Assessment of a Correlation between Malnutrition, Serum Hypotransferrin and Chronic Skin Ulcers

Aim. The aims of this study were to evaluate the correlation between malnutrition, serum hypotransferrin and chronic skin ulcers and the effect of supplementation with a dietary integrator on wound healing. The study population was 20 patients with chronic skin ulcers (12 men and 8 women; mean age 75.58 ± 8.51 years). Monthly assessments were carried out for 6 months (V1-V6) and comprised measurement of changes in wound surface area and blood chemistry parameters (hemoglobin [Hb], total proteins, albumin, transferrin, iron, total iron-binding capacity [TIBC], latent iron-binding capacity [LIBC], transferrin saturation index). Nutritional supplementation with an oral dietary integrator was initiated at day 45. At day 45, the mean blood chemistry values were: serum albumin 2.73 ± 1.07 g/dL (45.05 ± 15.84%); total proteins 6.35 ± 0.65 g/dL; total lymphocyte count 24.17 ± 0.09%; serum Hb 10.86 ± 1.47 g/dL; serum trasferrin 165.92 ± 75.95 g/dL; serum iron 40.5 ± 19.65 mg%; TIBC 207.4 ± 94.94 mgr%; LIBC 166.9 ± 92.45 mg%; transferrin saturation index 20.63 ± 9.73%. These values indicated moderate protein malnutrition. The mean wound surface area was 56.92 ± 47.95 cm2. At 90 days (V4) the mean values were: serum albumin 3.43 ± 0.68 g/dL (48.05 ± 8.15%); serum proteins 6.91 ± 0.51 g/dL; total lymphocyte count 40.44 ± 0.44%; serum Hb 12.47 ± 1.91 g/dL; serum trasferrin 223.73 ± 104.07 g/dL; serum iron 51.09 ± 22.66 mgr%; TIBC 279.66 ± 130.09 mgr%; LIBC 228.57 ± 133.37 mgr%; transferrin saturation index 21.54 ± 12.15%. The mean wound surface area was 20.41 ± 25.91 cm2. In conclusion, a correlation emerged between hypotransferrinemia and chronic skin ulcers, as demonstrated by the improvement in both parameters with treatment. Supplementation with the oral dietary integrator led to an increase in serum transferrin, and particularly in serum Hb and proteins and total lymphocyte counts, stimulating the healing of the chronic skin ulcers.


Introduction
Various risk factors interact to produce the tissue damage seen in patients with chronic skin ulcers.Among the extrinsic and intrinsic causes are uninterrupted pressures on a particular body area, immobility, incontinence, and advanced age.Although the physiological consequences of immobility are regarded as the main predisposing factor, just as important is the direct causal relationship between nutritional status and the development of pressure ulcers.Biochemical indicators of malnutrition include levels of serum albumin and transferrin and total lymphocyte count.Numerous studies have shown an association between hypoalbuminemia and pressure ulcers (Table 1) [1,2].The aim of this study was to determine whether there is an association between hypotransferrinemia and chronic skin ulcers or both have been an independent factors.
Arginine regulates many metabolic and physiologic functions, several of which aid in promoting wound healing and tissue repair [3,4].Experimental studies have shown that L-arginine supplementation enhances tissue repair markers, increases protein and hydroxyproline content in wounds, and improves T lymphocyte function [3,4].In addition, activated macrophages release arginine-derived nitric oxide, which exerts a bactericidal and a vasodilatory action on the vessels surrounding the wound, promoting the tissue oxygenation needed for wound repair [3,4].
Vitamin C is essential for connective tissue synthesis and collagen metabolism.Together with proteins, zinc plays an important role in collagen tissue synthesis.Nearly 80% of patients with pressure ulcers are noted to have zinc deficiency and zinc levels are thought to parallel albumin, a known zinc carrier [5][6][7].Transferrin, a rapid turnover protein, by virtue of its short half life, is used as a marker of nutritional status.While this affords a distinct advantage over other biomarkers, transferrin levels tend to increase in martial deficiency.Levels between 100 and 150 mg/mL indicate moderate protein depletion and levels <100 mg/mL indicate severe protein depletion.
Nutritional status is a recognized risk factor for pressure ulcers, which will inevitably develop when comorbidities and sustained pressure on body areas are present.As defined by anthropometric and biochemical parameters, poor nutritional status or malnutrition is common in patients with chronic ulcers: 70% of those with pressure ulcers and 55% of those at risk for developing pressure ulcers are undernourished.Malnutrition is not the result of protein loss from the wounds but rather is the manifestation of a primary decrease in protein intake due to malnutrition.In patients with pressure ulcers a significant association has been shown between hypoalbuminemia (<3 g/dL), total lymphocyte count (<1000/mm 3 ), total proteins (<6 g/dL), diastolic blood pressure (<50 mmHg) and mortality.

