Episode 25: The Impacts of Albumin on CKD Patients with Dr. Kam Kalantar
Lowlevels of albuminhavebeenassociated with increased mortality in patients on dialysisaccording to many studies. A type of protein made by the liver, albumin keeps fluid from leaking out of blood vessels while nourishing tissues and transporting hormones, vitamins, drugs, and substances like calcium throughout the body.Dr.KamKalantar,an expert in kidney diseases and epidemiology, and Professor of Medicine at the University of California-Irvine School of Medicine, joins Field Notes to explainthe importance ofmanagingalbumin in patients with chronic kidney disease.
Brad Puffer:Welcome everyone to this episode ofField Notes. IĢýmBrad Puffer on the Medical OfficeCommunications team at Ģý North America, and your host for this discussion today.ĢýHere we interview the experts, researchers, physicians,and caregivers who bring experience, compassion, and insight into the work we do every day.
Low levels of albumin have been associated withincreased mortality in patients on dialysis,Ģýaccording to many studies.Albumin is a type of protein made by the liver, and it keeps fluid from leaking out of blood vessels, while nourishing tissues and transporting hormones, vitamins, drugs, and substances like calcium throughout the body.ĢýSo,Ģýmaintaining healthy levels of albumin is important for patients living with chronic kidney disease.
To help us better understand the importance of managing albumin levels,and to discuss a recent journal publication about this issue, is Dr. KamKalantar, an expert in kidney diseases and epidemiology andprofessorof medicine at the University of California, Irvine School of Medicine. He is also a medical director for a FreseniusKidneyCareCenter. Dr.Kalantar,welcome toField Notes.ĢýĢý
Dr.KamKalantar:Thank you very much.Ģý
Brad Puffer:Well, I provided a very brief explanation of what albumin is and why it's important, but I'm wondering if you can elaborate and from your physician perspective, explain why we should care aboutalbumin.Ģý
Dr.KamKalantar:Serum albuminisan important protein. It's probably the most abundant protein in our circulations, in our blood.So,serum albuminhasĢýa number ofĢýimportant functions. One of them is to maintain the hemodynamic stabilitywithin the cardiovascular system, but there are also important other functions,such asmaintaining the nutritional status. Also, the molecule is a carrier. That means it carries different other molecules, such as vitamin D and thyroid-related hormones and other things,throughout this circulation or through the bloodstream to other parts of the body.ĢýAlso, it's a defense mechanism,in that serumalbuminis used to remove certain unwanted molecules in the blood.
Therefore,if I wantedto go over so many important functions of circulatingalbumin,Ģýit will go beyond the scope of today's presentation. Butsuffice to say that whether we are healthy with no disease states or we have disease states,such as chronic kidney disease, serum albumin plays an important role.Ģý
Brad Puffer:So,Dr.Kalantar,then how do you go about determining those albumin levels in your patients with kidney disease? Is this something that you measure every day andtalking to your patients about routinely?Ģý
Dr.KamKalantar:Yes.Serumalbuminisactually measured every month in essentially all dialysis patients. So, if we have over halfa million dialysispatients in the UnitedĢýStates,theirserum albuminis checked every month,so that should highlight the importance ofthis measurement.Itis measured throughhighly scenariosmethod,and it's compared to other patients and compared to the same patient,over time to see if there are any trends going up or going down to see howthepatient is doing.
Brad Puffer:Is this something, then,you touch base with your patient about every time you round or discuss with them?
Dr.KamKalantar:Yes. Then one of the areas that usually means you measure something, you are now responsible, you have to translate it intothepatientĢýs language.ĢýSo,I tell my patients, since I'm also a medical director of FKC,a large FKC dialysis center in Southern California,during myweekly rounds when I have thisserum albuminof the month available, I always tell the patients that, ĢýMr. Smith, Miss Jones,thisis your serum albumin.It's going to the correct direction,or not quite correct direction.ĢýThese are things that we share with essentially all patients.Ģý
Brad Puffer:Well, then what are the key causes of low albumin and how do you fix that?Ģý
Dr.KamKalantar:Yeah, that's actually as you absolutely mentioned, low albumin. Why? Because I would like my patients to have higherserum albumin,and I think I'm not the only nephrologist. We 12,000 nephrologists by providing care to CK and dialysis patients,we would like our patients to be resilient.Todo well.Patients should live well with kidney disease,as well as living well,andserum albumin- highserum albumin -is a strong predictor of that.
