Efficacy of albumin with diuretics in mechanically ventilated patients with hypoalbuminemia: A systematic review and meta-analysis.

BACKGROUND: Hypoalbuminemia is associated with fluid overload, the development of acute respiratory distress syndrome, and mortality. The co-administration of albumin and diuretics for the treatment of patients with hypoalbuminemia is expected to increase urine output, without hemodynamic instability, and improve pulmonary function; however, these effects have not been systematically investigated. Here, we aimed to clarify the benefits of the co-administration of albumin and diuretics in mechanically ventilated patients. METHODS: We searched for randomized, placebo-controlled trials that investigated the effects of the co-administration of albumin and diuretics compared with placebo and diuretics, in mechanically ventilated patients with hypoalbuminemia. We searched these trials in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed, and EMBASE databases. Primary outcomes were hypotensive events after the intervention, all-cause mortality, and the length of mechanical ventilation. Secondary outcomes were improvement in the ratio of partial pressure arterial oxygen and fraction of inspired oxygen (P/F ratio) at 24 hours, total urine output (mL/d), and the clinical requirement of renal replacement therapy (RRT). RESULTS: From the 1574 records identified, we selected 3 studies for quantitative analysis. The results of albumin administration were as follows: hypotensive events (risk ratio [RR] -1.05 [95% confidence interval {CI}: 0.15-0.81]), all-cause mortality (RR 1.0 [95% CI: 0.45-2.23]), the length of mechanical ventilation in days (mean difference -1.05 [95% CI: -3.35 to 1.26]), and improvement in P/F ratio (RR 2.83 [95% CI: 1.42-5.67]). None of the randomized controlled trials reported the total urine output, and one reported that no participants required RRT. Adverse events were not reported during the trials. The certainty of evidence was low (in the hypotensive events after the intervention and all-cause mortality) to moderate (in the length of mechanical ventilation in days, improvement of P/F ratio, clinical requirement of RRT, and adverse events). CONCLUSIONS: Although this treatment combination reduced the number of days for which mechanical ventilation was required, it did not reduce the all-cause mortality at 30 days. In conclusion, the co-administration of albumin and diuretics may reduce hypotensive events and improve the P/F ratio at 24 hours.

Is hypoalbuminemia a risk factor for high-dose methotrexate toxicity in children with acute lymphoblastic leukemia?

BACKGROUND: Repeated high-dose methotrexate (HDMTX) is a critical component of contemporary childhood acute lymphoblastic leukemia (ALL) treatment regimens. Serum albumin is considered a carrier of methotrexate (MTX) in the blood. Hypoalbuminemia is not a rare finding in children with leukemia. This study aimed to investigate the relationship between pre-infusion serum albumin and possible HDMTX toxicities. METHODS: Thirty Egyptian children with ALL were consecutively enrolled in the study between May 2018 and July 2020. They were prospectively followed up while receiving HDMTX during the consolidation phase of the TOTAL study XV protocol. HDMTX was administered intravenously as a 24-h infusion every 2 weeks. Doses of 2.5 g/m2 were used for low-risk patients and 5 g/m2 for standard/high-risk patients. The Common Terminology Criteria for Adverse Events (V.4.03) was used to report the observed toxicities after HDMTX cycles. Plasma MTX levels were estimated at 24 h (MTX24) from the beginning of HDMTX infusion in the first consolidation cycle. Serum albumin level was determined before HDMTX administration, and pre-infusion hypoalbuminemia was defined when serum albumin was <3.5 g/dL. RESULTS: The patients' age ranged from 2.3 to 13.3 years at diagnosis, and most of them had B cell ALL (86.7%). Overall, 120 HDMTX cycles were analyzed, equally distributed between low and standard/high risk. Grade 3-4 anemia, grades 3-4 thrombocytopenia, febrile neutropenia, and oral mucositis were significantly more frequent in HDMTX cycles with pre-infusion hypoalbuminemia than those with normal pre-infusion albumin (p=0.003, p=0.007, p=0.006, and p=0.001, respectively). In addition, pre-infusion hypoalbuminemia was significantly associated with additional hospitalization due to HDMTX toxicity (p=0.031). Most HDMTX toxicities were comparable irrespective of the MTX dose. Oral mucositis was more frequently encountered in the 2.5 g/m2 than the 5 g/m2 HDMTX cycles (46.7 vs. 26.7%, p=0.023). A significantly longer hospitalization (due to HDMTX toxicity) was observed in the 5 g/m2 HDMTX cycles (median= 7 days vs. 4 days, p=0.012). CONCLUSIONS: Serum albumin levels should be checked before starting HDMTX cycles, especially in resource-limited settings where malnutrition is common, and serum MTX monitoring may not be available. Optimizing serum albumin levels before HDMTX may help decrease the possibility of HDMTX toxicities.

