interval (CI) 0.13–0.76; P  = 0.014] and did not change in controls (0.18 g/dL; 95% CI − 0.05 to 0.40; P  = 0.108). CTR significantly decreased in the BCAA group (− 2.3%; 95% CI − 3.8 to − 0.8; P  = 0.014) and did not change in controls (− 1.0%; 95% CI − 2.3 to 0.3; P  = 0.111). Conclusion In-hospital HF patients with hypoalbuminemia supplemented with BCAAs showed increased serum albumin and decreased CTR. Clinical trial registration number UMIN000004488 [ http://www.umin.ac.jp/ctr/index.htm ]

For each outcome, forest plot, 95% confidence interval (CI), p value (< 0.05 considered statistically significant), and I2 statistic (> 50% considered as substantial heterogeneity) was generated using Open Meta Analyst (CEBM, Oxford, UK). The pathophysiology behind hypoalbuminemia in disease state (such as pancreatitis, infection, trauma, burn, and organ dysfunction) is thought to be secondary to increased capillary permeability, decreased protein synthesis, decreased half-life of serum albumin, decreased serum albumin total mass, increased volume of distribution, and increase expression of vascular endothelial growth factor [14]. Zhou Y, Zhang Z, Tian J, Xiong S. Risk factors associated with disease progression in a cohort of patients infected with the 2019 novel coronavirus.

Hypoalbuminemia predicts adverse outcomes in subjects with diabetes. We investigated how it relates to type, duration, control, and diabetic complications. Albumin levels were measured in subjects hospitalized for uncontrolled diabetes and unexpected weight loss in our diabetology ward from 2010 to 2019. All underwent a clinical interview and examination with a CT-scanner and were checked for chronic diabetic complications. By multivariate binary regression, we analyzed the determinants of low serum albumin (<38 g/L) or severe undernutrition (weight loss and albumin <30 g/L). The 334 subjects were in the majority men (60.5%), 59 ± 12 y old. They had recently lost –3.8 kg/3 mo (IQR: –5.0 to –1.5). The diabetes was mainly type 2: 78.7% (type 1: 15.3%, type 3, pancreatic: 6.0%), with means of 5 y duration (IQR: 0–13) and poorly controlled hemoglobin A1c (HbA1c) 10.5% ± 2.8%. The mean albuminemia was 37.6 ± 5.1 g/L (median: 38.5 g/L, IQR: 34.8–41.1). Low serum albumin was present in 151 subjects (45.2%), related to age, female sex, hepatic cirrhosis, C-reactive protein, HbA1c, and a high duration of diabetes. Severe undernutrition was present in 26 subjects (7.8%), also related to C-reactive protein, HbA1c, a high duration of diabetes, and pancreatic diabetes. The albumin levels were significantly lower (–2 g/L) both in subjects with diabetic retinopathy and neuropathy. After adjustment for age, sex, duration of diabetes, and HbA1c, a low serum albumin was related to neuropathy. In subjects with diabetes hospitalized for weight loss, a low serum albumin and severe undernutrition relate to poorly controlled and lengthy diabetes, especially pancreatic, and with diabetic neuropathy. •Low serum albumin (LSA) may relate to adverse outcomes in diabetes.•Among 334 subjects with T2D, 45.2% had LSA, and 7.8% severe undernutrition.•As expected, LSA related to inflammation and hepatic cirrhosis.•LSA related to the duration, control, complications (neuropathy), and type of diabetes.•Insulin deficiency probably contributes to LSA in diabetes with weight loss.

