HDCN Article Review/Hyperlink

Guijarro C, Massy ZA, Wiederkehr MR, Ma JZ, Kasiske BL

Serum albumin and mortality after renal transplantation

Am J Kidney Dis (Jan) 27:117-123 1996

A number of investigators have demonstrated that low serum albumin levels are a significant risk factor for mortality in patients with ESRD who receive chronic dialysis therapy. Guijarro et al. provide the first analysis of the relationship between serum albumin and mortality in patients who underwent renal transplantation. This cohort consisted of 706 patients who were transplanted between January 1, 1976 and June 1, 1991 at Hennepin County Medical Center in Minneapolis, Minnesota. In this cohort, all patients received azathioprine and corticosteroid based immunosuppression, 88.7% received Minnesota antilymphocyte globulin for induction therapy, 68.1% received a pre-transplant splenectomy (a procedure now largely abandoned) and 35.4% received cyclosporin, of which 80% of patients had elective withdrawal of cyclosporin approximately 1.2 years after transplantation.

The average time to death, last follow-up or return to dialysis was 7.0+_4.2 years. On average, serum albumin levels increased from 3.75 g/dl to 3.95 g/dl during the first year after transplantation, then had a slow linear decline to 3.8 g/dl over the ensuing 11 year period. For patients who survived at least six months and had a functioning allograft, independent risk factors for death after renal transplantation included serum albumin level (for each g/dl, relative risk [RR] of 0.26), age (for each decade, RR=1.53), ESRD from diabetes mellitus (RR=1.71), HDL cholesterol (for each 10 mg/dl, RR=0.83), creatinine clearance (for each 10 ml/min, RR=0.85), alternate day prednisone therapy (RR=0.44) and chronic disease (defined as liver disease, non-skin malignancies and cardiovascular disease, RR=4.26). The relationship between serum albumin level and mortality was seen for both cardiovascular and non-cardiovascular deaths. In addition, the effect of serum albumin on mortality was apparent even when the analysis was restricted to patients who died more than three years after serum albumin levels were obtained. Additional studies will be needed to determine which interventions may be effective in increasing serum albumin levels and whether these interventions will also lead to improved allograft and patient survival. (Michael V. Rocco, M.D., Bowman Gray School of Medicine)