espen congress lisbon 2004 water and electrolytes ... · water and electrolytes hyperhydration and...

ESPEN Congress Lisbon 2004

Water and electrolytes

Hyperhydration and hypoalbuminemia. How to proceed?

A Sigtes-Sierra

AlbuminAlbumin andand fluid fluid shiftsshifts

WhatWhat isis albuminalbumin andand whatwhat albuminalbumin isis meantmeant forfor??

•• STRUCTURE STRUCTURE andand KINETICSKINETICS-- Globular Globular proteinprotein (60,000 (60,000 daltondalton MW)MW)-- HalfHalf--lifelife ofof 21 21 daysdays-- IntraIntra (40%) (40%) andand extravascularextravascular (60%) (60%) poolspools-- Total Total albuminalbumin massmass = 250= 250--300 grs.300 grs.-- ReferenceReference valuesvalues forfor [s[s--albalb]: 35]: 35--50 g/L50 g/L

•• FUNCTIONFUNCTION-- Fluid Fluid shiftsshifts acrossacross capillarycapillary membranemembrane-- TransportTransport proteinprotein

AlbuminAlbumin as a as a riskrisk factorfactorShort Short termterm, general , general surgerysurgery

AlbuminAlbumin in in compositecomposite nutritionnutrition indicesindices

SeltzerSeltzer (1979)(1979) SS--albalb + + lymphocyteslymphocytesBuzbyBuzby (1980)(1980) SS--albalb + TSK, + TSK, transferrintransferrin, DHT, DHTDetskyDetsky (1987) (1987) SS--albalb + + subjectivesubjective assessmentassessmentChristouChristou (1989)(1989) SS--albalb + + anergyanergyWindsorWindsor (1988)(1988) SS--albalb + + organorgan failurefailureBuzbyBuzby (1991) (1991) SS--albalb + + weightweight lossloss

AlbuminAlbumin as a as a riskrisk factorfactor

VA VA StudyStudy. . ArchArch SurgSurg 19991999

AlbuminAlbumin as a as a riskrisk factorfactor

TheThe hypoalbuminaemichypoalbuminaemic patientpatient::a a metabolicmetabolic cripplecripple

•• AlteredAltered bodybody compostioncompostion•• DiminishedDiminished musclemuscle strengthstrength•• HigherHigher APACHE II APACHE II scoresscores•• DerangedDeranged endocrineendocrine responseresponse•• WorseWorse organorgan functionfunction•• ImmunesuppressionImmunesuppression•• ComorbidityComorbidity•• OldOld ageage

AlbuminAlbumin metabolismmetabolism

IntakeIntakeMuscleMuscle

Plasma Plasma aminoacidsaminoacidsNormal Normal metabolicmetabolic pathwayspathways

HepaticHepatic synthesissynthesis (14g/(14g/dayday))

IntravascularIntravascularalbuminalbumin

(120g; 40%)(120g; 40%)

ExtravascularExtravascularalbuminalbumin

(180g; 60%)(180g; 60%)(120g/(120g/dayday))

TissueTissue catabolismcatabolism(12g/(12g/dayday))

LossesLosses:: RenalRenal (0.4g/(0.4g/dayday))IntestinalIntestinal (1.0g/(1.0g/dayday))

((WhicherWhicher, 1987), 1987)

AlbuminAlbumin metabolismmetabolism

IntakeIntakeMuscleMuscle

PathogenesisPathogenesis ofof hypoalbuminaemiahypoalbuminaemia

Plasma Plasma aminoacidsaminoacids

HepaticHepatic synthesissynthesis (14g/(14g/dayday))

IntravascularIntravascularalbuminalbumin

(120g; 40%)(120g; 40%)

ExtravascularExtravascularalbuminalbumin

(180g; 60%)(180g; 60%)(120g/(120g/dayday))

TissueTissue catabolismcatabolism(12g/(12g/dayday))

LossesLosses:: RenalRenal (0.4g/(0.4g/dayday))IntestinalIntestinal (1.0g/(1.0g/dayday))

((WhicherWhicher. 1987). 1987)

AlbuminAlbumin distributiondistribution

45 (g/L)45 (g/L)

VascularVascularspacespace

InterstitialInterstitialspacespace

ExcludedExcludedspacespace

AvailableAvailablespacespace

AlbuminAlbumin in in thethe ExtracellularExtracellular WaterWater CompartmentCompartmentPhysiologyPhysiology

AlbuminAlbumin andand fluid fluid shiftsshiftsPhysiologyPhysiology

StarlingStarling’s Law’s Law

Net Net filtrationfiltration = = Lp*SLp*S ((∆∆ OncoticOncotic PP -- ∆∆ hydraulichydraulic P)P)

