The Effect of Albumin Extract on Tuberculosis with Malnutrition

Henggar Allest Pratamaa,, Geraldi Kusuma Wijayaa,, Aulia Suri Agunga,, Ngurah
Agung Reza Satria Nugraha Putraa, Muhammad Erdian Dwi Ramadhanib, Erfan
Efendic,d

a
Medical Doctor, Post Graduate, Medical Faculty of Jember University, Indonesia
b
Student, Medical Faculty of Jember University, Indonesia
c
Lecturer, Department of Biochemistry, Medical Faculty of Jember University,
Indonesia
d
Anesthesiologist, Balung General Hospital, Jember, Indonesia

Corresponding Author:
Henggar Allest Pratama, Balung General Hospital, Jember 68161, Indonesia
Email: henggarap@gmail.com

Abstract
Introduction: tuberculosis still have a high incidence. The best estimate is that 10.0
million people developed tuberculosis disease in 2017. Tuberculosis and
malnutrition is highly related. 60% tuberculosis patient have malnutrition. It is
marked by a weight loss then continue with hypo albumin. Albumin have a very
important role to transport anti-tuberculosis drug to eradicate Mycobacterium
tuberculosis. A decrease in albumin level causes anti-tuberculosis drug ineffective
so Mycobacterium tuberculosis still exist in the body, which is marked by the
presenting of Interferon gamma (IFN-γ).
Objective: to determine the effect of albumin extract on tuberculosis patient with
malnutrition.
Method: this study is an experimental research design. 30 participants randomly
selected then divided into experimental and control group. Participants in the
experimental group received albumin extract of snakehead fish (Chana striata)
1500 mg and anti-tuberculosis drug while control group receive anti-tuberculosis
drug and placebo for 30 days. All participants would did a measurement of body
weight, albumin level, and IFN-γ level before and after the treatment.
Result: there are a better improvement on body weight, albumin level, and IFN-γ
level in experimental group than control group.
Conclusion: albumin extract can help to increase the theraphy's outcome and
resolve malnutrition problems on tuberculosis patient.
Keywords: tuberculosis, malnutrition, albumin extract.

1. Introduction
Pulmonary tuberculosis is a respiratory infection disease caused by Mycobacterium
tuberculosis infection in lung. Tuberculosis still have a high incidence. Based on
Global Tuberculosis Report 2018, the best estimate is that 10.0 million people
developed tuberculosis disease in 2017. The 6.4 million cases reported represented
64% of the estimated 10.0 million new cases that occurred in 2017. Ten countries
accounted for 80% of the 3.6 million global gap, the top three being India (27%),
Indonesia (11%), and Nigeria (9%)1.

Tuberculosis and malnutrition is highly related. Patient with tuberculosis have a

febris, anorexia and increased metabolism. This condition cause malnutrition, 60%
tuberculosis patient have malnutrition2. The first sign of malnutrition is a weight
loss. It will followed by a decrease in albumin level. Albumin have a very important
role of tuberculosis treatment. Albumin’s function is to transport the anti-
tuberculosis drug to eradicate Mycobacterium tuberculosis3.

A decrease in albumin level causes anti-tuberculosis drug ineffective so

Mycobacterium tuberculosis still exist in the body. The existence of Mycobacterium
tuberculosis is marked by the presenting of Interferon gamma (IFN-γ)4. IFN-γ is a
body immune system’s response to Mycobacterium tuberculosis infection. IFN-γ is
produced by immune system to activate the macrophage cells in lung to start
phagocytosis Mycobacterium tuberculosis. But, Mycobacterium tuberculosis have
a defending system to protect against macrophage cell. Mycobacterium tuberculosis
induce Suppressor of Cytokine Signaling 1 (SOCS 1) to prevent macrophage
activation process by IFN-γ. It cause IFN-γ level on the blood serum stay high5.

