Hypoalbuminemia is a frequent marker of increased mortality in cardiogenic shock

Abstract

Introduction: The prevalence of hypoalbuminemia, early changes of plasma albumin (P-Alb) levels, and their effects on mortality in cardiogenic shock are unknown.

Materials and methods: 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.

Results: 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.

Conclusions: 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.

Trial registration: NCT01374867 at ClinicalTrials.gov.

Conflict of interest statement

VPH: Advisory board fees from Roche Diagnostics, research grant from Abbott, speaker fees from Orion, all outside the present work. KP: Advisory board fees from Roche Diagnostics (Finland). AM: lecture fees from Novartis, Orion, and Abbott, research grants from Roche, and consultant fees from Servier and Sanofi, all outside the present work. JL: Speakers bureau and consultancy fees: AstraZeneca, Bayer, Boehringer-Ingelheim, Novartis, OrionPharma, Pfizer, Roche Diagnostics, and ViforPharma, all outside the present work. All other authors report that they have no competing interests. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Figures

Fig 1. Kaplan-Meier survival curves of 90-day mortality according to baseline plasma albumin (P-Alb).

Fig 2. 90-day mortality by baseline albumin quartiles.

The P-Alb ranges for the quartiles were 34.0–42.9 g/L for the 1st quartile, 30.0–33.9 g/L for the 2nd quartile, 25.9–29.9 g/L for the 3rd quartile and 10.4–25.9 g/L for the 4th quartile.

Fig 3

A: Mean plasma albumin at different time points during hospitalization in 90-day survivors and non-survivors of cardiogenic shock. Mean change between 0 and 72h -4.6 g/L for survivors, -5.4 g/L for non-survivors; p = 0.54. B: Plasma albumin at different time points during hospitalization in patients with normoalbuminemia or hypoalbuminemia at baseline. Mean change between 0 and 72 h -10.8 mg/L for normoalbuminemic patients and -2.5 mg/L for hypoalbuminemic patients; p<0.001. P-values in the picture represent results for linear mixed model analysis of variance for repeated measures. * p<0.05 § p<0.10 for the difference in P-Alb between groups at this time point (Student’s t-test). Error bar = standard deviation.