The higher mortality associated with low serum albumin is dependent on systemic inflammation in end-stage kidney disease

PLoS One. 2018 Jan 3;13(1):e0190410. doi: 10.1371/journal.pone.0190410. eCollection 2018.


Background: The correlation of low serum albumin with mortality in patients with chronic kidney disease (CKD) is partly linked to its association with systemic inflammation. However, it is not clear to what extent albumin's correlation with mortality depends on concomitant systemic inflammation. Here we addressed this question in patients with CKD stage 5.

Methods: Serum albumin (S-Alb), systemic inflammation (high-sensitive C-reactive protein, hsCRP), cardiovascular disease (CVD) and nutritional status (subjective global assessment, SGA) were assessed at baseline in 822 patients: 523 incident dialysis patients, 212 prevalent hemodialysis (HD) and 87 prevalent peritoneal dialysis (PD) patients. Patients were divided into four groups according to hsCRP and S-Alb in each cohort: Group 1 -normal S-Alb and normal hsCRP (reference); Group 2 -low S-Alb and normal hsCRP; Group 3-normal S-Alb and high hsCRP; Group 4-low S-Alb and high hsCRP. Survival over 60 months was analyzed.

Results: In Cox analysis, Group 4 had an increased mortality risk (adjusted Hazard ratio (95% confidence interval): 1.62 (1.06-2.47); p = 0.02) whereas the augmented mortality risks for Groups 2 and 3 in univariate analyses were not significant after adjustments for age, gender, blood pressure, diabetes mellitus, smoking, SGA, renal function and renal replacement technique.

Conclusions: Whereas mortality risk was increased in CKD stage 5 patients with low S-Alb and high CRP, it was not increased in patients with low S-Alb and normal CRP. Our observation suggests that inflammatory status should be taken into account when using S-albumin for risk assessment in CKD stage 5 patients.

Publication types

  • Observational Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Cohort Studies
  • Female
  • Humans
  • Kidney Failure, Chronic / blood
  • Kidney Failure, Chronic / complications
  • Kidney Failure, Chronic / mortality*
  • Male
  • Middle Aged
  • Prospective Studies
  • Serum Albumin / metabolism*
  • Survival Analysis


  • Serum Albumin

Grants and funding

This study was supported by grants from Baxter Healthcare Corporation and Amgen Inc to Karolinska Institutet. The grant from Baxter Healthcare Corporation was a general grant to Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, to support research activities at Karolinska Institutet to promote the understanding and treatment of renal disease which made it possible to carry out this and other studies. The grant from Amgen Inc was given to Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, to support two observational studies on inflammation in dialysis patients treated by hemodialysis and peritoneal dialysis respectively. The study also benefited from generous support from Swedish Medical Research Council (K2014-65X-15320-10-3) (Peter Stenvinkel), Heart and Lung Foundation (20160384). Baxter Novum is a result of a grant from Baxter Healthcare to Karolinska Institutet. This study was also supported by Martin Rind Foundation (Peter Stenvinkel), Njurfonden (Peter Stenvinkel), and Westmans Foundation. Bengt Lindholm is employed by Baxter Healthcare. The funders provided support in the form of salaries for BL, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ‘author contributions’ section.