Role of serum albumin in monitoring nutritional status in patients with pulmonary tuberculosis

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1 Role of serum alumin in monitoring nutritional status in patients with pulmonary tuerculosis Sandeep Krishna Nalaothu 1*, Surendra Menon K 2 1 Senior resident, Department of Pulmonary Medicine, Siddartha Medical College, Vijayawada, India 2 Professor & Head of Department, Department of Pulmonary Medicine, Mahatma Gandhi Medical College & Research Institute, Puducherry, India ABSTRACT Background: Pulmonary tuerculosis is a communicale disease caused y mycoacterium tuerculosis. Serum alumin is a more accurate indicator of crucial fat-free mass and survival in patients treated for tuerculosis. Ojective: To study the role of serum alumin as iochemical marker for monitoring the nutritional status in newly diagnosed tuerculosis patients during treatment. Methodology: This was a longitudinal study carried out in Mahatma Gandhi Medical College and Research Institute, Puducherry. All the patients who satisfied inclusion criteria received tuerculosis chemotherapy. All the indices like Weight, Body Mass Index (BMI), Serum Alumin and sputum for Acid Fast Bacilli (AFB) were estimated efore start of treatment and followed up once in two months until completion of treatment. Results: Out of the 77 patients started the study, 5 patients completed the study. The pre-treatment mean weight, Body Mass Index and Serum alumin were 46.78kg, 17.22kg/m 2 and 25.68g/L respectively. The corresponding values at the end of six months of treatment were kg, 19.9kg/m 2 and 4.14g/L. These three variales showed significant improvement with treatment. Serum alumin showed statistically significant improvement with treatment when compared to weight and Body Mass Index. Conclusion: Both the Serum alumin and Body Mass Index pre-treatment values reveal that patients are malnourished at presentation. Serum alumin is more sensitive and reliale marker than weight and Body mass index for patients with tuerculosis that have an average of monthly visits to hospitals. Keywords: Nutritional status; Body mass index; Body weight; Serum alumin; Pulmonary tuerculosis. Introduction Pulmonary tuerculosis is a communicale disease of gloal importance caused y mycoacterium tuerculosis. Tuerculosis (TB) is on the increase throughout the world and is one of the leading causes of death among adults in developing countries like India. In 1993, the World Health Organization declared tuerculosis to e a gloal health emergency [1]. *Correspondence Dr. Sandeep Krishna Nalaothu Senior resident, Department of Pulmonary Medicine, Siddartha Medical College, Vijayawada, India iam_sandeep_krishna@yahoo.com Despite the availaility of effective therapy for TB, it continues to infect an estimated one-third of the world's population, to cause disease in 8.8 million people per year, and to kill 1.6 million of those afflicted with disease [2]. India has the highest numer of TB cases in the world and it is second leading cause of death among all diseases [3]. In most of the underdeveloped and developing countries of the world oth tuerculosis and malnutrition are still prolems of considerale magnitude [4]. Malnutrition may predispose people to development of disease and tuerculosis can contriute to malnutrition [5]. The risk of tuerculosis is higher among men who were at least 1% underweight at aseline y nearly four-fold than in men who were at least 1% overweight [6]. In tuerculosis, weight loss is one of the most ovious manifestations of nutritional wasting. The ulk of weight loss in patients with 486

2 tuerculosis is fat mass, though the fat free component, 4. Patients on long term Acetaminophen and Statin which is also lost in significant amounts, certainly has therapy. more of an effect on the physical functioning of 5. Patients with Hypoprotenaemia. patient. Protein deficiency has een descried in the context of tuerculosis, Protein calorie malnutrition has All the Patients who satisfied the inclusion criteria een identified as an essential risk factor for the attending the Pulmonary Medicine Out Patient predisposition to intracellular infection and leading to Department from Decemer 212 to January 214 death [7].Serum alumin has a half-life of 21days, it is received Directly Oserved Treatment Shortcourse a good index of ody nutrition, more so for patients (DOTS) chemotherapy for 6 months Category I under with pulmonary tuerculosis that have an average of Revised National Tuerculosis Control Programme monthly visits to the clinics. (RNTCP) This consists of Isoniazid, Rifampicin, Previous studies y Schwenk et al and Adeisi SA et al Ethamutol and Pyrazinamide. Pyrazinamide and have shown that protein is one of the major Ethamutol were used