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Residual Proteinuria in Capd Diminishes the Value of Serum Albumin in Audit

A reduced concentration of serum albumin is considered to be an important predictor of morbidity and mortality in patients receiving renal replacement therapy (1) and, consequently, it is used as a quality marker in the U.K. Renal Association Standards Document (1998) (2). We have audited this parameter prospectively, since 1991, at the Cumberland Infirmary renal department where hemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) are provided for the Health District of North Cumbria (population 320 000) in the United Kingdom. We observed that between 1991 and 1997 the proportion of patients with a serum albumin greater than 35 g/dL fell significantly. Using routine clinical data recorded in a computerized clinical database, we were able to conduct a retrospective audit of serum albumin and urinary protein losses back to April 1991. Indications for transfer from CAPD to HD include inadequate dialysis and persistent fluid overload. Since both of these situations arise more commonly in patients who have lost their residual urine output, we suspected that the transfer from CAPD to HD of patients who had lost their residual renal function (RRF) might result in the remaining patients on CAPD having a higher level of proteinuria as a group. This could explain a reduced level of serum albumin in those individuals remaining on CAPD, and raises the question of whether low serum albumin due to residual proteinuria, rather than due to malnutrition, is such a strong risk factor for mortality.