Letter to the Editor
June 2025
Comment on Ozgungor
et al.’s “Albumin Levels as Prognostic Markers in ICU Mortality”
By
Tianchen Lin, Jiannong Wu
Affiliations
- Intensive Care Unit, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
doi: 10.29271/jcpsp.2025.06.803
Sir,
Congratulations and commendations to the team for offering valuable insights into the serum albumin levels at 48-hour post-admission as independent predictors of 28-day mortality in their study.1 However, there are some key questions worth exploring in future studies to improve its rigour and clinical applicability.
To determine the correlation between serum albumin levels upon admission and intensive care unit (ICU) mortality rates, it is necessary to ensure that patients have consistent baseline albumin levels before admission, excluding those who received albumin infusion therapy prior to admission. Simultaneously, attention should be paid to the administration of albumin to cancer patients, and these two points should be considered in the exclusion criteria. Whether patients with severe hypoalbuminaemia were treated with albumin within 48 hours need to be disclosed, as the details of such treatment could potentially affect the outcomes.2
The studies have shown that in the presence of hypoalbuminaemia, the pharmacokinetic (PK) and pharmacodynamic (PD) parameters of antimicrobial medicines with high protein binding rates are altered,3 thereby affecting the therapeutic effect of antimicrobial treatment in critically ill patients. Consequently, hypoalbuminaemia must be considered when selecting antimicrobial medicines in experiments.
This study indicates that serum albumin levels at 48-hour post-admission were independent predictors of 28-day mortality. If further research could be conducted on the dynamics of albumin changes within the first 48 hours of admission, such as employing machine learning models to track the trajectory of albumin decline, this could further elucidate the issue.
Previous studies suggest that hypoalbuminaemia indicates a poor prognosis in ICU patients; however, the benefits of albumin therapy have not been clearly demonstrated in several studies.2,4 Future research should further investigate treatment protocols for hypoalbuminaemic ICU patients to better guide clinical decision-making.
COMPETING INTEREST:
The authors declared no conflict of interest.
AUTHORS’ CONTRIBUTION:
TL: Conception and drafting.
JW: Supervision.
Both authors approved the final version of the manuscript to be published,
REFERENCES
- Ozgungor Y, Yeniay H, Rollas K. Albumin levels as prognostic markers in ICU mortality. J Coll Physicians Surg Pak 2025; 35(1):30-3. doi: 10.29271/jcpsp.2025.01.30.
- Investigators SS, Finfer S, McEvoy S, Bellomo R, McArthur C, Myburgh J, et al. Impact of albumin compared to saline on organ function and mortality of patients with severe sepsis. Intensive Care Med 2011; 37(1):86-96. doi: 10.1007/s00134-010-2039-6.
- Yu YT, Liu J, Hu B, Wang RL, Yang XH, Shang XL, et al. Expert consensus on the use of human serum albumin in critically ill patients. Chin Med J (Engl) 2021; 134(14): 1639-54. doi: 10.1097/CM9.0000000000001661.
- Uhlig C, Silva PL, Deckert S, Schmitt J, de Abreu MG. Albumin versus crystalloid solutions in patients with the acute respiratory distress syndrome: A systematic review and meta-analysis. Crit Care 2014; 18(1):R10. doi: 10. 1186/cc13187.
Authors Reply Section
By
Yakup Ozgungor
Affiliations
- Dr. Yakup Ozgungor, Department of Anaesthesiology and Reanimation, Division of Intensive Care Medicine, Izmir Tepecik Training and Research Hospital, Izmir, Turkiye
AUTHOR’S REPLY
Sir,
The authors sincerely appreciate your valuable comments and insightful critiques regarding this study. Your feedback provides an opportunity to further elaborate on the findings and clarify certain aspects of the present research. Below, the authors address your concerns point by point:
Pre-admission Albumin Levels and Exclusion Criteria:
All patients in this study were transferred to the ICU from the emergency department; therefore, their pre-admission albumin levels were unknown. To minimise potential confound-ing factors, the authors excluded patients with conditions that could significantly affect albumin metabolism, including end- stage chronic kidney disease, malnutrition, liver failure, and proteinuria. Additionally, among the included patients, three had a diagnosis of breast cancer and four had gastric cancer. None of the patients received albumin transfusion within the first 48 hours after admission.
Impact of Hypoalbuminaemia on Antimicrobial Therapy:
The authors acknowledge the importance of considering PK and PD changes in antimicrobial therapy among hypoalbuminaemic patients. The altered medicine-binding properties in critically ill patients can indeed affect treatment efficacy. In future studies, we plan to incorporate this aspect into our research design to better evaluate the clinical implications of hypoalbuminaemia on antimicrobial therapy outcomes.
Expanding the Research Scope with Additional Biomarkers:
The present study is retrospective and small-scale, and we recognise the limitations you highlighted. However, the authors are currently working on a more extensive project which aims to include thyroid-stimulating hormone (TSH), T3, and T4 hormone levels. The planned study will assess the relationship between albumin levels, albumin decline, and TSH levels at admission in relation to all-cause mortality. The authors believe that this broader approach will provide a more comprehensive understanding of prognostic markers in critically ill patients.
Albumin Replacement Therapy and Study Population:
In this hospital and country, specific regulations govern albumin replacement therapy. According to these guidelines, albumin replacement is reimbursed only for patients with albumin levels below 2.5 g/dL or for ICU patients presenting with fluid resuscitation-resistant hypotension. Therefore, albumin replacement therapy is administered in strict accordance with clinical guidelines.
The authors are grateful for your thoughtful observations and suggestions, which will contribute to refining future research in this field. The authors hope that this response provides clarity on the addressed issues and look forward to further discussions on this important topic.