only for the first two months of components lost during an episode of tuerculosis; it is the therapy. not significantly regained during the course of In all the patients weight was measured using a treatment, making overall weight gain an inadequate weighing machine. Height was measured using a clinical marker for following the reversal of TB standard scale without wearing foot wear. Body Mass wasting.serum alumin may e a more accurate Index (BMI) was calculated using Quetelet s Index. indicator than weight of improving nutritional status Serum alumin levels were measured y Bromocresol [especially with regard to crucial fat-free mass] in green method [1]. patient treated for tuerculosis [8, 9]. Each patient was followed up for a period of six This study was therefore carried out to determine the months. All the indices like Weight, BMI, Serum degree of malnutrition among patients with pulmonary Alumin and sputum AFB were estimated on the first tuerculosis using their Body Mass Index and serum day of visit efore start of treatment and followed up alumin levels and to evaluate role of serum alumin once in two months until completion of treatment. as Biochemical marker for monitoring nutritional status SPSS version 19. (IBM SPSS, US) was used to of newly diagnosed smear positive pulmonary analyze the data. The quantitative variales have een tuerculosis patients during treatment. descried as mean ± SD or Frequency analysis with numers and percentage. Since data does not follow Methodology normal distriution non-parametric test Kruskal Wallis test and wilcoxon signed rank test are the statistical tests used for testing the hypothesis. Value of p<.5 was considered significant. The study was carried out in the department of Pulmonary Medicine, Mahatma Gandhi Medical College and Research Institute, pillayarkuppum, Puducherry, India after the clearance of the Institutional Human Ethical committee (IHEC). This is a prospective, longitudianl study that involves humans. Inclusion Criteria 1. Newly diagnosed pulmonary tuerculosis who is atleast one sputum specimen positive for Acid- Fast acilli (AFB) y microscopy. 2. Age aove 18years. Exclusion Criteria 1. Patients with Anormal liver function as measured y increased serum levels of Aspartate amino transferase (AST), Alanine amino transferase (ALT) and Biliruin levels. 2. Chronic renal failure as determined y elevated levels of serum urea and creatinine. 3. Patients with diaetes mellitus as measured y fasting lood glucose levels. Results Out of the 77 patients started the study, 27 of them were lost to follow up, while the remaining 5 patients followed up in department of pulmonary medicine, Mahatma Gandhi Medical College & Research Institute, Puducherry and completed the study. The 5 patients were made up of 32(64%) males and 18(36%) females. These patients y using pre-treatment data served as their own controls against which susequent data were compared. Tale I shows frequency of gender among patients. It is shows that majority of the patients are males 32(64%) and only 18(36%) of the patients are females. Tale II shows the mean values of weight, Body Mass Index and serum alumin of the patients.both the Body Mass Index (BMI) and Serum Alumin pre-treatment 487

3 values show clearly that the patients were malnourished at presentation. Tale III shows the results of analysis with wilcoxon signed rank test, using the pre-treatment values and the post treatment values of weight, Body Mass Index and serum alumin.the critical value ratio calculated (ztest) was , and , while their corresponding p-values were.,. and. respectively.this shows that with treatment there was significant improvement in all theoutcome variales. Tale IV shows further analysis of mean values of the patient s weight, Body Mass Index and serum alumin Tale I: Frequency of Gender with Kruskal-wallis test gave a chi square value/kruskal-wallis H of 1.74, and , while their corresponding p-values were.18,. and. respectively.this that the weight, Body Mass Index and serum alumin had changed significantly; the serum alumin with chi square value of is the most sensitive. Gender Frequency Percent (%) Male Female Total 5 1. Tale II: Mean and Standard deviation of Weight, Body Mass Index (BMI), and Serum Alumin efore treatment, end of 2 nd month, end of 4th month and at the end of treatment Variale Before Treatment After 2 months of ATT After 4 months of ATT End of treatment Mean SD Mean SD Mean SD Mean SD Weight(kg) BMI(kg/m 2 ) Serum Alumin(g/L) Tale III: Wilcoxon-signed rank test analysis of pre-treatment and end of treatment values of weight, Body Mass Index (BMI) and Serum Alumin. Weight(kg) - Weight(kg) Negative Positive N a 5 Ties c Mean Rank Sum of z- test P- valu e. Total 5 BMI(kg/m 2 ) - BMI(kg/m 2 ) Negative.. -.

