title: C-reactive protein/albumin ratio predicts 90-day mortality of septic patients.
abstract: BACKGROUND
  Residual inflammation at ICU discharge may have impact upon long-term mortality. However, the significance of ongoing inflammation on mortality after ICU discharge is poorly described. C-reactive protein (CRP) and albumin are measured frequently in the ICU and exhibit opposing patterns during inflammation. Since infection is a potent trigger of inflammation, we hypothesized that CRP levels at discharge would correlate with long-term mortality in septic patients and that the CRP/albumin ratio would be a better marker of prognosis than CRP alone.
  
  
  METHODS
  We evaluated 334 patients admitted to the ICU as a result of severe sepsis or septic shock who were discharged alive after a minimum of 72 hours in the ICU. We evaluated the performance of both CRP and CRP/albumin to predict mortality at 90 days after ICU discharge. Two multivariate logistic models were generated based on measurements at discharge: one model included CRP (Model-CRP), and the other included the CRP/albumin ratio (Model-CRP/albumin).
  
  
  RESULTS
  There were 229 (67%) and 111 (33%) patients with severe sepsis and septic shock, respectively. During the 90 days of follow-up, 73 (22%) patients died. CRP/albumin ratios at admission and at discharge were associated with a poor outcome and showed greater accuracy than CRP alone at these time points (p = 0.0455 and p = 0.0438, respectively). CRP levels and the CRP/albumin ratio were independent predictors of mortality at 90 days (Model-CRP: adjusted OR 2.34, 95% CI 1.14-4.83, p = 0.021; Model-CRP/albumin: adjusted OR 2.18, 95% CI 1.10-4.67, p = 0.035). Both models showed similar accuracy (p = 0.2483). However, Model-CRP was not calibrated.
  
  
  CONCLUSIONS
  Residual inflammation at ICU discharge assessed using the CRP/albumin ratio is an independent risk factor for mortality at 90 days in septic patients. The use of the CRP/albumin ratio as a long-term marker of prognosis provides more consistent results than standard CRP values alone.
authors.affiliation: Intensive Care Unit, Emergency Medicine Discipline, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil. otavioranzani@yahoo.com.br
authors.forename: Otavio T
authors.initials: OT
authors.lastname: Ranzani
authors.forename: Fernando Godinho
authors.initials: FG
authors.lastname: Zampieri
authors.forename: Daniel Neves
authors.initials: DN
authors.lastname: Forte
authors.forename: Luciano Cesar Pontes
authors.initials: LC
authors.lastname: Azevedo
authors.forename: Marcelo
authors.initials: M
authors.lastname: Park
mesh_terms: D000328:Adult; D000368:Aged; D015415:Biomarkers / Q000097:blood; D002097:C-Reactive Protein / Q000378:metabolism*; D005260:Female; D006801:Humans; D007249:Inflammation; D007362:Intensive Care Units; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge; D011237:Predictive Value of Tests; D011379:Prognosis; D012307:Risk Factors; D012709:Serum Albumin / Q000378:metabolism*; D012772:Shock, Septic / Q000097:blood* / Q000175:diagnosis / Q000401:mortality*; D016019:Survival Analysis
chemical_list: D015415:Biomarkers; D012709:Serum Albumin; D002097:C-Reactive Protein
references.citation: J Am Geriatr Soc. 2008 May;56(5):840-6
references.pmid: 18410327
references.citation: Circulation. 2007 Feb 20;115(7):928-35
references.pmid: 17309939
references.citation: Intensive Care Med. 2008 Mar;34(3):481-7
references.pmid: 17992507
references.citation: Br J Anaesth. 2010 Sep;105(3):318-25
references.pmid: 20630889
references.citation: J Crit Care. 2011 Jun;26(3):287-94
references.pmid: 21129911
references.citation: J Gerontol A Biol Sci Med Sci. 2002 May;57(5):M283-8
references.pmid: 11983721
references.citation: BMC Anesthesiol. 2010 Sep 27;10:17
references.pmid: 20875120
references.citation: N Engl J Med. 2003 Apr 17;348(16):1546-54
references.pmid: 12700374
references.citation: J Clin Epidemiol. 2003 Nov;56(11):1129-35
references.pmid: 14615004
references.citation: Crit Care. 2008;12(5):R123
references.pmid: 18838006
references.citation: Eur Respir J. 2005 May;25(5):804-12
references.pmid: 15863636
references.citation: Int J Mol Epidemiol Genet. 2012;3(1):66-76
references.pmid: 22493753
references.citation: Biomarkers. 2012 Mar;17(2):180-5
references.pmid: 22324487
references.citation: PLoS One. 2011;6(8):e22847
references.pmid: 21853050
references.citation: Crit Care. 2009;13(4):R128
references.pmid: 19653888
references.citation: Intensive Care Med. 2007 Mar;33(3):477-84
references.pmid: 17260130
references.citation: J Crit Care. 2006 Sep;21(3):259-65
references.pmid: 16990094
references.citation: BMC Nephrol. 2011 Jun 29;12:30
references.pmid: 21714897
references.citation: Crit Care Med. 2010 May;38(5):1276-83
references.pmid: 20308885
references.citation: J Crit Care. 2010 Jun;25(2):276-81
references.pmid: 20149587
references.citation: Crit Care. 2006;10(2):R63
references.pmid: 16635270
references.citation: Clin Med (Lond). 2009 Feb;9(1):30-3
references.pmid: 19271597
references.citation: Radiology. 1983 Sep;148(3):839-43
references.pmid: 6878708
references.citation: Thorax. 1993 Aug;48(8):785-9
references.pmid: 8211867
references.citation: Chest. 2010 Oct;138(4):856-62
references.pmid: 20173056
references.citation: Intensive Care Med. 1980 Nov;7(1):19-22
references.pmid: 7451716
references.citation: Crit Care Med. 2006 Feb;34(2):344-53
references.pmid: 16424713
references.citation: J Chronic Dis. 1987;40(5):373-83
references.pmid: 3558716
references.citation: Ann Intern Med. 2006 Jul 4;145(1):21-9
references.pmid: 16818925
references.citation: Thorax. 2006 Jan;61(1):10-6
references.pmid: 16284220
references.citation: Intensive Care Med. 2002 Mar;28(3):235-43
references.pmid: 11904651
references.citation: Surgery. 1998 Oct;124(4):799-805; discussion 805-6
references.pmid: 9781004
references.citation: J Crit Care. 2012 Oct;27(5):525.e9-15
references.pmid: 22227090
references.citation: Ann Surg. 2003 Mar;237(3):319-34
references.pmid: 12616115
references.citation: JAMA. 1997 Apr 2;277(13):1058-63
references.pmid: 9091694
references.citation: Braz J Med Biol Res. 2011 Nov;44(11):1184-93
references.pmid: 22002091
references.citation: Clin Infect Dis. 2005 Jun 15;40(12):1855-7
references.pmid: 15909277
references.citation: J Crit Care. 2008 Dec;23(4):475-83
references.pmid: 19056010
references.citation: Chest. 1998 Feb;113(2):421-9
references.pmid: 9498962