Therapeutic plasma exchange for the management of a type III hypersensitivity reaction and suspected immune-mediated vasculitis assumed to be caused by human albumin administration in a dog.

OBJECTIVE: To describe the successful treatment of a life-threatening type III hypersensitivity reaction suspected to have been related to human serum albumin (HSA) administration in a dog with therapeutic plasma exchange (TPE). CASE SUMMARY: A 3-year-old neutered male mixed breed dog was suspected to have developed immune-mediated vasculitis 2 weeks after the administration of HSA (740 mg/kg) for the management of hypoalbuminemia resulting from septic peritonitis. The dog was presented with fever, edema, hypoalbuminemia (26 g/L [2.6 g/dL]; reference interval, 30-44 g/L [3.0-4.4 g/dL]), and coagulopathy. The dog was treated with fresh frozen plasma (FFP) and glucocorticoids but remained hypoalbuminemic (18 g/L [1.8 g/dL]) and developed acute kidney injury (AKI). Over 4 days, 3 TPE treatments were performed, with a total of 2.7 plasma volumes exchanged. Replacement fluids consisted of a combination of FFP, hydroxyethyl starch 6%, and 0.9% saline solution. Following TPE treatments, serum albumin concentration increased (from 18 g/L [1.8 g/dL] to 25 g/L [2.5 g/dL]), serum creatinine concentration decreased (from 340 µmol/L [3.9 mg/dL] to 87 µmol/L [0.98 mg/dL]), and clotting times normalized (activated partial thromboplastin time decreased from 33 seconds to 14.5 seconds). There was a gradual but consistent clinical improvement of the edema and overall demeanor of the dog. No significant adverse effects were noted during the TPE treatments, and the dog was discharged after 8 days of hospitalization. Following discharge, the dog had complete clinical resolution of edema and AKI. NEW/UNIQUE INFORMATION: This is the first report describing successful use of TPE for the management of an immune-mediated reaction (type III hypersensitivity) following HSA administration.

Hypoalbuminemia affects one third of acute pancreatitis patients and is independently associated with severity and mortality.

The incidence and medical costs of acute pancreatitis (AP) are on the rise, and severe cases still have a 30% mortality rate. We aimed to evaluate hypoalbuminemia as a risk factor and the prognostic value of human serum albumin in AP. Data from 2461 patients were extracted from the international, prospective, multicentre AP registry operated by the Hungarian Pancreatic Study Group. Data from patients with albumin measurement in the first 48 h (n = 1149) and anytime during hospitalization (n = 1272) were analysed. Multivariate binary logistic regression and Receiver Operator Characteristic curve analysis were used. The prevalence of hypoalbuminemia (< 35 g/L) was 19% on admission and 35.7% during hospitalization. Hypoalbuminemia dose-dependently increased the risk of severity, mortality, local complications and organ failure and is associated with longer hospital stay. The predictive value of hypoalbuminemia on admission was poor for severity and mortality. Severe hypoalbuminemia (< 25 g/L) represented an independent risk factor for severity (OR 48.761; CI 25.276-98.908) and mortality (OR 16.83; CI 8.32-35.13). Albumin loss during AP was strongly associated with severity (p < 0.001) and mortality (p = 0.002). Hypoalbuminemia represents an independent risk factor for severity and mortality in AP, and it shows a dose-dependent relationship with local complications, organ failure and length of stay.

Idiopathic systemic capillary leak syndrome - An often missed diagnosis.

