INTRODUCTION

Sepsis is the main cause of death in hospitalized critically ill patients with a high mortality rate.^1,2Each year in the United States, 751,000 cases of sepsis are reported with an approximate mortality of 26.6% and an annual cost of 16.7 billion dollars, increasing by 9% each year.³Likewise, the incidence of sepsis is also high in our country.⁴Despite advances in diagnostic methods and therapeutic management, sepsis continues to be a challenge for different doctors in our country.

Likewise, currently, cases of sepsis have increased with COVID-19 as the main causal agent. This being a highly contagious virus. Since the first case was discovered in December 2019 in Wuhan, the COVID-19 infection has spread rapidly. Until March 5, 2020, around 86 countries, including six in Latin America, had reported at least one laboratory-confirmed case of COVID-19, which is why the COVID-19 outbreak was declared a pandemic, reaching our territory on March 6, 2020.⁵

Currently, there are countries that are known to have had a high mortality rate. For example, in March, Spain presented a high rate of infected with 1,549 cases/million inhabitants, adding around 72,248 cases, continuing with Italy where 1,529 cases / million inhabitants are reported with a total sum of 92 472 cases and France with 493 cases / million inhabitants, with a total of 39,964 cases.⁶

In Peru, the case curve is increasing. The group of older adults have the highest mortality rate; considering that the departments with the highest deaths from COVID-19 are Ancash, Callao, Ica, La Libertad, Lambayeque, Lima, and Piura⁷. Hypoalbuminemia being a frequent condition in older adults, it is considered important to establish whether hypoalbuminemia is a predictor of mortality. Therefore, the objective of the study was to determine whether hypoalbuminemia is a predictor of mortality in patients with sepsis due to COVID-19 hospitalized in the clinical service of Hospital II Chocope in 2020 and to identify the serum albumin value most frequently related to lethality.

METHODS

RESULTS

In this table we observe that 94.4% of the patients who died presented hypoalbuminemia; while in the group of patients who did not die, hypoalbuminemia appeared in 80.8%. It was determined that there is a statistically significant association between hypoalbuminemia and patient mortality (p = 0.014). Also, a 3.97 times greater risk of death was identified when presenting hypoalbuminemia in relation to the group of patients who presented normal albumin (OR = 3.97 95% CI 1.24 to 12.74). On the other hand, the mean albumin values ​​for the patients who died were 2.38 g / dl (± 0.67) vs. at 3.02 g / dl (± 0.65) for the other group.

This table shows the highly significant relationship between serum albumin levels and mortality (p = 0.00 <0.01) in patients with covid-19 sepsis. Also, 25 % of the patients had a severe albumin level and died while 26.4% of patients had mild hypoalbuminemia, and no deaths were recorded in this group.

Graph 1.  CROC curve of hypoalbuminemia in relation to mortality in patients with sepsis due to COVID-19 hospitalized in the Medical service Hospital II Chocope 2020 

The area under the curve indicates that the cut-off point for hypoalbuminemia is 1.38, which determines the highest sensitivity and specificity of the test.

Graph 2. Comorbidity in patients with sepsis due to COVID - 19 hospitalized in the Medical service Hospital II Chocope, 2020 

In this graph, it can be seen that the most frequent comorbidity in patients with covid sepsis was arterial hypertension, represented by 33.3%, and in second place, both overweight and obesity (29.2%). Likewise, 30.6% of patients did not present any comorbidity.

DISCUSSION

Although our finding of hypoalbuminemia as a predictor of mortality is not new, and numerous studies reported that hypoalbuminemia was associated with increased mortality in different patient groups and settings. It considers itself a poor prognostic factor in inflammatory processes^8-14. This is one of the first studies that evaluate hypoalbuminemia in patients with sepsis due to covid-19. Due to the current contingency, it was necessary to have enough tools to predict and prevent mortality.

Albumin levels can decrease due to several factors including poor nutritional status. Also, inflammation (eg, infectious disease, malignancy), due to interleukin-1 and tumor necrosis factor that decrease albumin production by the liver. Kidney disease or burns, due to loss of albumin in the urine or integument, respectively. Trauma or surgery results from associated stress, which increases protein and energy requirements by creating a hypermetabolic, catabolic state. Finally, liver disease.¹⁵Hypoalbuminemia patients may manage critical illness somewhat differently than patients with normal or high albumin levels.

Hypoalbuminemia in severe patients is related to an increased pro-inflammatory response to various infections. Both the severity of the disease and hypoalbuminemia are closely related in adult and pediatric patients.^10,14

Our results indicate an association between low levels of albumin and increased mortality; the lower the albumin level, the more frequent mortality was evident in all age groups. This relates to the results obtained by Luna J , et al¹⁶, whose albumin values ​​less than 3.5 g / dl within the first 2 days of admission showed a high risk of death with an OR 1.5 higher, especially in patients with albumin levels between 2.4-1.6 g / dl.

Cerpa et al.¹⁷analyzed 35 patients, with the mean serum albumin of 2.84 g / dl in the group of patients with mortality and obtained a Chi 2 = 8.67 with a significance level of p-value = 0.05, in addition all the deceased patients presented hypoalbuminemia almost similar to our study (94.4%).

Villalba S, et al.¹⁸found that among the factors associated with high mortality is arterial hypertension (p = 0.025), the same one that represents the 33.3% of associated comorbidities in our study. Likewise, Jellinge et al.¹⁹found that hypoalbuminemia’s discriminatory capacity was good (AUROC 0.73 (95% CI, 0.70-0.77)) and the calibration was acceptable, similar to what our study obtained. study.

Our study focused on analyzing the albumin values ​​generally obtained in the first 24 hours of sepsis patients due to covid-19 admitted to the Medical service. The results indicate high mortality in patients with decreased albumin values ​​and the population at risk were adults with a predominance of older adults and men. For this reason, we believe that serum albumin control is important in all patients who need hospitalization for COVID 19.

Since the study was based on a review of medical records, some data such as nutritional status and body mass index did not register. Another limitation was the lack of data on the specific cause of mortality, and no information was available on the intravenous administration of albumin during hospitalization.

CONCLUSION

Hypoalbuminemia is a predictor of mortality in patients with covid sepsis at the Hospital de Chocope because it is highly significant, with 3 times higher risk of dying. The highest sensitivity and specificity of the test was when the cut-off point for hypoalbuminemia was at 1.38 g / dl. The most frequent comorbidity in patients with COVID-19 sepsis who died was arterial hypertension.