Perioperative hypoalbuminemia predicts postoperative survival: a large cohort study with global context

Protein-energy malnutrition (PEM) remains a global health concern. Although hypoalbuminemia is widely used as a clinically accessible indicator associated with nutritional and inflammatory status, its impact on postoperative survival has not been fully characterized. This study combined global epidemiological analysis with a large-scale clinical cohort to provide complementary insights into the burden of PEM and the prognostic value of perioperative hypoalbuminemia.

Global trends in PEM-related mortality, prevalence, and disability-adjusted life years (DALYs) from 1990 to 2021 were assessed using Global Burden of Disease (GBD) 2021 data. In parallel, a retrospective cohort of 200,608 surgical patients (2014-2018) from a tertiary hospital was analyzed. Propensity score matching (PSM) and Cox proportional hazards models were applied to evaluate the association between perioperative hypoalbuminemia (serum albumin < 35 g/L) and short-term (3-month) and long-term (3-year) postoperative mortality.

GBD 2021 analysis showed a decline in PEM-related mortality and DALYs from 1990 to 2021, while prevalence decreased more slowly. In the clinical cohort, perioperative hypoalbuminemia was associated with increased postoperative mortality. After PSM, preoperative hypoalbuminemia was associated with higher short-term (HR 2.45, 95% CI 2.16-2.77) and long-term mortality (HR 1.63, 95% CI 1.55-1.72), while postoperative hypoalbuminemia showed stronger associations (HR 3.15 and 1.73, respectively). Associations were consistently observed across sex- and age-specific subgroups.

This study highlights the continuing burden of PEM and shows that hypoalbuminemia is associated with poor postoperative outcomes. The stronger association of postoperative hypoalbuminemia with short-term mortality suggests that postoperative nutritional assessment may warrant further prospective evaluation.