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Ramadori. Hepatoma Res 2020;6:28 Hepatoma Research
DOI: 10.20517/2394-5079.2020.43

Review Open Access

Hypoalbuminemia: an underestimated, vital
characteristic of hospitalized COVID-19 positive
patients?

Giuliano Ramadori

Clinic for Gastroenterology and Endocrinology, University Medical Center Göttingen, Göttingen 37075, Germany.

Correspondence to: Dr. Giuliano Ramadori, Clinic for Gastroenterology and Endocrinology, University Medical Center Göttingen,
Göttingen 37075, Germany. E-mail: giulianoramadori@gmail.com
How to cite this article: Ramadori G. Hypoalbuminemia: an underestimated, vital characteristic of hospitalized COVID-19
positive patients? Hepatoma Res 2020;6:28. http://dx.doi.org/10.20517/2394-5079.2020.43

Received: 21 Apr 2020 First Decision: 6 May 2020 Revised: 7 May 2020 Accepted: 13 May 2020 Published: 3 Jun 2020

Science Editor: Guang-Wen Cao Copy Editor: Jing-Wen Zhang Production Editor: Tian Zhang

Abstract
The COVID-19 pandemic has led to the greatest worldwide health crisis in decades. The number of infected
patients with severe SARS-CoV-2 (COVID-19) disease has overwhelmed the capacity of almost all health care
systems around world. Hypoalbuminemia has now been reported in patients with severe disease seeking help
in the emergency room because of COVID-19 infection. In the past, hypoalbuminemia was considered to be a
negative prognostic marker, not only in patients with chronic liver disease, but also in patients with SARS and MERS
infections. Albumin is the major serum protein synthesized by the liver. A low serum albumin level is an ominous
clinical sign. Introduction of amino acids to a patient’s diet is of fundamental importance to hepatic albumin
synthesis in different clinical situations. This highlights the importance of nutritional support during the early phases
of COVID-19-infection. Furthermore, albumin synthesis in the hepatocyte is downregulated at a pretranslational
level by the direct interaction of the major acute-phase cytokines which are released into the circulation during the
cytokine “storm” induced by the viral effects on the lungs. Both mechanisms contribute to severe hypoalbuminemia
which, combined with massive fluid losses due to the fever, is responsible for severe hypovolemia and shock
commonly observed in patients with COVID-19 in critical care settings.

Keywords: Severe acute respiratory syndrome cornonavirus 2, SARS-CoV-2, COVID-19, albumin synthesis, nutrition,
acute-phase reaction, cytokines, liver, extrahepatic organs

COVID-19 INFECTION AND THE CLINICAL RELEVANCE OF HYPOALBUMINEMIA
Severe acute respiratory syndrome, cornonavirus 2 (SARS-CoV-2), formally CoV-19, is a recently recognized
RNA-virus which belongs to a larger family of pathogenic human viruses. Severe acute respiratory syndrome

© The Author(s) 2020. Open Access This article is licensed under a Creative Commons Attribution 4.0
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