Albumin and C-reactive protein levels predict short-term mortality after percutaneous endoscopic gastrostomy in a prospective cohort study
Upper Gastrointestinal Research, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden. Gastrointestinal endoscopy
(Impact Factor: 5.37).
11/2010; 73(1):29-36. DOI: 10.1016/j.gie.2010.09.012
Percutaneous endoscopic gastrostomy (PEG) is a procedure with many complications that sometimes can be devastating. To give better advice to patients referred for PEG regarding risk of complications, important risk factors should be known.
To evaluate whether age, body mass index, albumin levels, C-reactive protein (CRP) levels, indication for PEG, and comorbidity influence the risk of mortality or peristomal infection after PEG insertion.
Prospective cohort study from 2005 to 2009. Follow-up 14 days after PEG.
This study involved 484 patients referred for PEG.
Mortality within 30 days and peristomal infection within 14 days after PEG insertion. All risk estimates were calculated with 95% CIs and adjusted for confounding.
Among 484 patients, 58 (12%) died within 30 days after PEG insertion. Albumin <30 g/L (hazard ratio [HR], 3.46; 95% CI, 1.75-6.88), CRP ≥10 (HR, 3.47; 95% CI, 1.68-7.18), age ≥65 years (HR, 2.26; 95% CI, 1.20-4.25) and possibly body mass index <18.5 (HR, 2.04; 95% CI, 0.97-4.31) were associated with increased mortality. Patients with a combination of low albumin and high CRP levels had a mortality rate of 20.5% compared with 2.6% among patients with normal values, rendering an over 7-fold increased adjusted risk of mortality (HR, 7.45; 95% CI, 2.62-21.19).
Missing data in some study variables. Although the sample size was large, weaker associations could not be established.
The combination of low albumin and high CRP levels indicates a substantially increased short-term mortality risk after PEG, which should be considered in decision making.
Available from: Dorothee Volkert
- "A variety of studies have tried to identify patient groups that may not benefit from PEG placement by analyzing differences in short-term mortality. Patient characteristics that have been shown to be associated with worse outcomes after feeding tube placement are: high age, increased number of comorbidities, hypoalbuminemia, elevated inflammatory markers and a low body mass index
[3,9-13]. Most data on risk factors imply that disease severity may be responsible for high short term mortality. "
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Percutaneous endoscopic gastrostomy (PEG) is an established procedure for long-term nutrition. However, studies have underlined the importance of proper patient selection as mortality has been shown to be relatively high in acute illness and certain patient groups, amongst others geriatric patients. Objective of the study was to gather information about geriatric patients receiving PEG and to identify risk factors associated with in-hospital mortality after PEG placement.
All patients from the GEMIDAS database undergoing percutaneous endoscopic gastrostomy in acute geriatric wards from 2006 to 2010 were included in a retrospective database analysis. Data on age, gender, main diagnosis leading to hospital admission, death in hospital, care level, and legal incapacitation were extracted from the main database of the Geriatric Minimum Data Set. Self-care capacity was assessed by the Barthel index, and cognitive status was rated with the Mini Mental State Examination or subjectively judged by the clinician. Descriptive statistics and group comparisons were chosen according to data distribution and scale of measurement, logistic regression analysis was performed to examine influence of various factors on hospital mortality.
A total of 1232 patients (60.4% women) with a median age of 82 years (range 60 to 99 years) were included. The mean Barthel index at admission was 9.5 ± 14.0 points. Assessment of cognitive status was available in about half of the patients (n = 664), with 20% being mildly impaired and almost 70% being moderately to severely impaired. Stroke was the most common main diagnosis (55.2%). In-hospital mortality was 12.8%. In a logistic regression analysis, old age (odds ratio (OR) 1.030, 95% confidence interval (CI) 1.003-1.056), male sex (OR 1.741, 95% CI 1.216-2.493), and pneumonia (OR 2.641, 95% CI 1.457-4.792) or the diagnosis group ‘miscellaneous disease’ (OR 1.864, 95% CI 1.224-2.839) were identified as statistical risk factors for in–hospital death. Cognitive status did not have an influence on mortality (OR 0.447, CI 95% 0.248-1.650).
In a nationwide geriatric database, no component of the basic geriatric assessment emerged as a significant risk factor for mortality after PEG placement, emphasizing individual decision-making.
- "The risk of a poor outcome is further increased in patients with hypoalbuminemia, high C-reactive protein, diabetes, chronic obstructive pulmonary disease, advanced cancer, severe neurological disease, cachexia, advanced age, mechanical ventilation and dialysis [8,12,36–38]. The combination of low albumin and high C-reactive protein levels has recently been shown to predict a high risk of early mortality after PEG . The short-life expectancy in these patients is probably not related to the PEG procedure in the majority of cases but is presumably caused by the background disease producing the need for PEG, especially regarding those with neurological disease . "
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ABSTRACT: Insertion of a percutaneous endoscopic gastrostomy (PEG) is an increasingly common procedure in patients with nutritional needs and dysphagia. Better knowledge of rates and patterns of complications after PEG might influence decision-making.
The objective was to prospectively evaluate the rate of six pre-defined complications (leakage, diarrhea, constipation, abdominal pain, fever and peristomal infection) and mortality occurring within 2 months after PEG in an unselected sample of patients. All patients (n = 484) who had a PEG inserted at the hospital during the study period were included. Kaplan-Meier curves were used to estimate mortality over the first 60 days following PEG and Fisher's exact test was used to test equality of proportions.
Of the 484 patients included, 85 (18%) died within 2 months after PEG insertion. The risk of early mortality was higher in the group with neurological disease than in the group with a tumor as indication (p < 0.001). After excluding mortality, the overall complication rates at 2 weeks and 2 months were 39% and 27%, respectively. The most common complications within 2 weeks were abdominal pain (13%), peristomal infection (11%), diarrhea (11%) and leakage (10%). At 2 months the most frequent complications were diarrhea (10%), leakage (8%) and peristomal infection (6%).
In the short-term perspective, there is a substantial risk of complications, including mortality, after PEG insertion. This should be considered during clinical decision-making and when informing the patients and caregivers.
Available from: Akira Horiuchi
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ABSTRACT: Background: To examine the effects of percutaneous endoscopic gastrostomy (PEG) on quality of life (QOL) in patients with de-mentia.
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