I would like to make suretheserum albuminis not low,andlow serum albumin could happen, usually it's referred to low serum albuminas a marker of nutritional status. That means malnutrition,that is called protein energy wasting, but lowserum albumincould also happen due to inflammation, infectionand also loss of albumin during the dialysis treatment. If the dialysis treatment,as weĢýrehopefullygoing to discuss,how this could happen.So altogether,serum albumin is avery precious protein that needs to be cherished and maintained.Ģý
Brad Puffer:And it sounds like nutrition is a big key factor in maintaining high levels of albumin. Is that correct?Ģý
Dr.KamKalantar:Yes, that's correct. That means that by providing good nutrition,serumalbumin is hopefully preserved,or even improvedand increased, but this is not the only factor that determines the level of serum albumin in the blood.Ģý
Brad Puffer:Well, as we get to those other factors,you know you mentioned that high levels of albuminareassociated with good outcomes, but I mentioned in the beginning that unfortunately low levels of albuminare associated with morbidity and mortality, as well. There are a lot of studies that have made that link,correct?Ģý
Dr.KamKalantar:Yes, the studies are relatively consistent in that low serum albumin is a predictor of poor outcome, and the oppositealso.High serum albumin is a predictor of longevity.ĢýAnd the consistency of these studieshasbeen remarkable, especially in dialysis patients. It's interesting that in the general population, also, all that emerging data suggests that your serum albumin, thatis in myself and yourself,is a very important predictor and determining factor. But in dialysis patients,in patients on dialysis, this is very important market. That means if yourserum albuminis low, we have a high-risk situation, and if serum albumin of my dialysis patient is higher, the higher the better,to the point that there is no way I can say that I'm satisfied, I try my best to increase serum albumin higher in all of my patients on dialysis.Ģý
Brad Puffer:And what is that target range that you're seeking, and can too much be a bad thing?
Dr.KamKalantar:Yeah, I don't think I'm going to say that too much is not a bad thing,but first of all,we have a challenge because only 30 to 40% of our patients have aserumalbumin above 4.0 grams per deciliter.So,this is answering your question, ĢýWhat is the target threshold,normal serumalbumin?ĢýMost laboratory centersaredescribed as 3.5 to 5.7.But I'm here to say,what is not coming from me, but coming from the literature over the past 30+years,as well as the experience,that we would like our dialysis patients to have aserumalbuminat least above 4.0. They run 30 to 40%,and if we are very lucky,maybe half of our patients achieve thatgoal.Ģý
Brad Puffer:And why is it so hard to maintain that albumin for dialysis patients?Ģý
Dr.KamKalantar:Well, dialysispatients,patients ondialysis,are dealing with many other problems. They have comorbid states.ĢýThey have other problems:infection, inflammation, also protein-energy wasting(PEW)and,on top of that,they receive dialysis therapy,and if you are not careful with their dialysis therapy,their dialysis membrane exhorts to maintain and preserve that protein store or could be also a gateway to losing more albumin.
Brad Puffer:We talked about how there's more to preserving albumin than just nutrition. Can you talk about some of those other factors? And my understanding isthateven dialyzers can play a role, correct?Ģý
Dr.KamKalantar:That's exactly what I was trying to mention or go over. Why? Because this is your dialysis patient, the dialysispatient is cominghere,and on average, most of thesepatients undergothree times a weekdialysis. Of course, there are also twice weekly dialysis patients, there are four times or five-times-a-weekdialysispatients.But,as seen on average three times a week, a patient comes to the dialysiscenter forthreetofour and a halfhours ofdialysistherapy.ĢýIf the choice of dialysis membrane is not correct, then we have added yet another risk factor for low albumin, which is called hypoalbuminemia. That means the dialysis membrane, which is supposed to be there to provide clearance to the patient, now could become a source of loss of albumin.Ģý
Brad Puffer:Well, you've studied the topic in depth. I mentioned in my intro that you actually were the lead author of an article that published in the International Journal of Nephrology and RenovascularDisease calledĢýSlippingThrough thePores.Ģý What was the biggest takeaway of your study? I know you spent some time looking atdialyzers.
Dr.KamKalantar:Yes, looking at differenttypes of dialyzers,and the dialyzers for example that are currently available, we're very proud and pleased to use those that are available in our dialysis centers as compared to also certaindialysismembranes that are beingmanufacturedfor certain indications.So here, itis very important to really understand what the indication of some of these dialysis membranes are,and what the challenging aspects or some of the drawbacks of some of theseare. So, the studyyouare talking about,this is a study where we reviewed five other studies.That means our goal was to put together the results of five otherstudies comparing high fluxdialysismembranes.High fluxdialysismembranesarewhat we are using in our dialysiscenters,as compared to a new generation of dialysis membranes that are consideredto have ahigh level of permeability,and it's allowingmore of these middle molecules to cross.And as I said, those things have certain indications. For example, let's say if you have a patient with abnormal proteins,such as multiple myeloma, it's a blood cancer or bone marrow cancers, then probablythis iswhere I could use thosedialysis members with larger pores.
But would I be happy to use these membranes, withahigh level of permeability for routine dialysis treatments of my patients? That's a very important question,asthisquestion not only pertainsto me and my dialysispatients, but to all 12,000 nephrologistsand all 550,000dialysispatients in the United States and all other countries. So, this is essentially a very important portion of my responsibility to make sure that the high-flux dialysis I prescribe to my patients do the job, and that IĢýve not switching that to something that could lead to loss of albumin for these dialysis patients.