Net Net filtrationfiltration = = Lp*SLp*S ((σ σ ((ΠΠcc--ΠΠii) ) -- ((PPcc--PPii))))σ σ = = reflectionreflection coefficientcoefficient (0(0--1, 1, permeabilitypermeability toto proteinsproteins))

RoseRose & Post, 5th & Post, 5th EditionEdition

AlbuminAlbumin distributiondistribution

45 (g/L)45 (g/L)PathophysiologyPathophysiology

29 (g/L)29 (g/L)

ECWECW ECWECW

VascularVascularspacespace

InterstitialInterstitialSpaceSpace

((hyaluronanhyaluronan gelgelmatrixmatrix))

ExcludedExcludedspacespace

AvailableAvailablespacespace

ProbablyProbably allall hypoalbuminaemichypoalbuminaemic patientspatients havehave ECW ECW expansionexpansion

66

88

1010

1212

1414

HaemoglobinHaemoglobin(g/dL)(g/dL)

p =0.02p =0.02

NonNon--expandedexpandedECW < 25 % wECW < 25 % w

(n=20)(n=20)

ExpandedExpandedECW ECW ≥≥ 25% w25% w

(n=30)(n=30)

ØØ Tumor*Tumor*(mm)(mm)

3030

4040

5050

6060

7070 p =0.002p =0.002

3030

3232

3434

3636

3838

4040 p =0.02p =0.02

AlbuminAlbumin(g/L)(g/L)

*n=23*n=23 n=12n=12

AlbuminAlbumin andand ECW in ECW in cancercancer patientspatients

DistributionalDistributional hypoalbuminaemiahypoalbuminaemiaPathophysiologyPathophysiology

29 (g/L)29 (g/L)

HighHigh/Normal//Normal/LowLow plasma plasma volumevolume

ExpandedExpanded interstitialinterstitial volumevolumeIncreasedIncreased availableavailable spacespace

ReducedReduced excludedexcluded spacespace

ECWECW

ECW ECW increaseincreaseA. A. InterstitialInterstitial illnessillness

B. B. CapillaryCapillary leakleaksyndromesyndrome

PlasmaPlasmacompartmentcompartment

……albumin shiftsalbumin shifts

AvailableAvailableinterstitiuminterstitium

HyaluronanHyaluronangellygelly matrixmatrix

……oedema developsoedema develops

……albumin shiftsalbumin shifts

PlasmaPlasmacompartmentcompartment

AvailableAvailableinterstitiuminterstitium

HyaluronanHyaluronangellygelly matrixmatrix

……oedema developsoedema developsEndotoxinEndotoxin / / CytokinesCytokines

DistributionalDistributional hypoalbuminaemiahypoalbuminaemia

ConvectiveConvective transporttransport ofof albuminalbumin(Fluid ((Fluid (over)loadsover)loads))

Fluid loadFluid load

……oedema developsoedema develops ……albumin shiftsalbumin shifts

MullinsRJMullinsRJ 19891989


ConvectiveConvective transporttransport ofof albuminalbumin(2L/1h fluid load in normal (2L/1h fluid load in normal volounteersvolounteers))

0 1 2 3 4 5 675

80

85

90

95

100

105

Time (hours)

% c

hang

e in

ser

umal

bum

inP=0.002

SalineDextrose

Lobo et al., Clin Sci 2001


ConvectiveConvective transporttransport ofof albuminalbumin(2L/1h fluid load in normal (2L/1h fluid load in normal volounteersvolounteers))

0 1 2 3 4 5 690

92

94

96

98

100

102

Time (hours)

% c

hang

e in

haem

atoc

ritP=0.01

SalineDextrose

Lobo et al., Clin Sci 2001

HypoalbuminaemiaHypoalbuminaemia

TherapeuticTherapeutic approachesapproaches

•• TreatTreat fundamental fundamental illnessillness•• NegativeNegative ECW balanceECW balance

•• DiureticsDiuretics•• WaterWater andand NaNa restrictionrestriction

•• CombinationCombination therapytherapy•• NutritionNutrition supportsupport ifif malnutritionmalnutrition•• Human Human serumserum albuminalbumin??

