We would like to thank Drs Cosenza and Jacobs, as well as Drs Pavan, Tulone, and Claps for their constructive comments on our study.1,2,3 Through the reinforcement of serum albumin's robust association (across various statistical modelling methods) with length of stay and readmission, we hope to reinforce nutritional optimization and its utility in routine care. Similarly, serum albumin levels could potentially serve as a screening tool for identifying patients in need of additional support for postoperative recovery. Drs Cosenza and Jacobs' kind words are appreciated. We concur that several residual confounders such as frailty and sarcopenia were not accounted for, the importance of which cannot be understated in light of their associations with survival and postoperative recovery.4-6 Further studies exploring the associations between albumin, sarcopenia, frailty, and the patient journey among renal cancer populations are encouraged in delineating a potential relationship. Drs Pavan, Tulone and Claps' recommendations for the clinical application of our findings are warranted and gratefully received. We feel the longitudinal 25-year design across evolving postoperative care and the potentially incomplete capture of out-of-system readmissions may serve as strengths and improve the generalizability of our study (particularly considering that the association between albumin and readmission remained strong despite readmissions potentially being under captured). Irrespective, they represent residual confounders alongside baseline renal function, additional inflammatory markers (ie, C-reactive protein), operative time, and blood loss. Importantly, given prior studies have documented no added benefit to albumin repletion, we agree that albumin may better serve as a screening tool rather than a modifiable causal pathway. As mentioned in their comment, prospective multi-institutional studies investigating targeted interventions in hypoalbuminemic patients represent the next step in this analysis.
Lahiji et al. (Sun,) studied this question.