Hypoalbuminemia in CKD and dialysis patients

Albumin and its function:

Albumin is a protein that can be found in meats, dairy products, and eggs. It can also be present in plants like beans, nuts, and seeds. Albumin is a type of protein that helps the body sustain growth and repair tissues. It can also aid in the elimination of fluids during dialysis. Fluid will traverse more easily from swollen tissues into the circulation if the albumin level is good, where it may be removed by the dialyzer. The optimum serum (blood) albumin range for dialysis patients is 4.0 g/dl or higher. Albumin is a major blood protein. It aids in maintaining the proper fluid balance between the blood vessels and the tissues they supply. To remove waste items from the blood, the kidneys filter it. The waste products should ideally wind up in the urine, whereas albumin and other proteins should remain in the blood vessels.

Introduction to hypoalbuminemia:

End-stage renal disease patients frequently have hypoalbuminemia (ESRD). This condition is caused by a combination of decreased albumin synthesis and enhanced degradation. A systemic inflammatory state causes impaired albumin homeostasis in ESRD patients, which is closely linked to mortality. Hypoalbuminemia is a reliable indicator of a poor prognosis.

A decrease in albumin synthesis rate (due to protein deficiency) and an elevation in comparatively small catabolic rate (FCR), both caused by acute phase response, are the most common causes of hypoalbuminemia in dialysis patients.

Individuals with and without CKD share many of the same factors that regulate serum albumin. Hypoalbuminemia is not always caused by a reduction in the glomerular filtration rate.

It gives the body the protein it needs for growth and tissue repair. Albumin in the blood aids in the elimination of fluid during dialysis. It helps “draw” surplus fluid from swollen tissues back into the circulation, where the dialyzer can remove it.

Many studies have found that people with chronic kidney disease (CKD) who have a low serum albumin have a higher risk of renal failure than those who have a normal serum albumin.

If predialysis or a stable plasma prealbumin level is employed to assess nutritional status, a value more than or equal to 30 mg/dL is indicated as the outcome goal for prealbumin.

Albumin is a major protein that is present in the blood. A patient with low albumin content in Urine is considered healthier than patients having more albumin. Presence of high amount of albumin in the urine or excretion of albumin is a definite indication of kidney disease. 

Hypoalbuminemia is a major predictor of poor outcomes in dialysis patients. Low serum albumin is sometimes attributed to a lack of protein intake, yet there is evidence that inflammation is the primary reason.

Importance of Albumin-creatinine ratio:

The urine albumin-creatinine ratio (uACR) determines if albumin is present in the urine. Albumin is a type of protein found in the bloodstream. Protein is required by the body. It’s a vital nutrient that aids in muscle growth, tissue healing, and infection resistance. A high ACR (Albumin creatinine ratio) implies that the renal disease is severe. The kidneys are most likely functioning normally if the ACR is quite low. It’s simpler to control or avoid complications from occurring if diabetes is well-managed, such as high blood pressure, which can occasionally lead to renal disease.

Edema arises when plasma proteins, particularly albumin, can no longer maintain sufficient colloid osmotic pressure to counteract hydrostatic pressure.

Severe hypoalbuminemia is described as serum albumin values of less than 24 g/L in the literature. Albumin levels were tested on the Synchron CX9 (Beckman Coulter) in our laboratory using the bromocresol purple method; the lower detection limit on this instrument is 10 g/L.

Hypoalbuminemia occurs in individuals with overwhelming illnesses like sepsis and septic shock as a result of the combined effects of decreased synthesis, increased tissue use, and increased transcapillary leakage from blood vessels due to increased vascular permeability.

Regulation of proteinuria

Nutritional deficiencies (not eating enough protein) can lead to albuminuria. 

Lack of appetite caused by inadequate dialysis (low Kt/V), illness, drug side effects, or depression can all lead to a decreased intake of protein-rich foods. A low albumin level can also be caused by a lack of knowledge about what foods to eat or a lack of protein-rich foods.

Protein depletion can be cited as another reason. 

Protein may be lost in the urine as a result of some types of renal disease (proteinuria).

Some protein passes the peritoneal membrane and exits the body in the effluent dialysate during peritoneal dialysis (the solution drains from the peritoneal cavity). When a person has peritonitis, a peritoneal infection, this loss accelerates.

Albumin levels can also be affected by liver disease (protein is generated in the liver) or blood loss.

Diagnosis and sample collection for Hypoalbuminemia

To determine the amount of albumin in the body, a blood sample for an albumin blood test can be taken. The albumin blood test determines whether the blood albumin level is excessively high, normal, or low. Lower-than-normal results could indicate an underlying medical issue.

