Transthyretin at Admission and Over Time as a Marker for Clinical Outcomes in Critically Ill Trauma Patients: A Prospective Single-Center Study

  • Tobias Haltmeier
  • Kenji InabaEmail author
  • Joseph Durso
  • Moazzam Khan
  • Stefano Siboni
  • Vincent Cheng
  • Beat Schnüriger
  • Elizabeth Benjamin
  • Demetrios Demetriades
Original Scientific Report



Transthyretin (TTR) has been described as a predictor for outcomes in medical and surgical patients. However, the association of TTR on admission and over time on outcomes has not yet been prospectively assessed in trauma patients.


This is a prospective observational study including trauma patients admitted to the intensive care unit (ICU) of a large Level I trauma center 05/2014–05/2015. TTR levels at ICU admission and all subsequent values over time were recorded. Patients were observed for 28 days or until hospital discharge. The association of outcomes and TTR levels at admission and over time was assessed using multivariable regression and generalized estimating equation (GEE) analysis, respectively.


A total of 237 patients with TTR obtained at admission were included, 69 of whom had repeated TTR measurements. Median age was 40.0 years and median ISS 16.0; 83.1% were male. Below-normal TTR levels at admission (41.8%) were independently associated with higher in-hospital mortality (p = 0.042), more infectious complications (p = 0.032), longer total hospital length of stay (LOS) (p = 0.013), and ICU LOS (p = 0.041). Higher TTR levels over time were independently associated with lower in-hospital mortality (p = 0.015), fewer infections complications (p = 0.028), shorter total hospital and ICU LOS (both p < 0.001), and fewer ventilator days (0.004).


In critically ill trauma patients, below-normal TTR levels at admission were independently associated with worse outcomes and higher TTR levels over time with better outcomes, including lower in-hospital mortality, less infectious complications, shorter total hospital and ICU LOS, and fewer ventilator days. Based on these results, TTR may be considered as a prognostic marker in this patient population.


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest or financial ties to disclose.

Ethical approval

This study was approved by the Institutional Review Board of the University of Southern California.


