Early changes in serum albumin: impact on 2-year mortality in incident hemodialysis patients

Pereira, Giselly Rosa Modesto; Strogoff-de-Matos, Jorge Paulo; Ruzany, Frederico; Santos, Sergio Fernando Ferreira dos; D'Almeida Filho, Eufrônio; Vasconcelos, Marcos Sandro Fernandes de; Barra, Ana Beatriz; Lugon, Jocemir Ronaldo

doi:10.5935/0101-2800.20150032

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Brazilian Journal of Nephrology

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Original Articles • J. Bras. Nefrol. 37 (2) • Apr-Jun 2015 • https://doi.org/10.5935/0101-2800.20150032 copy

Early changes in serum albumin: impact on 2-year mortality in incident hemodialysis patients

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Introduction/objective:

We evaluated the predictability of early changes in serum albumin (sAlb) on the two-year mortality of incident hemodialysis patients.

Methods:

Observational, longitudinal retrospective study using the database of Fresenius Medical Care of Latin America. Adult patients starting dialysis from January/2000 to June/2004, from 25 centers were included. Changes in sAlb during the first 3 months on hemodialysis were used as the main predictor. The outcome was death from any cause.

Results:

1,679 incident patients were included. They were 52 ± 15 years old, 58.7% male and 21.5% diabetic, with a median sAlb of 38 g/L (bromocresol green). 923 patients had sAlb < 38 g/L (Low sAlb Group) and 756 ones had sAlb > 38.0 g/L (Adequate sAlb Group). The mortality was significantly higher in Low sAlb Group (17% vs. 11%, p < 0.001). Early changes in sAlb significantly affected two-year mortality. Factoring the Kaplan Meier curve of Low sAlb Group by the presence of an increase in sAlb uncovered of a statistically significant difference in mortality favoring the ones whose sAlb went up (19% vs. 15%, p = 0.043). Differently, patients from Adequate sAlb Group with a decrease in their sAlb had a statistically higher mortality rate (13% vs. 8%, p = 0.029).

Conclusions:

Early sAlb changes showed a significant predictive power on mortality at 2 years in incident hemodialysis patients. Those with low initial sAlb may have a better prognosis if their sAlb rises. In contrast, patients with satisfactory initial levels can have a worsening of their prognosis in the case of an early reduction in sAlb.

Keywords:
kidney failure, chronic; mortality; renal dialysis; serum albumin

	Initial albumin
	All	< 38 g/L	> 38 g/L	p value^a a > 38 g/L vs. ≤ 38 g/L;
	(N = 1679)	(N = 923)	(N = 756)	p value^a a > 38 g/L vs. ≤ 38 g/L;
Gender (% males)	58.7	55.3	63.1	0.01
Age, years	52 ± 15^b b Mean ± S.D.;	54 ± 15	50 ± 15	< 0.001
> 65 years old, %	20.0	23.0	15.3	< 0.001
Primary renal disease, %
Diabetes	21.5	25.4	16.8	< 0.001
Hypertension	18.0	19.9	15.6	0.027
Chronic glomerulonephritis	79	70	8.9	0.190
Adult polycystic kidney	2.8	2.7	2.9	0.910
Others	19.8	19.6	20.0	0.880
Unknown	30.1	25.4	35.8	< 0.001
Body mass index (Kg/m²)	22.8 ± 4.4	22.7 ± 4.6	23.0 ± 4.1	0.10
Positive anti-HCV (%)	4.5	5.9	2.7	0.01
Positive HBsAg (%)	1.3	1.7	0.8	0.11
Positive HIV (%)	0.6	0.6	0.5	0.73
Hematocrit (%)	30.9 ± 6.1	34.0 ± 6.2	31.1 ± 5.9	0.29
sAlbi (g/L)^c c sAlbi = Initial serum albumin;	38.0 ± 5.3	3.4 ± 0.4	4.2 ± 0.3	< 0.001
Changes in sAlb (g/L)^d d Calculated as sAlb3 - sAlbi in which sAlb3 is the serum albumin collected at the end of the third month on regular hemodialysis;	0.3 ± 5.5	2.2 ± 4.9	-2.1 ± 5.4	< 0.001
Vascular catheter at start, %	48.2	49.4	46.9	0.414
Kt/V ^e e Mean of the first 3 months on hemodialysis.	1.36 ± 0.25	1.37 ± 0.25	1.35 ± 0.25	< 0.322