Idiopathic systemic capillary leak syndrome (ISCLS) is a potentially fatal disorder characterised by 'attacks' of varying intensity of hypovolemic shock in association with haemoconcentration and hypoalbuminaemia. It is a disease of exclusion, and the severity of attacks may mimic sepsis at presentation. We report a case of a lady with recurrent attacks of ISCLS with at least two life-threatening episodes, having been treated elsewhere as a case of steroid insufficiency. The diagnosis is often challenging, and treatment of an acute episode involves the judicious use of fluids and vasopressors, as required. Prophylaxis to prevent further attacks is of varied success.

The necessity of routine postoperative laboratory tests after total hip arthroplasty for hip fracture in a semi-urgent clinical setting.

BACKGROUND: Recent studies suggest that routine postoperative laboratory tests are not necessary after primary elective total hip arthroplasty (THA). This study aims to evaluate the utility of routine postoperative laboratory tests in patients undergoing THA for hip fracture in a semi-urgent clinical setting. MATERIALS AND METHODS: This retrospective study included 213 consecutive patients who underwent primary unilateral THA for hip fractures. Patient demographics, clinical information, and laboratory tests were obtained from the electronic medical record system. Multivariate logistic regression analysis was performed to identify risk factors associated with abnormal laboratory test-related interventions. RESULTS: A total of 207 patients (97.18%) had abnormal postoperative laboratory results, which were mainly due to anemia (190/213, 89.20%) and hypoalbuminemia (154/213, 72.30%). Overall, 54 patients (25.35%) underwent a clinical intervention, 18 patients received blood transfusion, and 42 patients received albumin supplementation. Factors associated with blood transfusion were long operative time and low preoperative hemoglobin levels. Factors associated with albumin supplementation were long operative time and low preoperative albumin levels. Of the 33 patients with abnormal postoperative creatinine levels, 7 patients underwent a clinical intervention. For electrolyte abnormalities, sodium supplementation was not given for hyponatremia, three patients received potassium supplementation, and one patient received calcium supplementation. CONCLUSIONS: This study demonstrated a high incidence of abnormal postoperative laboratory tests and a significant clinical intervention rate in patients who underwent THA for hip fracture in a semi-urgent clinical setting, which indicates that routine laboratory tests after THA for hip fracture are still necessary for patients with certain risk factors. LEVEL OF EVIDENCE: Level III. Trial registration Clinical trial registry number ChiCTR1900020690.

Phases of fluid management and the roles of human albumin solution in perioperative and critically ill patients.

OBJECTIVE: Positive fluid balance is common among critically ill patients and leads to worse outcomes, particularly in sepsis, acute respiratory distress syndrome, and acute kidney injury. Restrictive fluid infusion and active removal of accumulated fluid are being studied as approaches to prevent and treat fluid overload. Use of human albumin solutions has been investigated in different phases of restrictive fluid resuscitation, and this narrative literature review was undertaken to evaluate hypoalbuminemia and the roles of human serum albumin with respect to hypovolemia and its management. METHODS: PubMed/EMBASE search terms were: "resuscitation," "fluids," "fluid therapy," "fluid balance," "plasma volume," "colloids," "crystalloids," "albumin," "hypoalbuminemia," "starch," "saline," "balanced salt solution," "gelatin," "goal-directed therapy" (English-language, pre-January 2020). Additional papers were identified by manual searching of reference lists. RESULTS: Restrictive fluid administration, plus early vasopressor use, may reduce fluid balance, but in some cases fluid overload cannot be entirely avoided. Deresuscitation, with fluid actively removed through diuretics or ultrafiltration, reduces duration of mechanical ventilation and intensive care unit stay. Combining hyperoncotic human albumin solution with diuretics increases hemodynamic stability and diuresis. Hyperoncotic albumin corrects hypoalbuminemia and raises colloid osmotic pressure, limiting edema formation and potentially improving endothelial function. Serum levels of albumin relative to C-reactive protein and lactate may predict which patients will benefit most from albumin therapy. CONCLUSIONS: Hyperoncotic human albumin solution facilitates restrictive fluid therapy and the effectiveness of deresuscitative measures. Current evidence is mostly from observational studies, and more randomized trials are needed to better establish a personalized approach to fluid management.

Evaluation of the effects of hydroxyethyl starch (130/0.4) administration as a constant rate infusion on plasma colloid osmotic pressure in hypoabluminemic dogs.

