Assessment of Laboratory Assessment of Laboratory ValuesValues

Albumin and Albumin and MalnutritionMalnutrition

Reference Level at some Reference Level at some Facilities (Check yours)Facilities (Check yours)

Albumin:Albumin: 3.7 to 4.7 g/dL3.7 to 4.7 g/dL

Albumin:Albumin:Nutritional AssessmentNutritional Assessment

NormalNormal 3.5 – 4.7 3.5 – 4.7 g/dLg/dL

Mild depletionMild depletion 2.8 – 3.4 2.8 – 3.4 g/dLg/dL

Moderate depletion Moderate depletion 2.1 – 2.7 2.1 – 2.7 g/dLg/dL

Severe depletionSevere depletion < 2.1 g/dL< 2.1 g/dL

Albumin: FactsAlbumin: Facts Major plasma proteinMajor plasma protein Normal A/G (albumin to globulin) ratio is 1½ to 2 Normal A/G (albumin to globulin) ratio is 1½ to 2

Major determinant of intravascular volume and Major determinant of intravascular volume and

responsible for 70% of colloidal osmotic pressure. responsible for 70% of colloidal osmotic pressure. Albumin acts like tiny sponges to hold onto water, Albumin acts like tiny sponges to hold onto water,

thus promoting normal oncotic pressure and thus promoting normal oncotic pressure and hydrationhydration

Albumin level is strongly influenced by hydration Albumin level is strongly influenced by hydration status; levels drop with edema and increase with status; levels drop with edema and increase with dehydrationdehydration

Albumin: FactsAlbumin: Facts

Most nutrition texts state that Albumin levels Most nutrition texts state that Albumin levels ranging from 3.5 to 5.0 g/dL reflect normal ranging from 3.5 to 5.0 g/dL reflect normal protein status.protein status.

Albumin level suggests protein status over Albumin level suggests protein status over the past 12-21 days.the past 12-21 days.

Not an acute sensor of nutritional status in Not an acute sensor of nutritional status in critically ill individuals or of early critically ill individuals or of early malnutrition.malnutrition.

Albumin: FactsAlbumin: Facts

Albumin is the major carrier for non-soluble Albumin is the major carrier for non-soluble substances such as:substances such as:– lipids, lipids, – hormones, hormones, – Rx, Rx, – bilirubin, bilirubin, – metalsmetals

Marasmus Vs KwashiorkorMarasmus Vs Kwashiorkor

Marasmus: Marasmus: Starvation or FastingStarvation or Fasting

Weight is often </= 80% of normal but Weight is often </= 80% of normal but albumin may be within the reference range.albumin may be within the reference range.

(inadequate intake of calories and protein)(inadequate intake of calories and protein)

Kwashiorkor: Kwashiorkor: Hyoalbuminemic MalnutritionHyoalbuminemic Malnutrition (inadequate intake of protein; energy intake (inadequate intake of protein; energy intake may be marginal)may be marginal)

Starvation and Glycogen Stores Starvation and Glycogen Stores

Total caloric value of liver and Total caloric value of liver and muscle glycogen and circulating free muscle glycogen and circulating free glucose is approximately 1200 kcal, glucose is approximately 1200 kcal, less than 1 day’s resting energy less than 1 day’s resting energy requirementrequirement

Starvation and Body Protein StoresStarvation and Body Protein Stores

Body protein content is approximately 12 kg, Body protein content is approximately 12 kg, enough to theoretically supply 2 weeks enough to theoretically supply 2 weeks worth of energy needsworth of energy needs

Total depletion of protein would have Total depletion of protein would have profound adverse effects, including profound adverse effects, including depletion of visceral proteins, decreased depletion of visceral proteins, decreased immune response, impaired wound healing, immune response, impaired wound healing, impaired organ function and deathimpaired organ function and death

Starvation and Fat StoresStarvation and Fat Stores

During prolonged fasting, the body’s fat During prolonged fasting, the body’s fat supply is the major determinant of the length supply is the major determinant of the length of survival, which in a nonobese individual of survival, which in a nonobese individual coincides roughly with the predicted time of coincides roughly with the predicted time of depletion of fat stores (approximately 60 to depletion of fat stores (approximately 60 to 75 days)75 days)

