Clinical characteristics and prognostic significance of serum albumin changes in an internal medicine ward

doi:10.1016/j.ejim.2013.08.004

European Journal of Internal Medicine

Volume 24, Issue 8, December 2013, Pages 772-778

https://doi.org/10.1016/j.ejim.2013.08.004 Get rights and content

Highlights

•
Hypoalbuminemia associates with more severe characteristics than normoalbuminemia.
•
Hypoalbuminemia on hospital admission or discharge is associated with poor outcome.
•
Development of hypoalbuminemia during hospital stay predicts decreased survival.
•
In-hospital normalization of low serum albumin level predicts better survival.

Abstract

Background

The prognostic significance of hypoalbuminemia and the dynamic changes in serum albumin during hospitalization in internal medicine wards has not been sufficiently investigated.

Methods

Demographic, clinical and laboratory data were collected from 276 patients admitted to our internal medicine ward for a variety of acute disorders. Following discharge, all-cause mortality was recorded. These data were compared between patient groups, according to levels of albumin: hypoalbuminemia or normoalbuminemia (serum albumin < 34 g/l and ≥ 34 g/l, respectively), on admission and discharge.

Results

Hypoalbuminemia on admission and on discharge was found in 46% and 54% of patients, respectively. Anemia, renal dysfunction, malignant disease, hypocholesterolemia, lymphopenia and albuminuria were more prevalent in patients with hypoalbuminemia, compared to those with normoalbuminemia (p ≤ 0.03). During a median follow-up period of 23 months, 107 of 276 patients died. Mortality was significantly higher (p < 0.001) in patients with hypoalbuminemia than normoalbuminemia on admission (52.0% vs. 27.5%) and on discharge (53.7% vs. 21.2%), including those admitted with normoalbuminemia and discharged with hypoalbuminemia (43.6%). Survival rate was higher for patients admitted with hypoalbuminemia and discharged with normoalbuminemia than for those remaining with hypoalbuminemia (82.4% vs. 42.8%, p = 0.004). The level of albumin on discharge (each 10 g/l decrement) was the most powerful predictor of shortened survival (relative risk 2.79, 95% confidence interval 2.04–3.70).

Conclusions

Hypoalbuminemia on admission, as well as persistence or development of hypoalbuminemia throughout hospitalization, was associated with poor prognosis. Treatment aimed at increasing low albumin or maintaining its normal level may improve survival.

Introduction

Hypoalbuminemia presents frequently in hospitalized patients, and has been shown to be a predictor of morbidity and mortality [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13]. The half-life of albumin is approximately 21 days [5], [14], [15]. Therefore, serum albumin may decrease significantly within several days as a result of reduced synthesis, accelerated catabolism, altered body distribution and/or increased loss of albumin through the kidney, skin or bowel [5], [14], [15], [16]. These pathogenic mechanisms may be encountered in acute conditions such as infection, inflammation, trauma or major surgery, for which low serum albumin is considered a negative acute-phase protein rather than a marker of malnutrition [1], [5], [9], [15], [16], [17]. Hypoalbuminemia may also be caused or aggravated by a variety of disorders, including malignant diseases, heart failure, diabetes, malabsorption, nutritional deficiencies and liver failure [1], [3], [5], [8], [10], [11], [15], [16]. Many internal medicine inpatients suffer from conditions that may result in hypoalbuminemia on admission. In addition, hypoalbuminemia may develop or improve during hospitalization.

Hypoalbuminemia has been studied in inpatients within the context of specific disorders and older age [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12]. Limited information is available regarding differences in clinical characteristics and survival of patients with hypoalbuminemia, compared to patients with normal levels of serum albumin, in the general internal medicine ward population. In the one available study on this subject, hypoalbuminemia was associated with older age, infections, renal and malignant diseases, prolonged hospital stay, lower blood hemoglobin and lymphocyte count, as well as with higher erythrocyte sedimentation rate [13]. However, the prognostic significance of hypoalbuminemia was not evaluated in that report. Moreover, the prognostic value of the development of hypoalbuminemia or improvement of hypoalbuminemia to normal albumin level during hospital stay has not been sufficiently investigated. Therefore, the aim of this study was to compare the clinical characteristics and long-term survival between patients admitted to an internal medicine ward with and without hypoalbuminemia. In addition, we investigated the prognostic significance of dynamic changes of serum albumin during hospitalization.

Section snippets

Study population

The study population consisted of adult patients hospitalized in our internal medicine department (38 beds) during November 2009–December 2011. The patients had been randomly admitted from the Emergency Department for a variety of acute medical disorders. Two hundred seventy-six patients with available test results of serum albumin on admission and discharge (the minimal interval between the two determinations was 3 days) were included in the study. Serum albumin was determined routinely within

Entire group

Data of the 276 patients are presented in Table 1. Hypoalbuminemia on admission and on discharge was found in 127 (46%) and 149 (54%) patients, respectively. The median interval between measurements of serum albumin was 5 days.