OBJECTIVE: To evaluate the effects of 2 constant rate infusions of hydroxyethyl starch (HES) 130/0.4 on plasma colloid osmotic pressure (COP) in hypoalbuminemic dogs. DESIGN: Prospective, randomized clinical trial. ANIMALS: A total of 24 client-owned dogs. INTERVENTIONS: Hypoalbuminemic euvolemic dogs (albumin < 20 g/L [<2 g/dL]) with normal perfusion parameters requiring IV fluid therapy were enrolled. In addition to crystalloid, HES 130/0.4 was administered as a constant rate infusion over 24 hours at 1 mL/kg/h (group 1, n = 15) or at 2 mL/kg/h (group 2, n = 9), in order to support plasma COP. Before infusion, a blood sample was collected to perform CBC, serum electrophoresis, and serologic tests for some infective diseases. Plasma COP, albumin concentration, PCV, and total plasma protein concentration were evaluated serially at baseline (T0) and then at 6, 12, and 24 hours after the start of infusion, and a multilevel model was performed for these parameters to detect statistically significant differences between the 2 groups. MEASUREMENT AND MAIN RESULTS: Twenty-four dogs were included. No statistically significant differences in COP were found between the 2 groups; however, a high level of variability has been identified within the single individual. Among the other laboratory analyses, PCV was significantly decreased in group 1 at T12 and T24 compared with T0 (P < 0.001) and total plasma protein concentration was significantly increased in group 2 at T12 and T24 compared with T0 (P < 0.008). CONCLUSION: No significant effect on plasma COP was found following infusion with HES 130/0.4 at doses of 1 mL/kg/h and 2 mL/kg/h for 24 hours to hypoalbuminemic dogs. The administered concomitant dose of crystalloids, underlying disease, and small sample size were all potential confounding factors.

Delayed type III hypersensitivity reaction with acute kidney injury in two dogs following administration of concentrated human albumin during treatment for hypoalbuminemia secondary to septic peritonitis.

OBJECTIVE: To describe 2 dogs with acute kidney injury secondary to type III hypersensitivity reaction to 25% human serum albumin (HSA). CASE SERIES SUMMARY: Two dogs were presented with evidence of septic peritonitis. The dogs were hospitalized following definitive surgical correction of a jejunal laceration following routine ovariohysterectomy, and removal of a jejunal foreign body. In the postoperative period, both dogs developed hypoalbuminemia and received 25% HSA. At the time of initial discharge, both dogs were doing well clinically and had normal renal parameters. Eleven and 18 days after HSA infusion, respectively, both dogs were re-presented with clinical signs of inappetence, vomiting, and lameness that progressed to urticaria, peripheral and angioedema, and petechiae, consistent with a delayed type III hypersensitivity reaction. Treatment for the type III hypersensitivity reaction to HSA included administration of diphenhydramine and glucocorticoids. Despite partial resolution of edema and joint swelling, both dogs developed progressive azotemia together with hypoalbuminemia and proteinuria. One dog developed an anuric acute kidney injury (AKI). Both dogs were humanely euthanized. Histopathology of the kidneys of both dogs was consistent with immune complex deposition and vasculitis. NEW OR UNIQUE INFORMATION: Severe type III hypersensitivity reactions have been documented in healthy dogs and clinical patients following the administration of HSA. This report describes the first documented delayed type III hypersensitivity reaction in 2 dogs with septic peritonitis that resulted in AKI, glomerulonephritis, and oligo- to anuria in clinical patients following administration of 25% HSA.

Systemic Capillary Leak Syndrome Secondary to Coronavirus Disease 2019.

Systemic capillary leak syndrome is a rare disorder characterized by dysfunctional inflammatory response, endothelial dysfunction, and extravasation of fluid from the vascular space to the interstitial space leading to shock, hemoconcentration, hypoalbuminemia, and subsequent organ failure. The condition may be idiopathic or secondary to an underlying cause, which can include viral infections. Here we describe a patient with acute coronavirus disease 2019 (COVID-19) infection who presented with hemoconcentration, shock, and hypoalbuminemia. The patient subsequently developed rhabdomyolysis and compartment syndrome of all four extremities, requiring fasciotomies. This is the first reported case of systemic capillary leak syndrome associated with COVID-19 infection. This case adds to the evolving spectrum of inflammatory effects associated with this viral infection.

Obesity and hypoalbuminaemia are independent risk factors for readmission and reoperation following primary total knee arthroplasty.