Albumin extract is given to tuberculosis patient with malnutrition to improve body

weight, increase the albumin level, and make anti-tuberculosis drug more effective.
The improvement of the body from Mycobacterium tuberculosis infection is
marked by a decrease in IFN-γ level.

2. Material and Method

2.1 Study Design
The study was conduct by using an experimental research design with two different
group, the control group and experimental group. The experimental group received
albumin extract of snakehead fish (Chana striata) 500 mg three times daily (total
1500 mg) and anti-tuberculosis drug while control group receive anti-tuberculosis
drug and placebo. This study use single blinded design.

2.2 Study Place

The study was conducted in 6 primary health cares in Jember during February 2015
to June 2015.

2.3 Ethics Approval

The research proposal was submitted to the Department of Research Ethics in
Medical Faculty of Jember University for oral presentation. Then, The Department
of Research Ethics approved the proposal. Each participant informed about the
study before beginning the study. The participant who had approved to get in this
research study would signing the inform consent.

2.4 Inclusion Criteria

Age ranged from 18-60 years old with pulmonary tuberculosis. The participant was
a pulmonary tuberculosis (TB) patient which was diagnosed as BTA smear positive
pulmonary TB and had got at least 1 month of intensive phase of TB treatment
regularly. Initial medical screening was performed for each participant. The
participant which had normal value of SGOT, SGPT, and negative value of
proteinuria in screening test would approve to get in the study.

2.5 Exclusion Criteria

Patients were excluded if patient had Multi Drug Resistance (MDR) of pulmonary
TB, milliary TB, HIV with pulmonary TB, drop out category of TB treatment,
allergy of high protein meals, and others complication diseases that could affect or
interfere their safety.

2.6 Sample Size

30 patients with pulmonary tuberculosis was selected randomly from 6 of primary
health cares in Jember. Then, all participants divided into two groups. 15 persons
randomly assigned as an experimental group who received albumin extract of
snakehead fish (Chana striata) 1500 mg daily and anti-tuberculosis drugs. 15
persons also randomly assigned as a control group who received placebo and anti-
tuberculosis drugs.

2.7 Subject
All participants were asked to continue their drug therapies, regular diet, and normal
daily activities throughout the study. Patients in experimental group received
albumin extract capsule along with tuberculosis treatment and patients in control
group received only tuberculosis treatment.

2.8 Outcome Measurement

The experimental group received albumin extract of snakehead fish (Chana striata)
500 mg three times daily (total 1500 mg) and anti-tuberculosis drug while control
group receive anti-tuberculosis drug and placebo. All participants would did a
pretest before they started this study and also did a posttest after they finished this
study for 30 days. The test included of body weight measurement, albumin
measurement, and IFN-γ measurement. All of pretest and posttest data would be
presented in table and chart to compare the data difference of each groups.

3. Results
6 of 30 participants of this study had been drop out from this study. Only 24
participants could finished this study. There were 11 participants from experimental
group and 13 participants from control group that finished this study. It consider of
70% (n=17) male and 30% (n=7) female in this study. Participants were aged
between 18-60 years old (the mean age of control group is 32 years whereas
experimental group is 32 years too). The mean BMI of control group is 18.05
whereas experimental group is 18.40.

SEX GENDER

Experimental

Control

0 2 4 6 8 10
Frequency
Female Male

Fig-1: Gender of the Participants

AGES

Experimental

Control

0 2 4 6 8 10
Frequency
51-60 41-50 31-40 18-30

Fig-2: Ages of the Participants

Study showed that the increasing mean of albumin level in experimental group was
higher than the increasing mean of albumin level in control group. This study also
showed that the mean of weight gaining in experimental group was higher than the
mean of weight gaining in control group. Furthermore in this study, the mean of
decreasing IFN-γ level in experimental group was bigger than the mean of
decreasing IFN-γ level in control group.