4 d Positive e Serum Alumin(g/L) Serum Alumin(g/L) Ties f Total 5 Negative g Positive 5 h Ties i Total 5 a. Weight(kg) <Weight(kg). Weight(kg) >Weight(kg) c. Weight(kg) = Weight(kg) d. BMI(kg/m 2 ) <BMI(kg/m 2 ) e. BMI(kg/m 2 ) >BMI(kg/m 2 ) f. BMI(kg/m 2 ) = BMI(kg/m 2 ) g. Serum Alumin(g/L) <Serum Alumin(g/L) h. Serum Alumin(g/L) >Serum Alumin(g/L) i. Serum Alumin(g/L) = Serum Alumin(g/L) Tale IV: Kruskal-Wallis test for analysis of weight (kg), Body Mass Index (BMI) and Serum Alumin (g/l) Group N Mean Rank Chi-square value/krush al-wallis H P-value Weight (kg) Pre Treatment BMI(kg/m2) After 2 months of ATT BMI(kg/m2) After 4 months of ATT BMI(kg/m2) End of treatment BMI(kg/m2) Total 2 BMI (kg/m 2 ) Pre Treatment BMI(kg/m2) After 2 months of ATT BMI(kg/m2) After 4 months of ATT BMI(kg/m2) End of treatment BMI(kg/m2) Serum Alumin(g/L) Total 2 Pre Treatment BMI(kg/m2) After 2 months of ATT BMI(kg/m2) After 4 months of ATT BMI(kg/m2) End of treatment BMI(kg/m2) Total

5 Out of the 77 patients started the study, 27 of them were lost to follow up, while the remaining 5 patients followed up in department of pulmonary medicine, Mahatma Gandhi Medical College & Research Institute (MGMC&RI) and completed the study. The 5 patients were made up of 32(64%) males and 18(36%) females. Out of 5 patients 33(66%) patients had low Body Mass Index (BMI) and 17(34%) patients had normal Body Mass Index (BMI) with a mean Body Mass Index (BMI) of 17.22kg/m2 at start of treatment. This shows a clear association etween undernutrition and incidence of tuerculosis. Similar reports were given y Edwards LB et al and Tverdal A et al [6, 11]. In our present study, pre-treatment Serum alumin (25.68g/L) was significantly lower in patients with pulmonary tuerculosis. The lower levels of serum alumin in the present study might have een due to poor appetite, malnutrition and mal-asorption commonly oserved in tuerculosis. Similar reports were given y Yamagishi et al and Cegielski JP et al [12, 13]. In our study, Weight, Body Mass Index (BMI), Serum alumin values of the patients showed a steady improvement as the treatment progressed. The pre-treatment mean weight, Body Mass Index (BMI) and Serum alumin were 46.78kg, 17.22kg/m2 and 25.68g/L respectively. The corresponding values at the end of six months of treatment were 52.86kg,19.9kg/m2 and 4.14g/L.The consistent upward trends of these parameters during treatment show that they may e reliale markers of nutritional status for monitoring tuerculosis. Sujecting the patients pre-treatment value and the post treatment value of weight, Body Mass Index (BMI) and serum alumin using wilcoxon signed rank test, The critical value ratio calculated (z- Asian Pac. J. Health Sci., 214; 1(4): e-issn: , p-issn: Discussion test) was , and ,while their corresponding p-values were.,. and. respectively.this shows that with treatment there was significant improvement in all the outcome variales.similar oservation was mentioned y Adeisi S.A et al [8]. The study was carried out in the department of Pulmonary Medicine, Mahatma Gandhi Medical College & Research Institute (MGMC&RI) pillayarkuppum, Puducherry after the clearance of the Institutional Human Ethical committee (IAEC).This study was carried out over a