Protein Status in Marasmus Protein Status in Marasmus ((fasting malnutritionfasting malnutrition))

During starvation:During starvation:– Glycogen stores are depleted within 24 hrs Glycogen stores are depleted within 24 hrs – Insulin levels dropInsulin levels drop– About 75 grams of muscle protein (12 g nitrogen) About 75 grams of muscle protein (12 g nitrogen)

are catabolized during the first 2-3 days of a fast are catabolized during the first 2-3 days of a fast (for gluconeogenesis)(for gluconeogenesis)

– Voluntary reduction in physical work usually Voluntary reduction in physical work usually occurs (to reduce energy expenditure)occurs (to reduce energy expenditure)

– Involuntary reduction in BMR (to reduce the rate Involuntary reduction in BMR (to reduce the rate of deterioration of body stores)of deterioration of body stores)

Thermodynamic Law of StarvationThermodynamic Law of Starvation

When the initial changes (reduction When the initial changes (reduction of BMR, etc.) do not reequate energy of BMR, etc.) do not reequate energy status, the body switches to a fat status, the body switches to a fat burning engine to preserve protein burning engine to preserve protein stores. stores.

Body ProteinsBody Proteins

Somatic Proteins = Muscle ProteinsSomatic Proteins = Muscle Proteins Gut Proteins Gut Proteins Visceral Proteins = Organ ProteinsVisceral Proteins = Organ Proteins

Changes in Body Proteins with Changes in Body Proteins with MarasmusMarasmus

Decrease in somatic and gut proteinsDecrease in somatic and gut proteins Conservation of visceral protein stores Conservation of visceral protein stores Weight is often </= 80% of normal but Weight is often </= 80% of normal but

Albumin may be within the reference range. Albumin may be within the reference range.

Albumin in KwashiorkorAlbumin in Kwashiorkor

Kwashiorkor: protein depletion or Kwashiorkor: protein depletion or hypoalbuminemic malnutritionhypoalbuminemic malnutrition

Weight may be normal or excessive, but Weight may be normal or excessive, but protein stores (albumin) is lowprotein stores (albumin) is low

Conservation of somatic proteinsConservation of somatic proteins

Protein Wasting and Protein Wasting and Cancer CachexiaCancer Cachexia

Cancer Cachexia represents a Cancer Cachexia represents a maladaptation to the fasting state with maladaptation to the fasting state with ongoing mobilization of proteins ongoing mobilization of proteins

Decrease in protein synthesis also occursDecrease in protein synthesis also occurs

Albumin is Decreased in:Albumin is Decreased in:

Protein/calorie malnutrition (inadequate Protein/calorie malnutrition (inadequate calorie & protein intake results in eventual calorie & protein intake results in eventual depletion of protein stores)depletion of protein stores)

Kwashiorkor (= hypoalbuminemia)Kwashiorkor (= hypoalbuminemia) Liver disease (liver synthesizes albumin)Liver disease (liver synthesizes albumin) Metabolic Stress (decreased albumin seen Metabolic Stress (decreased albumin seen

w/ inflammation & infections; synthetic w/ inflammation & infections; synthetic functions switch to provide acute phases functions switch to provide acute phases proteins)proteins)

Catabolism (breakdown of muscle mass)Catabolism (breakdown of muscle mass)

Albumin is Decreased inAlbumin is Decreased in

Malabsorption Malabsorption Edema/ascites (increased fluids dilute albumin Edema/ascites (increased fluids dilute albumin

level)level) Cancer Cachexia (associated w/ wasting of LBM)Cancer Cachexia (associated w/ wasting of LBM) Renal Disease (e.g. nephrotic syndrome is Renal Disease (e.g. nephrotic syndrome is

associated with urinary loss of albumin and is associated with urinary loss of albumin and is characterized by hypoalbuminemia, characterized by hypoalbuminemia, hyperlipidemia, and edema. Protein restriction hyperlipidemia, and edema. Protein restriction rather than supplementation is more effective at rather than supplementation is more effective at managing this disorder.managing this disorder.