Primary aim
The primary aim was to determine whether there was a correlation between hypotransferrinemia, chronic skin ulcers and malnutrition or both have been an independent factors.Data were obtained by measuring blood chemistry values (serum transferrin, serum albumin, total lymphocyte count [TLC], hemoglobin [Hb], total iron-binding capacity [TIBC], latent ironbinding capacity [LIBC], transferrin saturation index) with immunoturbidimetric assay on serum, reepithelialization rate, and changes in wound surface area as measured using the Calcderm ® software program (software developed by our working group) [8][9][10].
This study was approved by ethics committees (ethical approval) of the Western University of Arad, Romania and "Villa Fiorita" Private Hospital, Aversa, Caserta, Italy.

Secondary aim
The secondary aim was to evaluate the usefulness of the study product (NP ® ) in the treatment of chronic skin ulcers by comparing the changes in blood chemistry parameters and wound surface area after 3-months therapy with the oral dietary integrator.
At day 45 (beginning of the follow-up period, V2-V3), treatment with the study product was initiated.The patients were instructed to take the dietary integrator 3 times daily with their main meals for 3 months.
Inclusion criteria were: written informed consent: age ≥ 18 years; either sex; bed-ridden patients with one or more chronic skin ulcers; malnutrition as measured by blood chemistry (Hb < 12 g/dL, serum albumin < 3.5 g/dL; serum transferrin < 170 g/dL) and the Instant Nutritional Assessment screening tool.Exclusion criteria were: age < 18 years; self-sufficiency; use of a dietary integrator in the 12 months prior to enrollment in the study.Patients could withdraw from participation in the study at any time because of: premature death; informed and free decision; occurrence of an exclusion criterion; occurrence of adverse events that require discontinuation of the treatment under study at the investigator's discretion.

Statistical analysis
Inferential data analysis was used to compare the data obtained before (before day 45) and during treatment (after day 45) using biomedical statistics as described by Sofastats (ver.1.4.6. 2012).Patient demographics are expressed as the means, standard deviation (SD), median, range, and correlation coefficient.Statistical significance of the data obtained between V1 and V4 was tested using ANOVA, Student's t-test, and the t-test for independent samples calculated with a confidence interval of 95% [11,12].

Results
All 20 patients completed the study (

Discussion
Our data show an improvement in all parameters, with a marked increase in mean serum transferrin from 165.92 g/dL to 203.6 g/dL between V1 and V5, indicating a change in nutritional status from mild to no malnutrition, an improvement of 18.5%, and a concomitant reduction of 69.8% in mean wound surface area from 56.92 to 17.2 cm 2 between V1 and V6.Comparison of the data from two study periods (day 0-45 from the start of the tral and day 46-150) shows that the mean wound surface area decreased by 26% in the      Proteins-Hb (g/dL); Wound surface area (cm 2 ); time (days); proteins, surface area, haemoglobin.1), a strong positive correlation between the changes in wound surface area and Hb levels (r=0.873;t=-5.09;P=0.001) (Figure 2) and between wound surface area and levels serum albumin (r=-0.655;t=-2.311;P=0.02886) (Figure 3), a weakly positive correlation between Hb and transferrin levels (r=-0.191;t=0.337;P=0.5739) (Figure 4), and a strong correlation between albumin and transferrin levels (r=0.754;t=2.298;P=0.01647) (Figure 5).The daily re-epithelialization rate calculated according to the equation.

Conclusions
Our data show a correlation between hypotransferrinemia and wound surface area, demonstrating a parallel improvement in both parameters during treatment with the study product.Our data also show a marked improvement in serum transferrin and a more pronounced improvement in serum Hb, proteins and TLC (Figures 6 and 7), indicating that the oral dietary integrator aided in stimulating healing of the chronic skin ulcers (Figures 8 and 9).Chronic skin ulcers arise in a setting of the hypercatabolic syndrome with protein-energy malnutrition, leading to socalled metabolic death with the loss of 70% of protein reserves.Indeed, proteinenergy malnutrition is a recognized factor in delayed tissue repair.
Our results suggest that supplementation with this oral dietary integrator, starting at the early stages of pressure ulcer in bedridden patients with malnutrition symptoms, for 3 months 3 times daily can help heal skin wounds or at least reduce wound surface area.The future studies can be conducted to see if the same results can be obtained by reducing the dose to two times a day, thus avoiding the occurrence of sporadic diarrhea, the only side effect recorded in the present study.

Figure 1 :
Figure 1: Correlation coefficient for changes in wound surface area and serum transferrin levels.

Figure 2 :
Figure 2: Correlation coefficient for changes in wound surface area and serum hemoglobin levels.

Figure 3 :
Figure 3: Correlation coefficient for changes in wound surface area and serum albumin levels.

Figure 4 :
Figure 4: Correlation coefficient for changes in Hb and serum transferrin levels.

Figure 5 :
Figure 5: Correlation coefficient for changes in Albumin and serum transferrin levels.

Figure 6 :
Figure 6: Time relationship between changes in wound surface area, serum protein and haemoglobin levels.

Figure 8 :
Figure 8: Before and After 120 days after administration of the integrator (measurements taken with Calcderm® software).

Figure 9 :
Figure 9: Before and After 60 days after administration of the integrator (measurements taken with Calcderm ®software).