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C-Reactive Protein/Albumin Ratio As an Independent Predictor of Mortality in Critically Ill Pediatric Patients

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C-Reactive Protein/Albumin Ratio As an Independent Predictor of Mortality in Critically Ill Pediatric Patients Published online: 2020-02-23 THIEME Original Article e1 C-Reactive Protein/Albumin Ratio as an Independent Predictor of Mortality in Critically Ill Pediatric Patients Shereen A. Mohamed1 Rabab ElHawary1 1 Department of Pediatrics, Kasr Alainy Faculty of Medicine, Cairo Address for correspondence Shereen Abdelmonem Mohamed, Kasr University, Cairo, Egypt Alainy Faculty of Medicine, Cairo University, Cairo 11562, Egypt (e-mail: [email protected]). J Child Sci 2020;10:e1–e11. Abstract It is necessary to stratify the risk of pediatric patients at the time of intensive care unit (ICU) admission and to predict their outcomes. This helps to allocate the scarce ICU resources to start the appropriate treatment. The objective of this study was to evaluate the prognostic value of C-reactive protein/albumin ratio on admission to pediatric intensive care unit (PICU) in predicting mortality, PICU length of stay, the need for mechanical ventilation, and the use of inotropic drugs. This cohort study was conducted at Pediatric Cairo University Hospital. The study included 178 critically ill children. Pediatric Risk of Mortality–III (PRISM-III) score was calculated; CRP and serum albumin levels were assessed within 24 hours from admission. The median CRP/albumin ratio was significantly higher in nonsurvivors than survivors (18.60 and 4.65, respectively). The CRP/albumin ratio at a cutoff of 25.83 had significant discriminatory power in predicting mortality (area under the curve [AUC] ¼ 0.795 Keywords and p < 0.001) with 85.4% accuracy. Furthermore, CRP/albumin ratio alone showed a ► C-reactive comparable discriminatory power to that of PRISM-III score (AUCs ¼ 0.795 and 0.793, protein/albumin ratio respectively). A multivariable logistic regression analysis revealed that each unit of increase ► hypoalbuminemia in the CRP/albumin ratio increased the risk of mortality by 1.075 (odds ratio [OR] ¼ 1.075). ► intensive care units CRP/albumin ratio showed a significantly higher median in ventilated (6.86) compared with ► mortality non-ventilated (5.22) patients. Patients supported with inotropes showed significantly ► outcomes higher median CRP/albumin ratio (11.70 and 3.68, respectively). CRP/albumin ratio at ► pediatric admission to PICU was a good independent predictor of mortality. Introduction Some scoring laboratory parameters are expensive, and their results may not be readily available on admission.6 Therefore, Critically ill children admitted to pediatric intensive care it is necessary to identify a simple, rapid, and readily units (PICU) have a high risk of mortality.1 The present accessible biomarker to confirm response to treatment and research is trying to optimize the consistency of care of these to predict prognosis of critically ill children at admission to children to improve their short- and long-term outcomes.2 the PICU. It seems necessary to stratify the risk of pediatric patients C-reactive protein (CRP) is an acute phase protein that is at the time of intensive care unit (ICU) admission and to produced following stimulation by various cytokines in predict their outcomes.3 This helps to allocate the scarce ICU response to infection, ischemia, trauma, and other inflam- resources, to start the appropriate treatment, and to satisfy matory conditions. High CRP levels have been studied in the needs of the patients’ families.4 relation to prognosis and mortality in critically ill patients.7 Various prognostic scoring systems have been devised CRP has also been shown to be a poor predictor of mortality and validated in PICU.5 However, the applicability of many of compared with other biomarkers in the pediatric these scales is precluded by the unavailability of resources. population.8 received DOI https://doi.org/ Copyright © 2020 Georg Thieme Verlag October 23, 2019 10.1055/s-0040-1701623. KG Stuttgart · New York accepted after revision ISSN 2474-5871. December 26, 2019 e2 CRP/Albumin Ratio a Predictor of Mortality Mohamed, ElHawary Serum albumin is the main determining factor of colloid the risk of mortality. The score consists of age in addition to 17 osmotic pressure and is a major plasma carrier of many physiological and laboratory parameters including systolic hormones, drugs, and bioactive elements.9 Hypoalbuminemia blood pressure, heart rate, temperature, pupillary response, at admission to a PICU has been investigated. It was associated mental status, acidosis, pH, arterial partial pressure of carbon with higher mortality and longer duration of mechanical dioxide (PaCO2), arterial partial pressure of oxygen (PaO2), ventilation.10 total carbon dioxide, prothrombin time (PT), partial