AIMS: Rates of readmission and reoperation following primary total knee arthroplasty (TKA) are under scrutiny due to new payment models, which penalize these negative outcomes. Some risk factors are more modifiable than others, and some conditions considered modifiable such as obesity may not be as modifiable in the setting of advanced arthritis as many propose. We sought to determine whether controlling for hypoalbuminaemia would mitigate the effect that prior authors had identified in patients with obesity. METHODS: We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for the period of January 2008 to December 2016 to evaluate the rates of reoperation and readmission within 30 days following primary TKA. Multivariate logistic regression modelling controlled for preoperative albumin, age, sex, and comorbidity status. RESULTS: Readmission rates only differed significantly between patients with Normal Weight and Obesity Class II, with a decreased rate of readmission in this group (odds ratio (OR) 0.82; 95% confidence interval (CI) 0.71 to 0.96; p = 0.010). The only group demonstrating association with increased risk of reoperation within 30 days was the Obesity Class III group (OR 1.38; 95% CI 1.05 to 1.82; p = 0.022). Hypoalbuminaemia (preoperative albumin < 35 g/L) was significantly associated with readmission (OR 1.62; 95% CI 1.41 to 1.86; p < 0.001) and reoperation (OR 1.52; 95% CI 1.18 to 1.96; p = 0.001) within 30 days. CONCLUSION: In this study, hypoalbuminaemia appears to be a more significant risk factor for readmission and reoperation than even the highest obesity categories. Future studies may assess whether preoperative albumin restoration or weight loss may improve outcomes for patients with hypoalbuminaemia. The implications of this study may allow surgeons to discuss risk of surgery with obese patients planning to undergo primary TKA procedures if other comorbidities are adequately controlled. Cite this article: Bone Joint J 2020;102-B(6 Supple A):31-35.

The clinical impacts of early using glutamine/arginine enriched high protein density formula at trophic dose in intolerant enteral nutrition cachectic hypoalbuminemic hospitalized patients.

BACKGROUND: We sought to evaluate the clinical impacts of the early administration of trophic doses of a glutamine/arginine enriched enteral nutrition formula (ENF) with a high protein density to cachectic hypoalbuminemic hospitalized patients intolerant to enteral nutrition. METHODS: A retrospective analysis was conducted using the nutritional and non-nutritional data of patients admitted to our institution from April 2017 through August 2019. Patients who died or were discharged before completing ≥1 weeks of hospital admission, or those whose data could not be obtained were excluded. Among other variables, percent changes in serum albumin levels (%∆ALB), C - reactive protein (CRP) and their ratios were expressed as Mean ± SD using the Independent Samples T-test, while categorical variables were expressed as numbers with percentages by using χ2 test. Two tested groups were determined based on the use of ENF: Group I received trophic doses of ENF, while Group II received no enteral nutrition. RESULTS: The overall hospital length of stay (LOS) and overall 28-day hospital mortality were significantly lower in Group I when compared with Group II with Means ± SDs of (11.32 ± 2.19 days vs 23.49 ± 4.33 days) and (13.13% vs. 28.16%), respectively. Also, significantly higher (%∆ALB) for Group I compared with group II (43.48% ± 7.89% vs. 33.45% ± 6.18%), respectively was observed. CONCLUSION: In malnourished hypoalbuminemic patients suffering from feeding intolerance, early trophic administration of glutamine/arginine enriched high protein density ENF was well tolerated and may be associated with increased plasma albumin levels, reduced LOS, and overall 28-day mortality, and hence may be considered in such patients.

Giant placental chorioangioma followed by circulatory failure of the newborn and infantile hemangioma: Case report.

Placental chorioangioma (CA) is a benign placental tumor. No specific treatment is required for asymptomatic cases. We report a female infant born to a mother with giant placental CA. However fetal growth was normal and, fetal hydrops was not detected by ultrasound examination until delivery, she had hydrops, subgaleal hematoma, thrombocytopenia, hemolytic anemia, respiratory distress and circulatory failure after birth. She was successfully treated without any neurological sequelae. At 2 months of age, infantile hemangioma appeared in her lower lip. The present case suggested that giant placental CA might cause postnatal problems and be associated with the development of infantile hemangioma.