The incidence and medical costs of acute pancreatitis (AP) are on the rise, and severe cases still have a 30% mortality rate. We aimed to evaluate hypoalbuminemia as a risk factor and the prognostic value of human serum albumin in AP. Data from 2461 patients were extracted from the international, prospective, multicentre AP registry operated by the Hungarian Pancreatic Study Group. Data from patients with albumin measurement in the first 48 h (n = 1149) and anytime during hospitalization (n = 1272) were analysed. Multivariate binary logistic regression and Receiver Operator Characteristic curve analysis were used. The prevalence of hypoalbuminemia (< 35 g/L) was 19% on admission and 35.7% during hospitalization. Hypoalbuminemia dose-dependently increased the risk of severity, mortality, local complications and organ failure and is associated with longer hospital stay. The predictive value of hypoalbuminemia on admission was poor for severity and mortality. Severe hypoalbuminemia (< 25 g/L) represented an independent risk factor for severity (OR 48.761; CI 25.276–98.908) and mortality (OR 16.83; CI 8.32–35.13). Albumin loss during AP was strongly associated with severity (p < 0.001) and mortality (p = 0.002). Hypoalbuminemia represents an independent risk factor for severity and mortality in AP, and it shows a dose-dependent relationship with local complications, organ failure and length of stay.

The prevalence of hypoalbuminemia, early changes of plasma albumin (P-Alb) levels, and their effects on mortality in cardiogenic shock are unknown. P-Alb was measured from serial blood samples in 178 patients from a prospective multinational study on cardiogenic shock. The association of hypoalbuminemia with clinical characteristics and course of hospital stay including treatment and procedures was assessed. The primary outcome was all-cause 90-day mortality. Hypoalbuminemia (P-Alb < 34g/L) was very frequent (75%) at baseline in patients with cardiogenic shock. Patients with hypoalbuminemia had higher mortality than patients with normal albumin levels (48% vs. 23%, p = 0.004). Odds ratio for death at 90 days was 2.4 [95% CI 1.5-4.1] per 10 g/L decrease in baseline P-Alb. The association with increased mortality remained independent in regression models adjusted for clinical risk scores developed for cardiogenic shock (CardShock score adjusted odds ratio 2.0 [95% CI 1.1-3.8], IABP-SHOCK II score adjusted odds ratio 2.5 [95%CI 1.2-5.0]) and variables associated with hypoalbuminemia at baseline (adjusted odds ratio 2.9 [95%CI 1.2-7.1]). In serial measurements, albumin levels decreased at a similar rate between 0h and 72h in both survivors and nonsurvivors (ΔP-Alb -4.6 g/L vs. 5.4 g/L, p = 0.5). While the decrease was higher for patients with normal P-Alb at baseline (p<0.001 compared to patients with hypoalbuminemia at baseline), the rate of albumin decrease was not associated with outcome. Hypoalbuminemia was a frequent finding early in cardiogenic shock, and P-Alb levels decreased during hospital stay. Low P-Alb at baseline was associated with mortality independently of other previously described risk factors. Thus, plasma albumin measurement should be part of the initial evaluation in patients with cardiogenic shock. NCT01374867 at ClinicalTrials.gov.

Chronic kidney disease (CKD) is a global health issue, affecting approximately 10% of the population. Hypoalbuminemia, a common complication in advanced CKD, is associated with poor prognosis. This study aimed to investigate the association between a microbiota-friendly dietary scoring system (Dietary Index for Gut Microbiota, DI-GM) and serum albumin levels in patients with CKD. We utilized a cross-sectional cohort from the NHANES 2007–2018, which included 2,947 CKD patients. Multivariable logistic regression and restricted cubic spline models were applied to analyze the relationship between DI-GM scores and serum albumin. Higher DI-GM scores were significantly associated with increased serum albumin levels (β = 0.18 g/L, 95% CI: 0.07–0.28, p = 0.002). Furthermore, each 1-point increase in DI-GM score was linked to a 15% reduction in the odds of hypoalbuminemia (OR: 0.85, 95% CI: 0.74–0.97, p = 0.014). The findings suggest that a high DI-GM diet may have beneficial effects in managing hypoalbuminemia in CKD patients by modulating gut microbiota composition and reducing inflammation. This diet pattern could be a promising dietary intervention for improving clinical outcomes in CKD patients, especially those at risk for malnutrition and inflammation.