Low Serum Albumin Before Surgery is Predictor of Complications Following Radical Cystectomy

David C. Johnson, MD, MPH

Poor nutritional status—specifically, a low level of serum albumin—is a predictor of complications following radical cystectomy for patients with bladder cancer, according to an analysis conducted under the umbrella of the American College Of Surgeons National Quality Improvement Program (NSQIP).¹

Patients with albumin levels of < 3g/L before surgery are 2.1 times as likely to experience complications, the team of surgeons from the University of North Carolina at Chapel Hill School of Medicine and UNC Lineberger Comprehensive Cancer Center found. They presented their findings in October at the 2013 Clinical Congress of the American College of Surgeons.

Investigators conducted the analysis because poor nutrition is a known cause of complications such as infections and poor wound healing after surgery, including radical cystectomy, but the specifics of that trend had not been studied.

“The prevalence of nutritional deficiency is very high in patients with bladder cancer, partly because of their disease and partly because of their advanced age—73 years on average,” said David C. Johnson, MD, MPH, lead author of the study and a senior Urology resident at the UNC School of Medicine, in a statement released by the institution.²

To conduct the study, Johnson et al performed a retrospective review of the NSQIP 2005-2011 Participant Use Data Files, looking at 1085 patients who underwent radical cystectomy at 315 US medical centers from 2005 to 2011, according to the statement. NSQIP seeks to measure and improve the quality of care in private hospitals by collecting data on 135 variables, including pre- and intraoperative data, 30-day post-operative complications, and mortality, on all major surgical procedures at participating institutions, UNC explained in the statement.

As potential predictors, the investigators considered whether preoperative albumin was above or below 3 g/dL; whether patients had lost more than 10% of their body weight within 6 months before surgery; and whether patients’ BMIs were above or below 30.

The team found an overall 30-day complication rate of 53% (n=575). Of those patients, 6% (n=32) had a preoperative albumin level <3, 32% (n=182) were obese, and 5% (n=28) had lost more than 10% of their body weight within 6 months before their surgery. After controlling for age, resident involvement, operation year, and prior operation, only albumin at levels <3g/dl remained as a significant predictor of postoperative complications (P = .04), the authors reported.

“This finding supports the importance of preoperative nutritional status in this population and highlights the need for the development of effective nutritional interventions in the preoperative setting,” the authors wrote.

“We are currently implementing a nutritional protocol in which all cystectomy patients will receive a preoperative nutritional assessment by a certified clinical nutritionist to address and optimize nutritional deficiencies,” added Angela Smith, MD, assistant professor of Urology, UNC Lineberger member, and senior author and lead investigator on the study. “Furthermore, a nutritionist will be involved in postoperative care, both on an inpatient and outpatient basis. We hope that proactive emphasis on nutrition will lead to improved outcomes in this vulnerable population.”

Odds Ratio

95% CI

P value

Low

High

Serum Albumin (< 3 g/dL)

2.11

1.02

4.40

0.0447

Weight loss (>10%/6mo)

1.19

0.49

2.84

0.7016

BMI (< 30 vs ≥ 30)

0.92

0.62

1.38

0.7004

References

1. Johnson D, Ferguson J, Smith A, et al. Nutritional Predictors for Complications Following Radical Cystectomy: an Analysis of the American College Of Surgeons National Quality Improvement Program (ACS-NSQIP). Presented at: the Clinical Congress of the American College of Surgeons; October 6-10, 2013; Washington, DC.
2. University of North Carolina at Chapel Hill. Patients with poor nutritional status before bladder cancer operation have a higher risk of postoperative complications. UNC website. http://news.unchealthcare.org/news/2013/october/bladder-cancer. Published October 16, 2013. Accessed November 27, 2013.