Effect of postoperative hypoalbuminemia and supplement of human serum albumin on the development of surgical site infection following spinal fusion surgery: a retrospective study.

PURPOSE: To determine the association between postoperative hypoalbuminemia and the development of surgical site infection (SSI) and evaluate whether the supplement of exogenous human serum albumin (HSA) in patients following spinal surgery would decrease the rate of postoperative SSI. METHODS: We performed a retrospective review of all patients who underwent lumbar spinal fusion surgery in our institution between January 2014 and December 2018. Patients with postoperative SSI were identified. We reviewed the demographic and clinical records of the patients and performed multiple logistic regression models to clarify the relevance between postoperative hypoalbuminemia, the supplement of HSA and SSI. Statistical adjustment for the potential confounders was also performed to exclude possible variation. RESULTS: Twenty-four of 602 patients developed SSI after lumbar spinal fusion surgery. No statistical significance was found between postoperative hypoalbuminemia and SSI rate (OR 0.74; 95% CI 0.22-2.48; P = 0.6199). However, the supplement of exogenous HSA was significantly associated with increased postoperative SSI rate (OR 1.21; 95% CI 1.05-1.41; P = 0.0094). Interestingly, stratified analyses showed supplement of HSA in patients without postoperative hypoalbuminemia increased the risk of SSI (OR 2.55; 95% CI 1.01-6.45; P = 0.0475), compared with patients with postoperative hypoalbuminemia (OR 1.17; 95% CI 1.00-1.36; P = 0.0434). CONCLUSIONS: The present study suggests that postoperative hypoalbuminemia is not associated with the development of SSI after spinal surgery. However, the supplement of HSA following spinal surgery will increase the rate of SSI. These slides can be retrieved under Electronic Supplementary Material.

Supplementation of enteral nutritional powder decreases surgical site infection, prosthetic joint infection, and readmission after hip arthroplasty in geriatric femoral neck fracture with hypoalbuminemia.

BACKGROUND: Nearly half of elderly patients with hip fracture were malnourished, indicated with a serum marker of hypoalbuminemia. Malnutrition was a risk factor for poor outcomes in geriatrics after hip replacement. The purpose of this study was to investigate if oral nutritional supplementation after the procedure in geriatrics with hypoalbuminemia was beneficial for outcomes. METHODS: A retrospective cohort study of older (≥ 65 years old) patients suffering femoral neck fracture and undergoing hip replacement with hypoalbuminemia was conducted. Outcomes were compared between patients with and without postoperative nutritional supplementation. RESULTS: There were 306 geriatric patients met the criteria. Following adjustment for baseline characteristics, patients with nutritional supplementation showed a lower grade of wound effusion with adjusted OR 0.57 (95% confidence interval (CI), 0.36 to 0.91, P < 0.05). And also a lower rate of surgical site infection (5.5% compared with 13.0% [adjusted OR 0.40, 95% CI, 0.17 to 0.91, P < 0.05]), periprosthetic joint infection (2.8% compared with 9.9% [adjusted OR 0.26, 95% CI, 0.08 to 0.79, P < 0.05]), and 30 days readmission (2.1% compared with 8.7% [adjusted OR 0.22, 95% CI, 0.06 to 0.79, P < 0.05]). The average total hospital stay was longer in patients without nutritional supplementation (10.7 ± 2.0 compared with 9.2 ± 1.8 days, P < 0.05). CONCLUSIONS: The data suggest that postoperative nutritional supplementation is a protective factor for surgical site infection, periprosthetic joint infection, and 30-days readmission in geriatric with hypoalbuminemia undergoing a hip replacement. Postoperative nutritional supplementation for these patients should be recommended.

Treatment of Severe Protein Malnutrition After Bariatric Surgery.

