Grading of Severity of the Condition in Burn Patients by Serum Protein and Albumin/Globulin Studies

Abstract

Capillary permeability increases after inflammation with consequent leak of fluid, electrolytes, and proteins. The albumin molecule size being smaller (69 kDa) than the globulin molecule (90-156 kDa) will leak relatively at an early stage of the disease (with moderate increase in capillary pore size) than globulin leading to albumin/globulin reversal. In cases with severe permeability changes with rapid progression to larger pore size with simultaneous leak of both albumin and globulin, albumin/globulin reversal will not occur. In this study estimation the serum protein and albumin/globulin (A/G) ratio at frequent intervals was done to grade the severity of the condition of burn patients by assessing the severity of capillary leak.A total of 61 admitted patients (from March 2002 to December 2004) based on the protein values were divided into 3 groups (group 1: 6-8 g/dL, group 2: 5.1-5.9 g/dL, group 3: < or =5.0 g/dL), and all the patients who showed change in their protein levels during the study were shifted to appropriate group and were classified as group shifters. The mean survival time and mortality of various groups were compared, and A/G ratio of all the expired cases was analyzed.Group 3 patients showed higher mortality (95%) as compared to that in other groups (group 1 and 2: 0% each and group shifters: 30.2%). Median survival time of group 3 was significantly low as compared to that of group 1 (P < 0.0026), group 2 (P < 0.0006), and group shifters (P < 0.0000). In group shifters the mean time (days) required for shifting from one group to other just before death or discharge in survivors was significantly higher than that in expired cases. Of 26 cases expired during the study, initial A/G ratio at the time of first assigning the group was not reversed in 22 cases (84.6%).The study concluded that the severity (indicated by lower serum protein values) and speed (judged by A/G ratio changes and median survival time analysis) of capillary permeability changes were associated with high mortality, and therefore, it is possible to grade the severity of the condition in burn patients.

The Gamma Gap and All-Cause Mortality

“…Further, prospective studies have shown a relationship between total protein and mortality in transplant patients [ 11 ], total protein with low albumin and mortality in hospitalized patients [ 12 ], albumin-to-globulin ratio and mortality in cancer patients [ 13 – 15 ], IgA levels and cancer-related mortality in elderly patients [ 16 ], and hypergammaglobulinemia and decreased survival in patients with rheumatologic conditions [ 17 , 18 ]. A study of patients admitted to a burn unit with serial measures of serum albumin and protein, showed that developing a lower albumin-to-globulin ratio, which would be equivalent to a greater gamma gap, was associated with higher mortality [ 19 ]. Moreover, a recent actuarial manuscript, using billing data described serum globulins as an important predictor of mortality [ 20 ].…”

Serum albumin level as a risk factor for mortality in burn patients

“…This process peaks during the first 12–24 hours, coupled with a reduction in the albumin mRNA response to the burn and an increased synthesis and accumulation of acute-phase reactants. After this initial phase, hypoalbuminemia persists because of the lack of its synthesis, its loss through damaged skin areas, and deficiencies in nutritional support (33–35). In our patients, hypoalbuminemia was closely related to the burned BSA, which is considered to have predictive value for mortality.…”

Lower Serum Albumin Shortly After Admission Predicts Prolonged Hospital Stay in Younger Burn Patients

“…30 Flora et al observations comment on age as the next most important predictor in LOS once adjusted for TBSA. 22,31 Studies performed by Johnson et al 2 notes on the linear correlation in LOS in accord with TBSA within each age group. However, the linearity in correlation becomes discontinuous on increasing decile age.…”

“…Length of hospitalization for burn patients involves a complex interplay of factors such as size and depth of the burn, patient age, infection complications, patient's sex, and management protocol by the treating institution. 2,13,17,[22][23][24] A combination of the aforementioned factors provides an estimated risk of mortality and length of hospitalization; however, length of hospitalization for individual patients is still quite unpredictable. First described by Baux in 1961, the parameter of age and percentage burned established the rule of thumb for predicting mortality rate.…”