Mechanisms and implications of hypoalbuminemia in head-injured patients

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✓ Severely head-injured patients are hypermetabolic/hypercatabolic and exhibit many aspects of the postinjury acute-phase response. These patients have hypoalbuminemia, hypozincemia, hypoferremia, hypercupria, fever, and increased synthesis of acute-phase proteins such as ceruloplasmin and higher C-reactive protein levels. It has been suggested that increased interleukin-1 (IL-1) in the ventricular fluid may be responsible, at least in part, for these metabolic abnormalities. In the present study, serum albumin levels were evaluated throughout an 18-day study period in 62 head-injured patients receiving aggressive nutritional support. Hypoalbuminemia (mean ± standard error of the mean 3.10 ± 0.2 gm/dl; normal value 3.5 to 5 gm/dl) was observed upon hospital admission; these albumin levels continued to decrease until 2 weeks postinjury, despite aggressive nutritional support. This hypoalbuminemia may be mediated via altered endothelial permeability properties due to endothelial cell dysfunction caused by cytokines such as IL-1. Transendothelial movement of albumin was assayed using a pulmonary artery endothelial cell culture system. Both a crude macrophage supernatant derived from a murine P388D cell line having IL-1 activity (mIL-1) and human recombinant IL-1 (rIL-1) were tested. The amount of albumin transferred was time- and concentration-dependent, with maximal transfer at 24 hours and 20 U of mIL-1 per 0.5 ml of culture medium. Endothelial permeability changes observed after incubation with mIL-1 were confirmed using rIL-1. Compared to control cultures, 20 U of rIL-1 and 20 U of mIL-1 increased albumin transfer across endothelial monolayers 205% and 459%, respectively. These findings suggest that the mechanism of hypoalbuminemia seen after severe head trauma can be explained in part by IL-1-induced endothelial cell injury, resulting in enhanced endothelial permeability to albumin.

Article Information

Address reprint requests to: Craig J. McClain, M.D., Division of Digestive Diseases and Nutrition, MN 650, University of Kentucky Medical Center, 800 Rose Street, Lexington, Kentucky 40536-0084.

© AANS, except where prohibited by US copyright law.

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    Graphs showing findings from the 62 severely head-injured patients in this series. Values are means ± standard error of the mean. Upper Left: Serum albumin levels were depressed on admission (3.02 ± 0.12 gm/dl) and remained depressed throughout the study period in spite of aggressive nutritional support. Upper Right: Serum C-reactive protein (CRP) levels peaked at 16.74 ± 1.62 mg/dl on study Days 3 to 5 and then gradually decreased during the study period. At the end of the study, the values were still well above the normal limit of 1.5 mg/dl. Center Left: Serum zinc levels were markedly depressed on admission (35.9 ± 1.95 µg/dl) and gradually increased toward the normal range of 70 to 120 µg/dl during the study period. Center Right: Patients were febrile on admission without evidence of infection. Body temperature remained elevated in many patients; persistence of the fever later in the hospital course may have been related to infections in some patients. Lower: Patients had leukocytosis on admission without evidence of infection. Later during hospitalization some patients developed infections which may have explained the chronic leukocytosis. WBC = white blood cells.

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    Graph showing that exposure of endothelial cells to interleukin-1 (IL-1) altered their permeability properties. The rate and amount of albumin transfer across cultured endothelial cell monolayers were dependent on the concentration of IL-1 to which the cultures were exposed, up to 40 U/ml culture medium, where maximum transfer appears to have been reached. Both semipurified murine IL-1 (mIL-1) and recombinant human IL-1 (rIL-1) were studied at the 20-U dose.

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