BACKGROUND: Severe protein malnutrition, with a serum albumin < 25 g/L, is one of the complications that may develop after bariatric surgery. It is associated with increased morbidity and mortality and requires timely diagnosis and appropriate treatment to prevent rapid clinical deterioration. However, evidence-based recommendations for a specific treatment approach are currently not available. The present study describes the efficacy of a newly developed treatment regimen for post-bariatric patients presenting with severe hypoalbuminemia. METHODS: A single-centre, retrospective analysis of eleven post-bariatric patients presenting with severe hypoalbuminemia, treated with continuous 24 h nasal-jejunal tube feeding of a medium chain triglyceride (MCT) formulation in combination with pancreatic enzyme supplementation every 3 h. RESULTS: Duration of tube feeding ranged from 25 to 156 days (median 64 days) and pancreatic enzyme was supplemented for 22-195 days (median 75 days). An increase in serum albumin levels of 5 g/L and 10 g/L was achieved after a median period of 20 (range 6-26 days) and 36 days (range 21-57 days), respectively. Albumin levels were > 35 g/L after a median period of 58 days (range 44-171 days). CONCLUSION: In this case series, a continuous 24-h nasal-jejunal MCT tube feed combined with frequent pancreatic enzyme supplementation was effective in all patients presenting with severe post-bariatric hypoalbuminemia and was not associated with adverse effects.

Disseminated strongyloidiasis in an immunocompetent male: A Case Report.

Strongyloidiasis is a human parasitic disease caused by infection of Strongyloidesstercoralis. It can manifest from asymptomatic eosinophilia in an immunocompetent host and disseminate the disease in the immunocompromised ones. The inconsistency of eosinophilia and low sensitivity of a standard microscopic stool examination makes it difficult to diagnose the disease. We report a case of chronic strongyloidiasis who, despite being immunocompetent, developed dissemination. The patient was a 30-years-old male who presented with diarrhoea, vomiting, high-grade fever and dyspnoea. On examination, he was pale, oedematous and had ascites with systolic murmurs in tricuspid area. After a fullworkup for differentials, biopsy confirmed the diagnosis of strongyloidiasis. Echocardiogram revealed vegetations on mitral and tricuspid valves and regurgitation through the valves, which confirmed dissemination to endocardium. A course of Ivermectin 9 mg daily for two weeks eradicated the infection in time. In conclusion, awareness for physicians and the use of various diagnostic methods like serology, endoscopy and biopsy should be considered for high risk patients.

Clinical use of cryopoor plasma continuous rate infusion in critically ill, hypoalbuminemic dogs.

OBJECTIVE: To investigate the impact of cryopoor plasma (CPP) continuous rate infusion (CRI) on albumin concentration and colloid osmotic pressure (COP) in critically ill dogs with hypoalbuminemia. DESIGN: Retrospective study between 2013 and 2015 with a 90-day follow-up on survivors. SETTING: University teaching hospital. ANIMALS: Ten hypoalbuminemic dogs receiving a CPP CRI for albumin replacement or oncotic support. All patients with documented hypoalbuminemia or low COP receiving CPP administration for albumin or oncotic support during the study period were included. INTERVENTIONS: CRI of CPP. MEASUREMENTS AND MAIN RESULTS: Mean age was 7.4 ± 4.5 years. Mean survival prediction index score was 0.66 ± 0.13. Seven dogs were septic, with 2 of 7 in septic shock and 5 of 7 having septic peritonitis. The mean pre- and postinfusion albumin was 15 ± 4 g/L and 21 ± 2 g/L, respectively. The median pre- and postinfusion COP was 8.6 mm Hg (4.9-9.7 mm Hg) and 10.2 mm Hg (8.1-13.3 mm Hg), respectively. The median duration of CRI was 16 hours (11-121 h). The mean CPP rate was 1.8 ± 0.6 mL/kg/h, the mean crystalloid rate administered concurrently was 0.8 ± 0.9 mL/kg/h, and the mean hydroxyethyl starch rate administered concurrently was 1.2 ± 0.9 mL/kg/h. The difference in pre- and postinfusion albumin was significantly correlated with CPP rate (P = 0.0004), whereas the difference in pre- and postinfusion COP was correlated with hydroxyethyl starch rate (P = 0.0128). Mean duration of hospitalization was 8.6 ± 3.9 days. Mann-Whitney U and Fisher's exact tests were used to compare survivors and nonsurvivors. Survivors were significantly younger than nonsurvivors (3.5 vs 11.5 y, P = 0.033). No side effects were reported. Survival to discharge was 40% with identical 90-day survival. Of the nonsurvivors, 50% died naturally. CONCLUSIONS: There was an association between the rate of CPP and the change in albumin after CPP CRI in critically ill dogs, suggesting that CPP may be a viable option for treatment of hypoalbuminemia.