Lab Tests used to Asses Protein / Lab Tests used to Asses Protein / Nutritional StatusNutritional Status

Albumin (1/2 life of 12-21 days)Albumin (1/2 life of 12-21 days) Retinol Binding Protein (1/2 life of 10-12 Retinol Binding Protein (1/2 life of 10-12

hours): hours): circulates in a 1:1 molar ratio with PAB and transports circulates in a 1:1 molar ratio with PAB and transports vitamin A W/ renal disease, its half-life is prolonged. Levels decrease vitamin A W/ renal disease, its half-life is prolonged. Levels decrease in hyperthyroidism, vitamin A deficiency, and acute catabolic states.in hyperthyroidism, vitamin A deficiency, and acute catabolic states.

Prealbumin (1/2 life of 2-3 days)Prealbumin (1/2 life of 2-3 days) Transferrin (1/2 life of 8-10 days)Transferrin (1/2 life of 8-10 days) CholesterolCholesterol

Lab Test / ½ Lab Test / ½ life (CASE life (CASE program)program)

Normal Normal ValueValue

PCMPCM AIRAIR InfectionInfection

Retinol Retinol Binding Binding Protein / 8-10 Protein / 8-10 hrshrs

2.6-7.6 2.6-7.6 mg/dLmg/dL

LowLow Un-Un-changedchanged

Un-Un-changedchanged

Prealbumin / Prealbumin / 2-3 days2-3 days

16-36 16-36 mg/dLmg/dL

LowLow Very lowVery low LowLow

Albumin / Albumin /

12-21 days12-21 days

3.5-5.0 3.5-5.0 g/dLg/dL

LowLow Very lowVery low LowLow

CholesterolCholesterol < 200 < 200 mg/dLmg/dL

Declining or < Declining or < 160 mg/dL 160 mg/dL (when not on (when not on Rx)Rx)

Un-Un-changedchanged

Un-Un-changedchanged

Laboratory AssessmentLaboratory AssessmentLab TestLab Test Reference Reference

Ranges at Ranges at some some FacilitiesFacilities

Critical Critical ValuesValues

States associated States associated with Hyper levelswith Hyper levels

States associated States associated with Hypo levelswith Hypo levels

AlbuminAlbumin 3.7-4.7 gdL 3.7-4.7 gdL (but normal (but normal protein status protein status reflected by reflected by 3.5-4.7)3.5-4.7)

None (but None (but albumin albumin <2.4 <2.4 increases increases risk of risk of edema)edema)

Dehydration and Dehydration and diabetes insipidus diabetes insipidus (increased thirst, (increased thirst, urination and fatigue urination and fatigue without change in without change in blood glucose)blood glucose)

Overhydration, Overhydration, malnutrition, malnutrition, malabsorption, liver malabsorption, liver failure, burns, metastatic failure, burns, metastatic carcinoma, nephrotic carcinoma, nephrotic syndrome, dialysissyndrome, dialysis

PrealbuminPrealbumin 17-39 mg/dL17-39 mg/dL nonenone Euvolemic status in Euvolemic status in chronic renal failure chronic renal failure (excess body water, (excess body water, mainly intracellular); mainly intracellular); hemodialysis (attributed hemodialysis (attributed to decreased renal to decreased renal catabolism of PAB)catabolism of PAB)

Malnutrition, liver disease, Malnutrition, liver disease, stress, infectionstress, infection

TransferrinTransferrin 204-345 204-345 mg/dLmg/dL

nonenone Increased iron Increased iron storesstores

Iron deficiency, blood Iron deficiency, blood loss, liver diseaseloss, liver disease

Protein DepletionProtein Depletion

Albumin Albumin (g/dL)(g/dL)

Prealbumin Prealbumin (mg/dL)(mg/dL)

Transferrin Transferrin (mg/dL)(mg/dL)

““Normal”Normal” 3.5-4.7 3.5-4.7 17-3917-39 201-345201-345

Mild Mild DepletionDepletion

2.8-3.42.8-3.4 10-1610-16 151-200151-200

Moderate Moderate DepletionDepletion

2.1-2.72.1-2.7 7-107-10 100-150100-150

Severe Severe DepletionDepletion

<2.1<2.1 <7<7 <100<100