  1. 1.
    Bae HJ, Lee HJ, Han DS et al (2011) Prealbumin levels as a useful marker for predicting infectious complications after gastric surgery. J Gastrointest Surg 15:2136–2144CrossRefGoogle Scholar
  2. 2.
    Shum J, Markiewicz MR, Park E et al (2014) Low prealbumin level is a risk factor for microvascular free flap failure. J Oral Maxillofac Surg 72:169–177CrossRefGoogle Scholar
  3. 3.
    Yu PJ, Cassiere HA, Dellis SL et al (2014) Impact of preoperative prealbumin on outcomes after cardiac surgery. J Parenter Enter Nutr 39:870–874CrossRefGoogle Scholar
  4. 4.
    Geisler JP, Linnemeier GC, Thomas AJ et al (2007) Nutritional assessment using prealbumin as an objective criterion to determine whom should not undergo primary radical cytoreductive surgery for ovarian cancer. Gynecol Oncol 106:128–131CrossRefGoogle Scholar
  5. 5.
    Zago L, Dupraz H, Weisstaub A et al (2000) Indices of protein status as predictors of complications in low risk surgical patients of hernias and lithiasis. Nutr Res 20:203–213CrossRefGoogle Scholar
  6. 6.
    Huang L, Li J, Yan JJ et al (2012) Prealbumin is predictive for postoperative liver insufficiency in patients undergoing liver resection. World J Gastroenterol 18:7021–7025CrossRefGoogle Scholar
  7. 7.
    Yang HT, Yim H, Cho YS et al (2012) Prediction of clinical outcomes for massively-burned patients via serum transthyretin levels in the early postburn period. J Trauma Acute Care Surg 72:999–1005CrossRefGoogle Scholar
  8. 8.
    Yang HT, Yim H, Cho YS et al (2013) Serum transthyretin level is associated with clinical severity rather than nutrition status in massively burned patients. J Parenter Enter Nutr 38:966–972CrossRefGoogle Scholar
  9. 9.
    Devakonda A, George L, Raoof S et al (2008) Transthyretin as a marker to predict outcome in critically ill patients. Clin Biochem 41:1126–1130CrossRefGoogle Scholar
  10. 10.
    Mears E (1996) Outcomes of continuous process improvement of a nutritional care program incorporating serum prealbumin measurements. Nutrition 12:479–484CrossRefGoogle Scholar
  11. 11.
    Robinson MK, Trujillo EB, Mogensen KM et al (2003) Improving nutritional screening of hospitalized patients: the role of prealbumin. J Parenter Enter Nutr 27:389–395CrossRefGoogle Scholar
  12. 12.
    Bernstein LH, Leukhardt-Fairfield CJ, Pleban W et al (1989) Usefulness of data on albumin and prealbumin concentrations in determining effectiveness of nutritional support. Clin Chem 35:271–274PubMedGoogle Scholar
  13. 13.
    Raguso CA, Dupertuis YM, Pichard C (2003) The role of visceral proteins in the nutritional assessment of intensive care unit patients. Curr Opin Clin Nutr Metab Care 6:211–216CrossRefGoogle Scholar
  14. 14.
    Parent B, Seaton M, O'Keefe GE (2016) Biochemical markers of nutrition support in critically ill trauma victims. J Parenter Enter Nutr 148607116671768Google Scholar
  15. 15.
    Houston-Bolze MS, Downing MT, Sayed AM et al (1996) Gender differences in the responses of serum insulin-like growth factor-1 and transthyretin (prealbumin) to trauma. Crit Care Med 24:1982–1987CrossRefGoogle Scholar
  16. 16.
    Davis CJ, Sowa D, Keim KS et al (2012) The use of prealbumin and C-reactive protein for monitoring nutrition support in adult patients receiving enteral nutrition in an urban medical center. J Parenter Enter Nutr 36:197–204CrossRefGoogle Scholar
  17. 17.
    Pinilla JC, Hayes P, Laverty W et al (1998) The C-reactive protein to prealbumin ratio correlates with the severity of multiple organ dysfunction. Surgery 124:799–805CrossRefGoogle Scholar
  18. 18.
    Cheng V, Inaba K, Haltmeier T et al (2015) Serum transthyretin is a predictor of clinical outcomes in critically ill trauma patients. Surgery 158:438–444CrossRefGoogle Scholar
  19. 19.
    6 Ventilator-associated Pneumonia (VAP) Events - 6pscvapcurrent.pdf. Available from:
  20. 20.
    9 Surgical Site Infection (SSI) Event - 9pscssicurrent.pdf. Available from:
  21. 21.
    Bone RC, Balk RA, Cerra FB et al (1992) Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest 101:1644–1655CrossRefGoogle Scholar
  22. 22.
    Heydari A, Emami Zeydi A (2014) Is gastric residual volume monitoring in critically ill patients receiving mechanical ventilation an evidence-based practice? Indian J Crit Care Med 18:259–260CrossRefGoogle Scholar
  23. 23.
    O'Leary-Kelley CM, Puntillo KA, Barr J et al (2005) Nutritional adequacy in patients receiving mechanical ventilation who are fed enterally. Am J Crit Care 14:222–231PubMedGoogle Scholar
  24. 24.
    Villet S, Chiolero RL, Bollmann MD et al (2005) Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients. Clin Nutr 24:502–509CrossRefGoogle Scholar
  25. 25.
    Marik PE, Zaloga GP (2001) Early enteral nutrition in acutely ill patients: a systematic review. Crit Care Med 29:2264–2270CrossRefGoogle Scholar
  26. 26.
    Heidegger CP, Berger MM, Graf S et al (2013) Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomised controlled clinical trial. Lancet 381:385–393CrossRefGoogle Scholar
  27. 27.
    Ingenbleek Y, Bernstein LH (2015) Plasma transthyretin as a biomarker of lean body mass and catabolic states. Adv Nutr 6:572–580CrossRefGoogle Scholar
  28. 28.
    Ortega-Deballon P, Radais F, Facy O et al (2010) C-reactive protein is an early predictor of septic complications after elective colorectal surgery. World J Surg 34:808–814. CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Welsch T, Muller SA, Ulrich A et al (2007) C-reactive protein as early predictor for infectious postoperative complications in rectal surgery. Int J Colorectal Dis 22:1499–1507CrossRefGoogle Scholar
  30. 30.
    Hoeboer SH, Groeneveld AB, Engels N et al (2015) Rising C-reactive protein and procalcitonin levels precede early complications after esophagectomy. J Gastrointest Surg 19:613–624CrossRefGoogle Scholar
  31. 31.
    Kano K, Aoyama T, Nakajima T et al (2017) Prediction of postoperative inflammatory complications after esophageal cancer surgery based on early changes in the C-reactive protein level in patients who received perioperative steroid therapy and enhanced recovery after surgery care: a retrospective analysis. BMC Cancer 17:812CrossRefGoogle Scholar
  32. 32.
    Adamina M, Steffen T, Tarantino I et al (2015) Meta-analysis of the predictive value of C-reactive protein for infectious complications in abdominal surgery. Br J Surg 102:590–598CrossRefGoogle Scholar
  33. 33.
    Bakker J, Nijsten MW, Jansen TC (2013) Clinical use of lactate monitoring in critically ill patients. Ann Intensive Care 3:12CrossRefGoogle Scholar
  34. 34.
    Fuller BM, Dellinger RP (2012) Lactate as a hemodynamic marker in the critically ill. Curr Opin Crit Care 18:267–272CrossRefGoogle Scholar
  35. 35.
    Joshi R, de Witt B, Mosier JM (2014) Optimizing oxygen delivery in the critically ill: the utility of lactate and central venous oxygen saturation (ScvO2) as a roadmap of resuscitation in shock. J Emerg Med 47:493–500CrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2019

Authors and Affiliations

  • Tobias Haltmeier
    • 1
    • 2
  • Kenji Inaba
    • 1
    Email author
  • Joseph Durso
    • 1
  • Moazzam Khan
    • 1
  • Stefano Siboni
    • 1
  • Vincent Cheng
    • 1
  • Beat Schnüriger
    • 2
  • Elizabeth Benjamin
    • 1
  • Demetrios Demetriades
    • 1
  1. 1.Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Los Angeles County and University of Southern California Medical CenterUniversity of Southern CaliforniaLos AngelesUSA
  2. 2.Division of Acute Care Surgery, Department of Visceral Surgery and MedicineInselspital, Bern University HospitalBernSwitzerland

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