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Albumin: depleted fatty acid carrier needed to withstand the reductive stresses imposed by surgery a
- Richard G Fiddian-Green (11 April 2005)
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Richard G Fiddian-Green, N/A N/A
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This study (1) suggests that the decrease in serum albumin concentration in sepsis might be the product of an increase in metabolic utilization. Polyunsaturated fatty acids (PUFAs)are also decreased in sepsis(2). As albumin is an important carrier of fatty acids in plasma, fatty acids being insoluable in aqueous solutions unless combined with albumin or lipoproteins, the decrease in both albumin and PUFAs might be due to a greatly increased demand for fatty acids by mitochondria imposed by the acute reductive stress present in sepsis. In which case administering even more albumin possibly combined with omega-3-fatty acids and even phosphate, to support the anticipated increase in rate of ATP syntheis, might be of considerable metabolic benefit (3). If fatty acids are needed to cope with the acute reductive stresses imposed by surgery and anaesthesia, as I have argued, this could explain why a low albumin is an independent predictor of operative mortality and morbidity in the National VA Surgical Risk Study(4). "A decrease in serum albumin from concentrations greater than 46 g/L to less than 21 g/L was associated with an exponential increase in mortality rates from less than 1% to 29% and in morbidity rates from 10% to 65%. In the regression models, albumin level was the strongest predictor of mortality and morbidity for surgery as a whole and within several subspecialties selected for further analysis. Albumin level was a better predictor of some types of morbidity, particularly sepsis and major infections, than other types". Support for this interpetation is provided by a clinical study done at Harvard 20 years ago by Skillman. "Albumin synthesis rate, nitrogen balance, plasma hormone levels, and selected substrates were measured after operation in 12 patients who underwent colonic operations who were randomized to receive an intravenous fluid regimen that contained either 3.5% amino acids with 20% fat and 2.5% glucose or 3.5% amino acids with 20% fat alone. The albumin synthesis rate was higher in patients who received the first of these intravenous mixtures (357 +/- 34 mg/kg/day versus 216 +/- 22 mg/kg/day; p less than 0.01), but they also had a significantly higher intake of calories (10.2 +/- 1.1 calorie/kg/day versus 6.4 +/- 0.6 calorie/kg/day; p = 0.01). The mean albumin synthesis rate in the group who received amino acids with glucose and fat is the highest we have measured in our series of studies". Thirty years ago Skillman reported that, "Pulmonary arteriovenous admixture was significantly less in the albumin group than in the electrolyte group on the first postoperative day" (6). "He had randomized patients to receive either an albumin- or a sodium-rich intraoperative fluid regimen. That was before perioperative management had become contaminated by "haemodymanic management". The question needs to be addressed again without this contamination. 1. M. P. Margarson and N. C. Soni Changes in serum albumin concentration and volume expanding effects following a bolus of albumin 20% in septic patients Br. J. Anaesth. 2004; 92: 821-826 2. Ortiz-Leyba, C, Pita-Calandre, M, Estad, M R Moyano del, Jimenez-Jimenez, J, et al. Plasma fatty acids profile in sepsis Journal of Parenteral and Enteral Nutrition, Jan/Feb 2004 3. The anti-anapleuretic action of statins Richard G Fiddian-Green (19 August 2004) eLetter re: Rodrigo B. Cavalcanti Does perioperative lipid-lowering therapy reduce in-hospital mortality after major noncardiac surgery? CMAJ 2004; 171: 328 4. Gibbs J, Cull W, Henderson W, Daley J, Hur K, Khuri SF. Preoperative serum albumin level as a predictor of operative mortality and morbidity: results from the National VA Surgical Risk Study. Arch Surg. 1999 Jan;134(1):36-42. 5. killman JJ, Rosenoer VM, Young JB, Young VR, Long PC, Munro HN. Energy intake can determine albumin synthesis in man after surgery. Surgery. 1985 Mar;97(3):271-7. 6. Skillman JJ, Restall DS, Salzman EW. Randomized trial of albumin vs. electrolyte solutions during abdominal aortic operations. Surgery. 1975 Sep;78(3):291-303. --------------------------------------------------------------------- ----------- Conflict of Interest:None declared |
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