Albumin Level in Control Group

6
Albumin Level (g/dL)

5
4
3
2
1
0
1 2 3 4 5 6 7 8 9 10 11 12 13
Sample of Participants
Pretest Posttest

Fig-3: Chart of Albumin Level in Control Group

Albumin Level in Experimental Group

6
Albumin Level (g/dL)

5
4
3
2
1
0
1 2 3 4 5 6 7 8 9 10 11
Sample of Participants
Pretest Posttest

Fig-4: Chart of Albumin Level in Experimental Group

 Weight Gaining Level in Experimental and
Control Group
6
Body Weight(kg)

4
2
0
-2
-4
1 2 3 4 5 6 7 8 9 10 11 12 13
Sample of Participants

Control Group Experimental Group

Fig-5: Chart of Weight Gaining Level in Experimental and Control Group

IFN-γ Level in Control Group

4
IFN-γ Level (pg/ml)

0
1 2 3 4 5 6 7 8 9 10 11 12 13
Sample of Participants

Pretest Posttest

Fig-6: Chart of IFN-γ Level in Control Group

 IFN-γ Level in Experimental Group
IFN-γ Level (pg/ml) 4

0
1 2 3 4 5 6 7 8 9 10 11
Sample of Participants

Pretest Posttest

Fig-7: Chart of IFN-γ Level in Experimental Group

Study Group
Control Experimental
Mean Increasing of 0,52 g/dL 1,10 g/dL
ΔAlbumin Level
Table-1: Comparison Mean Increasing of ΔAlbumin Level between Control and
Experimental Group

Study Group
Control Experimental
Mean Weight Gaining 1,046 kg 4,789 kg
Level
Table-2: Comparison of Mean Weight Gaining between Control and Experimental
Group
 Study Group
Control Experimental
Decreasing Mean of 0,42 pg/ml 1,20 pg/ml
ΔIFN-γ Level
Table-3: Comparison Decreasing Mean of ΔIFN-γ Level between Control and
Experimental

4. Discussion:
Study demonstrated that the mean of albumin increasing level in experimental
group was higher than the mean of albumin increasing level in control group. It
indicates that albumin extract of snakehead fish has effect to increase albumin
serum level and increase the activity of anti-tuberculosis drugs by increasing
binding of anti-tuberculosis drugs with albumin. Increasing binding of albumin and
anti-tuberculosis drugs will make the drugs more effective to eradicate
Mycobacterium tuberculosis infection. Inflammation of Mycobacterium
tuberculosis infection can reduce in line with effectiveness of anti-tuberculosis
drugs activity so IFN-γ, which was one of immunological marker tuberculosis
infection, will be decrease. Furthermore, the increasing of albumin level in the
blood and the reducing of Mycobacterium tuberculosis infection will increase the
body weight more significant and resolve malnutrition.

5. Conclusion:
Albumin extract of snakehead fish (Chana striata) with dose 1500mg/days can help
to increase theraphy's outcome and resolve malnutrition problems on tuberculosis
patient.

6. References
1. WHO. 2018. Global Tuberculosis Report 2018.
2. Pratomo, I. P., Burhan, E., and Tambunan, V. 2012. Malnutrition and
Tuberculosis. J Indon Med Assoc, 62(6): 231-236.
3. Younes, H. M. and Amsden, B. G. 2001. Interferon-g Therapy: Evaluation of
Routes of Administration and Delivery Systems. Journal Of Pharmaceutical
Sciences. 91(1):1-16.
4. Pai, Couvery, Marylin, Hamiltoon, Thomas, Boom and Harding. 2003.
Inhibition of IFN-y Induced Class II Transactivator Expression by 19 kDa
Lipoprotein from Mycobacterium tuberculosis : A Potential Mechanism for
Immune Evasion. The Journal of Immunology, 171:175-184.

5. Yoshimura, A., Naka, T., and Kubo, M. 2007. SOCS Protein, Cytokine
Signalling and Immune Regulation. Nature Publishing Group, Vol 7.