Search

In Reply.— Dr Rubinstein proposed several possible pathogenetic mechanisms for hypoalbuminemia associated with multiple myeloma that we have recently described. 1 Some of these mechanisms have already been discussed in our article. We would like to elaborate on the following points: Agreeing with Rubinstein, we also feel that hypoalbuminemia is likely a part of the cachexia syndrome associated with neoplasia. It, however, merits reemphasizing, as we did in our article, that cachexia is not simply the result of inadequate nutritional intake in patients with cancer, but may represent a set of characteristic biochemical and metabolic changes,2 possibly mediated by various tumor- and/or host-derived cytokines. We have mentioned specific suppression of hepatocyte albumin gene expression by interleukin 1. Other cytokines, such as tumor necrosis factor α/cachectin33 and interleukin 6,4 may also act additively or synergistically. Thus, correction of nutritional deficiency or supplementation with excess calorie and protein by hyperalimentation is

• Clinical data of 65 patients with myeloma were analyzed to identify factors associated with hypoalbuminemia. The serum albumin level was not affected by patient age and gender, type of myeloma, and the occurrence of Bence Jones protein, lytic bone lesions, or hypercalcemia, and it was not related to changes in body weight or in liver and renal function. The albumin level, lower in patients with proteinuria, was unrelated to severity of proteinuria. Albumin level correlated significantly with the monoclonal IgG level, hemoglobin concentration, clinical stage of disease, and estimated body tumor burden. Further analysis indicated the disease stage or the tumor burden as the dominant factor in determining albumin level. An albumin level of 29.0 g/L or less identified unequivocally advanced disease. Practically all patients with stage III myeloma had a serum albumin level of 37.0 g/L or less. Thus, hypoalbuminemia is primarily related to the extent of myeloma proliferation and is therefore of diagnostic and prognostic importance. ( Arch Intern Med . 1990;150:605-610)