Brad Puffer:Well, I think that's the key point you make there because I'm sure we can't 100% say, you know, the dialyzer is causing the increase in albumin, but you know that serum albumin can go up, especially with the right nutrition and other interventions, with a high-flux dialyzer.ĢýBut what you're saying is you're not necessarily seeing that with these other dialyzers. In fact, you're seeing loss,regardless. So,I assume as a physician, if you're working closely with your patients and you're getting their nutrition the right way to increase albumin, but a dialyzer is then stripping that albumin away, that's a problem for you.Ģý
Dr.KamKalantar:That's a serious problem. Let me tell you why: Because I do everything in my power as you,again,absolutely measure from nutrition to providing adequate protein, and also avoiding or treating inflammation, treating infection and anything that could interfere with albumin generation and maintenance.So, I do all these things and it would be heartbreaking that while I'm also providing dialysis therapy,that the choice of membrane is the one that could lead to the loss of this asset. That meansserum albumin,this is the protein.This isthe most importantprotein-basedasset that my patients have.ĢýSo, it's an important level of responsibility and accountability for us as dialysis care providersandnephologiststo ensure that we do not cause any risk by considering or ordering dialysis membranes that could also be used for certain symptoms. As I said, maybe those highly permeable or protein-leaking dialyzers are very good for certain disease states, rare disease states, such as multi-level, but would I help my patients by providing these protein-leaking dialyzers to everybody, or to most of our patients. That's actually very important and serious question for all of us.Ģý
Brad Puffer:Albumin may be something that most physicians are familiar with, they're comfortable talking about. Do you think as many thinksabout this loss as much as they should,and what would your recommendation be to physicians about albumin?Ģý
Dr.KamKalantar:Yes, actually a gooddialysismembraneshould not lead to any loss of albumin. Serum albuminshould maintainif I use the high-flux dialyzers that are currently available and are being used,including in our dialysis center. However, there is a discussion about use of the so-called highly permeable or middle cutoff dialyzers and studies are relatively consistentthat they lead to loss ofalbumin levels, and sometimes justify that there are so many other good benefits coming out of this membrane, and let's ignore that loss.That's the price,and I wouldn't agree with that. Why should we pay a price? I mean, this is a very expensive price. This is a very high priceif I want to do something for my patients, at the cost of losing albumin, during dialysis therapy.
Brad Puffer:You've been pretty passionate about this issue for a long time. Do you think other physicians are starting to realize how important this issue is?Ģý
Dr.KamKalantar:I believe so.As I said, studies have shown consistently-if there is one marker, if we are going to choose one laboratory measure as the strongest predictor of survival and longevity, thatĢýsserum albumin. Of course,there is also hemoglobin, phosphorus, calcium, and other things.ĢýBut the one that has been consistently associated withthestrongest prediction ofsurvival is serum albumin.I'm not the only onewhois proud ofthe serum albumin levels of my patients, and IĢým not the only one who has usedthe keyword passion. Weshould all be passionate about this becausethese arepatients.Thepatienthas trustedus.They have chosen dialysisfor their hopes and longevity, and I have every reason to ensure that they achieve those goals.Ģý
Brad Puffer:What would be yourbiggestpiece of advice to physicians about how they can even better incorporate discussions of albumin and thinking about this issue, especially when talking to theirpatients.Ģý
Dr.KamKalantar:We nephrologists,we should continue to provide the great care that my colleaguesare providing, ensuring adequate nutritional status, good nutritional status, and adequate nutritional supply,high protein diets,supplements, if necessary, timely and effective treatment of infections and inflammatory causes of problems. But at the same time,we should know that nothing should be justifiedby providing something greater at the expense ofthe loss of protein, which is albumin. So, we should really continue to be passionate about this. We should be aware of the consistency of the data, and we should do the best for our patients. That means ensuring that their serum albumin levels remain high.Ģý
BradPuffer:Well, I think that's a great way to end this conversation, Dr.Kalantar.It's really been interesting and thank you so much for joining us to discuss your research and passion for this subject.Ģý
Dr.KamKalantar:My pleasure, thank you.Ģý
Brad Puffer:And to our audience, thank you for joining us. Please know that your feedback is always welcome. If you have comments on today's episode,topics of interest to you,or speakers you want to hear from, let us know by clicking thefeatured on theField Noteswebsite onFMCNA.com.ĢýAnd don't forget you can find Field Noteson the, or, or right hereat FMCNA.com,where you can also find ourannual medical reportand otherfeatured articles.ĢýWe hope you'll come back and join us as we have many more topics to discuss in the weeks ahead. Until next time,I'm Brad Puffer,and you've been listening toField Notes by Ģý.Take care everyone.Ģý