thrombo- The prognostic performance of the CRP/albumin ratio has plastin time (PTT), blood glucose, serum concentrations of been investigated in critically ill adult patients and revealed potassium, blood urea nitrogen (BUN), creatinine, and total favorable findings.7,11 However, it has not been evaluated in white blood cells (WBCs) and platelet count.12 the pediatric population. C-reactive protein and serum albumin levels were deter- Based on this knowledge, the aim of our study was to mined for all patients within the first 24 hours of admission. evaluate the prognostic value of CRP/albumin ratio on admis- Albumin analysis was done using on automated auto analyz- sion to PICU in predicting mortality, the duration of PICU stay, er (dimension clinical chemistry system). Hypoalbuminemia and the need for mechanical ventilation, and inotrope use. was defined as a serum albumin level of less than 3.5 g/dL.10 Additionally, to compare the performance of CRP/albumin Serum concentration of CRP was determined by nephelom- ratio with Pediatric Risk of Mortality–III (PRISM-III) score. etry on a Nephstar protein analyzer (Goldsite Diagnostic Inc., Shenzhen, China). CRP/albumin ratio was calculated using Methods SPSS software program (Statistical Package for Social Science version 24 for windows; SPSS Inc., Chicago, IL, United States) Ethical Considerations by dividing serum CRP levels by serum albumin levels. The protocol of this study was approved by the Research Ethics Primary outcome was the survival to discharge. Secondary Committee of the Faculty of Medicine, Cairo University. In- outcome was the Length of PICU stay, need for inotropes, and formed consent was obtained from the patients’ guardians. All mechanical ventilation. patients’ data were kept confidential after assigning a code number to each patient, known only by the researchers. Statistics Data analysis was performed using SPSS version 22. All numer- Study Design and Setting ical variables were checked for normality by Shapiro–Wilk test. This cohort study was conducted at Pediatric Cairo Universi- Normally distributed numerical variables were presented as ty Hospital, a tertiary educational medical institution. Data mean Æ SD, and differences between the two groups were were collected from critically ill patients admitted to the tested using independent t-test. Abnormally distributed nu- PICU between March 2018 and February 2019. merical variables were expressed as a median and interquartile range (25th–75th percentile), and differences between the two Eligibility Criteria groups were tested using Mann–Whitney U test. Categorical Inclusion criteria: All patients admitted to the PICU of variables were summarized as frequencies and percentages, Pediatric Cairo University Hospital whose age was 1 month and the association between variables was tested using χ2 tests to less than 14 years were included. (Pearson’s chi-square for independence or Fisher exact tests as Exclusion criteria: Patients aged less than 1 month or appropriate). Spearman’s rank correlation was performed be- more than 14 years were excluded. Additionally, patients tween PICU stay and CRP/albumin ratio. The receiver operating with severe protein-energy malnutrition; chronic liver characteristic (ROC) curve analyzed the discriminatory power disease/cirrhosis; nephrotic syndrome or nephritis; chronic of CRP/albumin ratio in predicting different outcomes. Cutoff gastrointestinal or kidney disease affecting the growth values were identified along with associated sensitivity, speci- (malabsorption syndrome, celiac disease, inflammatory ficity, and accuracy. A multivariable logistic regression analysis bowel disease, chronic renal failure); second or third-degree using forward stepwise (likelihood ratio) method was per- burns; and receipt of parenteral nutrition, blood products, or formed to determine the independent predictors of mortality. albumin before admission were also excluded. All variables showed significant differences between survivors and nonsurvivors (body mass index [BMI], serum CRP level, Collection of Data serum albumin level, CRP/albumin ratio, All patients were subjected to full history taking (including PRISM III score, the need for mechanical ventilation, the demographic data and reason for admission) and thorough need for inotropes, BUN, and platelets count) were included. medical assessment (including vital signs, nutritional status A p-value of 0.05 was considered statistically significant. and systematic examination). All data were recorded in the data collection sheet. Patients were followed up until dis- Results charge or death, and the outcome measures (including mortality after PICU admission, the length of PICU stay, the Three hundred fifty critically ill patients were admitted to need for mechanical ventilation, and the need for inotrope the PICU between March 2018 and February 2019. This study support)
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