Comparison between groups 1 (hypoalbuminemia on admission) and 2 (normoalbuminemia on admission) (Table 1)

Patients with hypoalbuminemia tended to be older, more likely admitted for malignancy and less likely for cardio-cerebrovascular disorders, and more often presenting with anemia, renal dysfunction and malignant diseases. Patients from group 1 were more likely than those in

Discussion

We compared demographic, clinical and laboratory characteristics, as well as survival rates, between patients with hypoalbuminemia and normoalbuminemia in an internal medicine ward. The clinical significance of hypoalbuminemia in such patients has not been sufficiently studied. Other investigations of hypoalbuminemia generally focused on inpatients of older age [4], [7], [9] and with specific disorders including pneumonia [12], heart failure [10], [11], renal failure [6] or malignant diseases

Conclusion

Hypoalbuminemia commonly presents in internal medicine wards. Clinical and laboratory characteristics were found to be more severe among patients with hypoalbuminemia than among those with normoalbuminemia. Hypoalbuminemia at hospital admission, as well as the persistence or development of hypoalbuminemia throughout hospitalization, are associated with poor prognosis. Effective treatment of patients with hypoalbuminemia, aimed at increasing or maintaining albumin levels, may improve survival.

Learning points

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Patients with hypoalbuminemia in an internal medicine ward have more severe clinical and laboratory characteristics than those with normoalbuminemia.
•
The presence of hypoalbuminemia at hospital admission, and more so on discharge, is associated with increased long-term mortality.
•
Persistence as well as development of hypoalbuminemia during hospitalization predicts decreased survival.
•
Improvement of serum albumin from low to normal levels throughout hospital stay is associated with better survival.

Conflict of interests

The authors state they have no conflicts of interest.

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Application of Nutritional Risk Score-2002 Questionnaire and Other Nutritional Status Parameters Among Hospitalized Elderly
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Percentage of patients at nutritional risk determined with NRS was 18.8%. This result was significantly lower than in other studies. With accordance to results of other researchers, values of the NRS increased with age. Results regarding the relationship between the NRS values and albumin concentration, AC and CC (negative correlations) and albumin concentration with CC and AC (positive correlations) were consistent with the results of other researchers. In the assessment of the nutritional status of hospitalized elderly, the NRS-2002 should be combined with basic anthropometric measurements.
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Malnutrition is a prevalent condition in older inpatients and has been shown to increase morbidity and direct medical costs. A number of established tools to assess malnutrition are available but malnourished patients rarely receive adequate nutritional assessment and treatment. The medical and economic consequences of malnutrition in hospitalized patients are therefore often underestimated.
This study investigates whether the Geriatric Nutritional Risk Index (GNRI) predicts hospital mortality, correlates with length of hospital stay (LOS) and inflammatory markers in older inpatients.
We conducted a prospective monocentric study in 500 hospital patients over 65 years of age (female: 248; male: 252; age: 76.3 ± 0.31 years). GNRI was correlated to C-reactive protein (CRP), lymphocyte count, LOS and all-cause mortality, adjusted for potential confounders.
The median body mass index was 24.1 (25th percentile: 21.1; 75th percentile: 27.8) kg/m² and the mean GNRI 82.2 ± 0.56. A higher risk GNRI was associated with increased CRP levels (p < 0.05) and low lymphocyte counts (p < 0.05) after multivariable adjustment. Moreover, we found positive correlation between a higher risk GNRI and length of hospital stay, whereas, the association with in-hospital mortality was not significant.
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To analyze risk factors associated with short and long-term mortality in nonagenarians hospitalized due to acute medical conditions.
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Original articleClinical characteristics and prognostic significance of serum albumin changes in an internal medicine ward

Highlights

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Study population

Entire group

Comparison between groups 1 (hypoalbuminemia on admission) and 2 (normoalbuminemia on admission) (Table 1)

Discussion

Conclusion

Learning points

Conflict of interests

J Clin Epidemiol

Clin Nutr

Am Heart J

J Infect

Eur J Intern Med

Clin Nutr

Serum albumin level on admission as a predictor of death, length of stay, and readmission

Arch Intern Med

Serum albumin: a prognostic indicator in patients with colorectal cancer

J R Coll Surg Edinb

Changes in nutritional status during the hospital stay: a predictor of long-term survival

Aging (Milano)

Original article
Clinical characteristics and prognostic significance of serum albumin changes in an internal medicine ward