HypoalbuminaemiaHypoalbuminaemia

TherapeuticTherapeutic approachesapproaches in in differentdifferent scenariosscenarios

•• ElectiveElective cancercancer surgerysurgery•• ObstructiveObstructive jaundicejaundice•• AcuteAcute injuryinjury::

•• PolytraumaPolytrauma•• BurnsBurns•• InfectiousInfectious diseasedisease

•• PostoperativePostoperative complicationscomplications•• MalabsorptionMalabsorption/SBS/SBS

HypoalbuminaemiaHypoalbuminaemia in in gastricgastric cancercancer

A A patientpatient withwith gastricgastric cancercancer

•• 76 76 yryr. . oldold malemale withwith epigastricepigastric painpain•• GastricGastric adenocarcinomaadenocarcinoma ((bodybody))•• WeightWeight lossloss ofof 16%16%•• SS--albalb 28 g/L28 g/L•• HbHb 9 g/dl 9 g/dl •• CandidateCandidate forfor total total gastrectomygastrectomy

HypoalbuminaemiaHypoalbuminaemia in in gastricgastric cancercancer

A A patientpatient withwith gastricgastric cancercancer

•• ECW ECW measurementmeasurement ((bioimpedancebioimpedance))•• Oral/Oral/EnteralEnteral refeedingrefeeding•• IronIron//BloodBlood transfusiontransfusion•• OmeprazolOmeprazol•• PhysiotherapyPhysiotherapy•• FurosemideFurosemide (10(10--40 40 mgmg//dayday) )

HypoalbuminaemiaHypoalbuminaemia in in obstructiveobstructive jaundicejaundice

A A patientpatient withwith obstructiveobstructive jaundicejaundice

•• 68 68 yryr. . malemale withwith malignantmalignant obstructiveobstructive jaundicejaundice•• CholangiocarcinomaCholangiocarcinoma (distal 1/3 CBD)(distal 1/3 CBD)•• WeightWeight lossloss 18%18%•• SS--albalb 31 g/L31 g/L•• No No clinicalclinical signssigns ofof cholangitischolangitis•• PotentialPotential candidatecandidate toto pancreaticoduodenectomypancreaticoduodenectomy

HypoalbuminaemiaHypoalbuminaemia & & jaundicejaundice

BenignBenign MalignantMalignant PP

Ideal Ideal bodybody weightweight 97±1197±11 88±1588±15 .03.03BilirubinBilirubin mgmg/dl/dl 9±69±6 15±915±9 .04.04AlkAlk PhosPhos U/LU/L 366±330 366±330 1068±9101068±910 .003.003EndotoxinEndotoxin (EU/ml)(EU/ml) 17±1017±10 10±910±9 NSNSTNFTNF--αα ((pgpg/ml)/ml) 32±2632±26 87±6787±67 .01.01CCK (CCK (pmolpmol/L)/L) 2.5±22.5±2 3.9±1.43.9±1.4 .05.05SS--albuminalbumin (g/L)(g/L) 35±335±3 30±430±4 0.0050.005

PadilloPadillo J et al., World J J et al., World J SurgSurg 20012001

HypoalbuminaemiaHypoalbuminaemia & g.i. & g.i. cancercancerHypoalbuminaemiaHypoalbuminaemia in in obstructiveobstructive jaundicejaundice

ImprovedImproved foodfood intakeintake afterafter internalinternal biliarybiliary drainagedrainage

800

900

1000

1100

1200

1300

1400

1500

1600

1700

0 2 3 4 5 6

BenignMalignant

** ** **

** **

PadilloPadillo FJ et al, 2001FJ et al, 2001

HypoalbuminaemiaHypoalbuminaemia afterafter resuscitationresuscitation

•• 69 69 yryr. . femalefemale withwith postoperativepostoperative peritonitisperitonitis•• BP 90/50 BP 90/50 mmHgmmHg, , metabolicmetabolic acidosis, oliguriaacidosis, oliguria•• ResuscitationResuscitation: : fluidsfluids, , antibioticsantibiotics, , surgerysurgery•• DayDay 3: S3: S--albalb 21 g/dl, 21 g/dl, dependentdependent oedemaoedema•• PostoperativePostoperative coursecourse: BP : BP unstableunstable, oliguria, oliguria•• VentilatorVentilator andand dopaminedopamine requiredrequired

ProblemsProblems afterafter anan anterior anterior resectionresection forfor rectal rectal cancercancer


Do Do notnot use use albuminalbumin forfor resuscitationresuscitationNegativeNegative oror incocnlusiveincocnlusive datadata

Human Human albuminalbumin solutionsolution forfor resuscitationresuscitation andand volumevolume expansionexpansion in in criticallycritically illillpatientspatients. . AldersonAlderson P et al. P et al. CochraneCochrane DatabaseDatabase SystSyst RevRev 2002; (1):CD001208.2002; (1):CD001208.

HypoalbuminemiaHypoalbuminemia in in acuteacute illnessillness: : isis therethere a a rationalerationale forfor interventionintervention? A meta? A meta--analysisanalysis ofof cohortcohort studiesstudies andand controlledcontrolled trialstrials. . VincentVincent JL et al. JL et al. AnnAnn SurgSurg 2003; 237:3192003; 237:319--34.34.