	H.R. (95% C.I.)	P
Increase in sAlb (y/n)^a a Calculated as a percent increase > 3% at the 3rd month of hemodialysis;	0.707 (0.505-0.990)	0.044
sAlb (g/L) at entrance	0.66 7 (0.441-1.009)	0.055
Age, years	1.032 (1.019-1.044)	< 0.001
Male gender	1.041 (0.741-1.461)	0.818
Body mass index (Kg/m²)	0.991 (0.952-1.031)	0.670
Diabetes	1.629 (1.146-2.315)	0.007
Hematocrit at entrance (%)	0.989 (0.962-1.016)	0.415
Positive hepatitis C serology	1.566 (0.842-2.911)	0.156
% Variation in dry weight at the 3^rd month	0.987 (0.968-1.007)	0.210
Kt/V^b b Mean of the first 3 months on hemodialysis.	0.236 (0.118-0.472)	< 0.001

	MODEL 1		MODEL 2		MODEL 3		MODEL 4
VARIABLES	H.R.	p	H.R.	p	H.R.	p	H.R.	p
	(C.I.95%)	value	(C.I. 95%)	value	(C.I. 95%)	value	(C.I.95%)	value
Increase in sAlb (y/n)	0.579 (0.399-0.838)	0.004	0.592 (0.410-0.856)	0.005	0.602 (0.416-0.872)	0.007	0.586 (0.405-0.847)	0.005
sAlb at entrance (g/L)	0.514 (0.334-0.792)	0.003	0.484 (0.309-0.758)	0.002	0.493 (0.312-0.779)	0.002	0.526 (0.336-0.823)	0.005
Age (years)			1.032 (1.019-1.045)	< 0.001	1.031 (1.018-1.044)	< 0.001	1.031 (1.018-1.044)	< 0.001
Diabetes (y/n)					1.396 (0.980-1.988)	0.065	1.311 (0.919-1.871)	0.135
Mean Kt/V							0.261 (0.130-0.526)	< 0.001

	H.R. (95% C.I.)	p
Reduction in sAlb (Y/N)^a a Calculated as a percent reduction > 3% at the 3rd month of hemodialysis;	1.716 (1.051-2.804)	0.031
sAlb at entrance (g/L)	1.033 (0.510-2.089)	0.929
Age, years	1.039 (1.021-1.057)	< 0.001
Male gender	1.041 (0.541-1.415)	0.586
Body mass index at entrance (Kg/m²)	1.022 (0.966-1.081)	0.452
Diabetes	2.337 (1.408-3.877)	0.001
Hematocrit at entrance (%)	0.994 (0.955-1.035)	0.774
Positive hepatitis C serology	1.182 (0.289-4.831)	0.816
%Variation in dry weight at the 3rdmonth	0.954 (0.908-1.002)	0.061
Kt/V^b b Mean of the first 3 months on hemodialysis. Cox proportional models with progressive inclusion of the independent variables with p values < 0.10 in the univariate analysis Cox proportional models with progressive inclusion of the independent variables with p values < 0.10 in the univariate analysis	0.851 (0.328-2.210)	0.741

VARIABLES	MODEL 1		MODEL 2		MODEL 3
VARIABLES	H.R. (C.I. 95%)	p value	H.R. (C.I. 95%)	p value	H.R. (C.I. 95%)	p value
Reduction in sAlb (y/n)	1.642 (1.005-2.683)	0.048	1.600 (0.979-2.617)	0.061	1.360 (0.818-2.261)	0.236
Age (years)	1.038 (1.021-1.056)	< 0.001	1.036 (1.018-1.054)	0.000	1.036 (1.017-1.055)	< 0.001
Diabetes (y/n)			1.864 (1.118-3.107)	0.017	1.870 (1.094-3.196)	0.022
%Variation in dry weight					0.956 (0.909-1.005)	0.077

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[1] Correspondência para: Jocemir Ronaldo Lugon. Universidade Federal Fluminense. Hospital Universitário Antônio Pedro. Rua Marquês de Paraná. nº 303, 2º Andar, Centro de Diálise. Centro, Niterói, RJ, Brasil. CEP: 24033-900. E-mail: jocerl@huap.uff.br Tel: 55 (21) 2629-9260.