period of one and half year from Decemer 212 to July 214. Through this study, an attempt was made to study the role of serum alumin as iochemical marker for monitoring the nutritional status in newly diagnosed smear positive pulmonary tuerculosis patients during treatment and to find out association etween sputum conversion and serum alumin levels at the end of intensive phase of treatment. Sujecting the patients pre-treatment value and the post treatment value of weight, Body Mass Index (BMI) and serum alumin using wilcoxon signed rank test, The critical value ratio calculated (z-test) was , and ,while their corresponding p-values were.,. and. respectively. This shows that with treatment there was significant improvement in all theoutcome variales. Similar oservation was mentioned yadeisi S.A et al [8]. Conclusion This study suggests that weight, Body Mass Index (BMI) and serum alumin are very reliale markers of nutritional status in patients with newly diagnosed smear positive pulmonary tuerculosis. Of these three parameters, serum alumin is the most sensitive. Since serum alumin is free from some of the short comings of weight and ody Mass Index (BMI) like drug induced vomiting and diarrhoea. As serum alumin is a relatively easily availale iochemical marker can e used in addition to weight and Body Mass Index (BMI) in monitoring the nutritional status of patients with pulmonary tuerculosis. References 1. Reichmann LB. How to ensure the continued resurgence of tuerculosis. Lancet. 1996: World Health Organization. Tuerculosis Fact Sheet. Fact Sheet No Dye C, Scheele S, Dolin P, Raviglione MC. Consensus Statement. Gloal urden of TB: estimated incidence, prevalence, and mortality y country. WHO Gloal surveillance and Monitoring Project. JAMA. 1999; 282: Ruin S.A. Tuerculosis: Captain of all these men of death. Radio ClinNoth Am. 1995; 33: Macallan DC. Malnutrition in tuerculosis. Diagn Microial Infect Dis. 1999; 34: Edwards LB, Livesay VT, Acquavivi FA, Palmer CE. Height, Weight, tuerculosis infection and tuerculous disease. Arch Environ Health. 1971; 22:

6 7. Tupasi TE, Velmonte MA, Sanvictores ME, 1. Dumas BT, Watson WA, Biggs HG. Alumin Araham L. Determinants of moridity and standards and the measurement of serum mortality due to acute respiratory infections: alumin with Bromocresol green Implications and intervention. J Infect Dis. ClinChimActa 1997; 258: ; 157: Tverdal.A et al. Body mass index and incidence 8. Adeisi SA, Oluoyo PO, Oladipo OO. The of tuerculosis. Eur J Respiratory Diseases usefulness of serum alumin and urinary 1986; 69: creatinine as iochemical indices for monitoring 12. Yamagishi F, Sasaki Y, Yasi T. Mizutani F. A the nutritional status of Nigerians with case of pulmonary tuerculosis case with pulmonary tuerculosis. Niger Post grad Med J. pancytopenia accompanied to one marrow 23; 1: gelatinous transformation.1999; 74 (4): Achim schwenk et al. Nutrient partitioning 13. Cegielski JP, Ara L, Cornoni-Huntle J. during treatment of tuerculosis: gain in ody Nutritional risk factors for tuerculosis among fat mass ut not in protein mass. adults in the United States Am J Ajcn.nutrition.org August 5, 213. Epidemiology. Septemer 212; 176(5): Source of Support: NIL Conflict of Interest: None 491