JOURNAL READING

Posttranscriptional Changes of Serum

Albumin:
Clinical and Prognostic Significance in
Hospitalized
Patients With Cirrhosis

PPDS: dr. Reagan Paulus Rintar

Aruan

ABSTRACT
OBJECTIVE

RESULTS

INTRODUCTION

Human serum albumin (HSA) is the most

abundant plasma protein, and its oncotic power
largely determines the fluid distribution in the
different compartments of the body

Besides its oncotic capacity, HSA presents other

biological properties, such as antioxidant and
scavenging activities, binding and transport of
many endogenous and exogenous substances,
and regulation of endothelial function and
inflammatory response

INTRODUCTION

Physiological conditions, the occurrence of lowlevel posttranscriptional changes, resulting from

oxidation, glycosylation, and truncation
involving the Cys-34 and other molecular sites,
contributes to the microheterogeneity of the
circulating molecule

In patients with advanced liver disease, HSA is

immersed in a stressful microenvironment as a
result of the elevated serum concentration of
proinflammatory and pro-oxidant substances

INTRODUCTION

Diabetes is present in
approximately one third of
patients with cirrhosis,
additional stress can also
derive from
hyperglycemia. besides
the universal finding of
hypoalbuminemia, a
significant damage of the
molecule can be expected
in these patients. And,
indeed, the reversible and
irreversible oxidation of the
Cys-34 residue occurs in
advanced cirrhosis

Furthermore, the
circulating level of
ischemia modified
albumin, which
predominantly
reflects the
cobaltchelating
activity at the Nterminal portion,6 is
significantly increased
in patients with acuteon-chronic liver failure

INTRODUCTION

In the present study, we first analyzed the

HAS posttranscriptional changes in a large
cohort of patients with cirrhosis admitted
to the hospital because of a clinical
complication of the disease.

Then, we assessed whether these HSA

isoforms are associated with the severity
of disease, specific clinical features, and
patient prognosis.

PATIENTS AND METHODS

From

July 2011 to March 2012, all the

patients with cirrhosis admitted to
our department

The

diagnosis of cirrhosis was based

on clinical, biochemical, ultrasound
(US), and endoscopic features

Exclusion criteria
Age

under 18 years
Admission for a scheduled procedure
Hepatocellular carcinoma (HCC)
exceeding the Milan criteria
Heart and respiratory failure
Organic renal diseases
Oncohematologic disorders
Protein-losing syndromes
Albumin infusion in the previous month
Ongoing immunosuppressive treatment.

Study Design

At the time of inclusion for outpatients with

cirrhosis and controls, and within 24 hours
from admission for hospitalized patients,
peripheral blood was withdrawn from the
brachial vein into pyrogen-free tubes

Blood samples were immediately

centrifuged at 3,000xg for 10 minutes, and
plasma was aliquoted into cryotubes, and
stored at -80C until analysis

Study Design
Posttranscriptional

HSA molecular
changes were identified and
quantified by using a highperformance liquid
chromatography/electrospray
ionization mass spectrometry
technique.

Study Design
Clinical

and biochemical parameters

were also recorded and hospitalized

Patients

were followed for up to 1

year.
7

HSA isoforms carrying one or more

posttranscriptional changes were
identified

Statistical Analysis

Variables were expressed as mean and SD or

frequencies according to their distribution.

Comparisons between categorical variables were

made by means of the chi-square (x2) test.

Differences in HSA isoform relative abundance

between control subjects, outpatients, and
hospitalized patients with cirrhosis were assessed
by one-way analysis of variance (ANOVA)
with Bonferronis correction for multiple
comparisons

Statistical Analysis

The relationship between relative abundance of

HSA isoforms and MELD and Child-Pughscores was
evaluated with Spearmans rho.

The univariate analysis of the association between

HAS isoforms relative amount, age, MELD and
Child-Pugh scores, and specific clinical complication
(ascites, renal impairment, and bacterial infection)
in hospitalized patients was assessed by means of
the Student t test

The association between HSA isoforms, serum

albumin concentration, and 1-year survival was
assessed using Coxs proportional hazard

Statistical Analysis

The best cutoffs of HSA isoforms significantly

associated with patients survival and of serum
albumin concentration were determined through
receiver operating characteristic (ROC) curve
analysis in order to plot survival curves using
Kaplan-Meiers method

All tests were two sided, and values of P < 0.05

were considered statistically significant.

The analyses were performed using SPSS

Statistics 20.0 software

RESULT
S

Data are
presented as
mean SD
or frequencies
(%).
*Renal
impairment =
serum
creatinine
>1.5 mg/dL.
Prothrombin
time

Table 1. Clinical Characteristics

of Patients
With Cirrhosis at Study
Enrollment

Fig. 1. Representative deconvoluted ESI-MS spectra from a control subject (A)

and a patient with cirrhosis (B). In addition to native HSA, seven HSA isoforms
carrying the following structural alterations were detected: truncation of the
last two amino acid residues at the Nterminal portion (HSA-DA); truncation of
the last amino acid residue at the C-terminal portion (HSA-L); cysteinylation
of the Cys-34 residue (HSA1CYS); sulfinylation of the Cys-34 residue
(HSA1SO2H); and glycosylation (HSA1GLYC). Two additional HSA isoforms
were generated from the combination of the cysteinylated with the N-

DISCUSSIONS
In

this study, posttranscriptional

structural changes of albumin in
cirrhosis were assessed by HPLC/ESIMS
for the first time.

This

proteomic technique provides a

spectrum of molecules with high
resolution, discriminating between
isoforms whose molecular weight differs
by a few Daltons

Fig. 3. Kaplan-Meiers survival

curves for HSA1CYS-DA (A),
native
HSA (B), and serum albumin
concentration (C) in
hospitalized patients with
cirrhosis dichotomized
according their best cut-off
values

DISCUSSIONS
The

first important finding of the

present study is that the molecular
structure of HSA is extensively altered
in patients with cirrhosis. Indeed, the
extent of many posttranscriptional
molecular changes, which can also be
detected at a low, physiological level
in healthy subjects, was significantly
increased in patients

CONCLUSIONS
Extensive

posttranscriptional changes of HSA,

involving several molecular sites and increasing in
parallel with disease severity, occur in patients with
cirrhosis.
Altered isoforms are independently associated with
specific clinical complications, whereas the residual,
native HSA isoform independently predicts patient
survival.
These findings support the concept of the effective
albumin concentration, which implies that the
global HSA function is related not only to its
serum concentration, but also to the
preservation of its structural integrity.