A A comparisoncomparison ofof albuminalbumin andand salinesaline forfor fluid fluid resuscitationresuscitationSAFE SAFE GroupGroup. N . N EnglEngl J J MedMed 2004; 350:22472004; 350:2247--56.56.



GuiraoGuirao et al., J et al., J SurgSurg Res 1995Res 1995

rr22= 0.87= 0.87p= 0.0007p= 0.0007

2020

1010

00

--1010--3030 --2525 --2020 --1515 --1010 --55 00

AlbuminAlbumin decreasedecrease prepre--TPN (g/l)TPN (g/l)

NaNa balance balance 00--3d TPN3d TPN((mEqmEq/3d)/3d)



GuiraoGuirao et al., J et al., J SurgSurg Res 1995Res 1995

rr22= 0.9= 0.9p= 0.0001p= 0.0001

400400

350350

300300

250250

200200--3030 --2525 --2020 --1515 --1010 --55 00

AlbuminAlbumin decreasedecrease prepre--TPN (g/l)TPN (g/l)

ECW / ECW / kgkg endend TPNTPN(ml/(ml/kgkg))


ProblemsProblems afterafter anan anterior anterior resectionresection forfor rectal rectal cancercancerManagementManagement ofof hypoalbuminaemiahypoalbuminaemia

•• ImproveImprove haemodynamicshaemodynamics•• EnhanceEnhance diuresisdiuresis•• PromotePromote a a negativenegative ECW balanceECW balance•• StartStart TPN in a TPN in a stablestable patientpatient•• LowLow sodiumsodium//waterwater TPNTPN

HypoalbuminaemiaHypoalbuminaemia in in malabsorptionmalabsorption

•• 54 54 yryr. . malemale withwith massivemassive SB SB resectionresection•• VenousVenous thrombosisthrombosis. 45 cm. SB . 45 cm. SB withwith coloncolon•• PostoperativePostoperative diarrheadiarrhea. TPN . TPN forfor 2 2 mosmos..•• 2 2 mosmos. . afterafter weaningweaning: : ankleankle oedemaoedema, 15% , 15% weightweight lossloss, , paresthesiaeparesthesiae, s, s--albalb: 22 g/L. : 22 g/L. CaCa: 6.5 : 6.5 mgmg/dl. /dl. MgMg: 0.5 : 0.5 mgmg/dl/dl•• AdmittedAdmitted forfor lobarlobar pneumoniapneumonia

Short Short bowelbowel syndromesyndrome

HypoalbuminaemiaHypoalbuminaemia & TPN& TPN

HypoalbuminaemiaHypoalbuminaemia duringduring i.v. i.v. refeedingrefeeding

NonNon--respondersrespondersRespondersResponders

∆ Weight∆ Weight-3-3-2-2-1-1001122

--1.51.5--11

--0.50.500

111.51.522

∆ Albumin∆ Albuminlbslbs g/Lg/L StarkerStarker et al. et al. AnnAnn SurgSurg 19831983


HypoalbuminaemiaHypoalbuminaemia duringduring i.vi.v. . refeedingrefeeding∆∆

in a

lbum

in (g

/l)in

alb

umin

(g/l)

-5

0

5

10

15

20 R=R=--0.61 0.61 PP=0.003=0.003

-25 -20 -15 -10 -5 0

∆∆ in weight (kg)in weight (kg)Lobo et al., Lobo et al., ClinClin NutrNutr 19991999


HypoalbuminaemiaHypoalbuminaemia duringduring i.vi.v. . refeedingrefeedingPreoperativePreoperative malnutritonmalnutriton. TPN . TPN forfor 10 10 daysdays

Standard Diet Low NaStandard Diet Low Na--water diet Pwater diet Pn =19 n =22n =19 n =22

________________________________________________________________________________________________________________

SS--albumin (g/L)albumin (g/L) 31.731.7±±4.14.1 35.335.3±±3.83.8 0.0080.008∆∆ SS--albumin (g/L)albumin (g/L) --0.70.7±±2.82.8 2.32.3±±3.53.5 0.0060.006∆∆ Weight (Kg)Weight (Kg) 0.80.8±±0.90.9 --1.51.5±±1.11.1 0.00010.0001Daily Daily diuresisdiuresis ((mLmL)) 1,2301,230±±310310 959959±±245245 0.0030.003Water balance (10 d)Water balance (10 d) 478478±±11341134 --10911091±±12561256 0.0010.001Na balance (Na balance (mEqmEq/day)/day) 4040±±33 --2727±±1818 0.00010.0001Urea (mg/dL)Urea (mg/dL) 4141±±1212 6161±±3434 0.020.02

Gil J et al. Gil J et al. NutritionNutrition 19971997

espen congress lisbon 2004 water and electrolytes ... · water and electrolytes hyperhydration and...

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