Depending on the symptoms, the healthcare practitioner may test the albumin levels on their own or undertake a panel test to evaluate the health of your organs, such as a metabolic panel that analyses liver and kidney function as well as nutritional levels, or a liver panel that assesses liver function.

A microalbuminuria test or an albumin-to-creatinine ratio test can be performed on a sample of the urine of the patient by the healthcare professional.

Causes of Hypoalbuminemia:

Hypoalbuminemia is caused by an underlying medical problem. Finally, the ailment is a symptom of another ailment. Liver illness is one of the most common causes of hypoalbuminemia. Several other diseases leading to Hypoalbuminemia is mentioned below. 

  • Heart failure is a serious condition.

  • A vitamin deficit or malnutrition.

  • Inflammatory bowel disease is a condition in which the intestines become inflamed.

  • Kidney disease is a condition that affects many people.

  • Hypoalbuminemia can also be caused by stress.

  • Thyroid illness is a condition affecting the thyroid gland.

  • Diabetes, Nephrotic syndrome is a condition that affects the kidneys, Lupus, Cirrhosis can also lead to Hypoalbuminemia.

  • Individuals who have recently been hospitalized may develop hypoalbuminemia, especially if they: are given fluids through an IV, have surgery, and have been exposed to a ventilator.The healthcare practitioner will monitor the albumin levels on a regular basis to see how well the treatment for the underlying disease is working.

Hypoalbuminemia and prevalence:

Hypoalbuminemia was found in almost 58% of hospitalized people over the age of 70 (76-85 years), according to the graphical representation below compared to other age groups. Hypoalbuminemia is usually a sign of another illness, leading to a specific diagnosis.

Hypoalbuminemia can cause weakness and weariness in persons over the age of 70, putting them at risk of falling or physical harm. 

Hypoalbuminemia symptoms that appear suddenly could indicate an underlying medical issue. Albumin levels in the blood might be raised by treating the underlying illness.

Urine albumin concentration should not exceed 30mg/g. . Even if the GFR is at 60, anything above 30 mg/g could be indicative of renal disease. The dialysis team can help one obtain an albumin level of 4.0 mg/dl.

Symptoms of Hypoalbuminemia:

Hypoalbuminemia can be life-threatening if left untreated. Symptoms that go untreated can lead to:

  • If one loses their appetite, one might become malnourished.

  • Ailment of the liver or kidneys.

  • Insufficiency of the heart (circulatory collapse).

  • GFR ranging between 30-60mg/g can be also indicative of renal disease. Excess protein in the urine, as revealed by a urine test, is one of the most common symptoms of hypoalbuminemia.

  • Swelling caused by fluid retention, particularly in the feet and hands.

  • Jaundice symptoms include yellow skin and eyes.

  • Feelings of fatigue or weakness

  • A fast heartbeat

  • Nausea, vomiting, and diarrhea

  • Drastic changes in appetite.

Treatment of Hypoalbuminemia:

Hypoalbuminemia is treated differently depending on what caused the albumin protein levels to drop. The albumin level can be restored to normal by treating the underlying problem that caused hypoalbuminemia. Hypoalbuminemia can be treated with a well-balanced diet, which can help with malnutrition and heart disease.

To treat kidney disease or heart failure, One may need to take blood pressure medicine.

Anti-inflammatory medication is used to treat inflammation (NSAIDs) can be administered to such patients.

Dialysis is being used to treat renal disease.

The healthcare practitioner will regularly monitor the treatment to follow the symptoms and ensure that the body’s albumin protein level rises.

Malnutrition or a vitamin deficiency could cause hypoalbuminemia. Vitamin D supplementation and a well-balanced diet rich in protein such as lean meats, fish, nuts (almonds, cashews, walnuts, etc.) and eggs, as well as dairy products (milk, yogurt, cheese) and whole-grain carbohydrates (wheat and rice), can help your body generate more albumin.

One can lower their risk of hypoalbuminemia by eating a well-balanced diet that includes dairy, protein, and whole-grain carbs, or by taking supplements to boost one’s protein and calorie intake.

Eliminating high-sodium (salt) foods from the diet is needed.

Taking medication or getting therapy for underlying health problems.

Limiting the amount of alcohol, one consumes is important.

Goals for preventing or combating proteinuria: 

  • Monitoring the amount of albumin in the body on a monthly basis is crucial.

  • Consuming a well-balanced diet is of utmost importance. For instance, a nutritious diet with vegetables and fruits as well as with sufficient amounts of protein.

  • Inflammations and infections can be prevented and treated using antibiotics or any other supplements. 

  • Any signs or symptoms of infection or inflammation should be reported.

  • Infections can be avoided by following good hygiene measures.

If the above goals are attained and strict adherence to the treatment and dietary regimen is maintained, hypo albuminuria can be mitigated. 

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