Serum Albumin as Nutritional M arker for PEM?

1. Serum Albumin as Nutritional Marker for PEM? Allie Lawrence Dietetic Intern

2. Ice Breaker What are some of the major indicators of malnutrition (under nutrition) in patients you encounter?

3. Why is this important? • As far back as 1974, malnutrition has been associated with1 : • Increased length of stay • Clinical deterioration • greater use of hospital resources • Higher risk of complications • Indentifying at-risk pts. can and should improve clinical outcomes and decrease total cost.

4. The follow must be true for serum albumin to be an accurate measure nutritional status: • Should react to intervention in a short period of time. • Should improve/change with nutrition intervention • Should not be altered by other factors (ex. inflammation, disease state, etc.) 1

5. Non-nutrition related factors affecting serum alb. levels1: ⇑Increases serum alb. • blood transfusions, exogenous albumin ⇓Decreases serum alb. • Ascites, eclampsia, over hydration, hepatic failure, inflammation, nephrotic syndrome, protein losing state, burns, trauma, post-op, collagen disease, cancer, corticoid steroid use, bed rest, zinc deficiency, pregnancy

6. Did you know 2… • Marasmus = usually normal serum albumin • Kwashiokor = low serum albumin • Anorexia nervosa = maintain normal serum albumin levels even when BMI hits low teens

7. Physically Impaired Elderly Patients: • 2007 study by Kuzuya, et al (Clinical Nutrition)3 • 262 elderly without acute illness were evaluated • Nutrition assessment included – serum albumin, total cholesterol, anthropomorphic measurements, subjective global assessment (SAG), and physical function (measured using ADL rating) • 80% of the participants with low ADL who were evaluated as being well nourished had lower than normal serum alb. levels. • Conclusion - serum alb. a questionable nutritional indicator for elderly pts. with low ADL.

8. Simplified Nutrition Screenings: • 2008 study by Yamada, et al (Am J ClinNutr)6 • 422 HD pts. in Japan. No bed bound, no comorbidty, must be on HD >6months • Compared 5 simplified nutritional screening tools with the Malnutrition-inflammation score (MIS) as reference standard • Mini Nutrition Assessment Short Form (MNA-SF) • Nutritional Risk Score (NRS) • Malnutrition Universal Screening (MUST) • Malnutrition Screening Tool (MST) • Geriatric Nutritional Risk Index (GNRI) – uses alb. • Conclusion – GNRI was the most reliable of the simplified screening tools for this population based on MIS.

9. For children? • 2007 study by Secker, et al (The American Journal of Clinical Nutrition)4 • 175 children, age 31days to 17.9 years, having major thoracic or abdominal surgery • Examine Subjective Global Nutritional Assessment as an indicator for nutritional status compared to several biochemical measures including serum albumin. • Even the lowest mean serum albumin fell within the hospitals normal range • Conclusion – serum albumin not clinically useful in identifying malnourished or predicting outcomes.

10. 2013 AND and ASPEN Position 5: • Currently no single universally accepted way to dx and document adult malnutrition. • Serum alb.  inflammatory response • Serum alb. ≠ respond to feeding intervention • Dx – 2 or more of the following characteristics: • Insufficient energy intake • Weight loss • Loss of muscle mass • Loss of subcutaneous fat • Localized or generalized fluid accumulation • Diminished func. status measured by hand grip strength • Must be assessed routinely and frequently during hospitalization

11. Conclusion… Serum albumin useful in predicting occurrence of complications, morbidity/ mortality, and overall clinical success not a good indicator or marker for the diagnosis of malnutrition

12. References: • Bahn, L. (Oct. 2006). Serum Protein as Markers of Nutrition: What Are We Treating? Practical Gastroenterology, 43. Retrieved from http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/BanhArticle.pdf • Friedman, A.N., and Fadem, S.Z. (Jan. 14, 2010). Reassessment of Albumin as a Nutritional Maker in Kidney Disease. Journal of American Society of Nephrology, 21. Retrieved from http://jasn.asnjournals.org/content/21/2/223.full • Kuzuya, M., Izawa, S., Enoki, H., Okada, K., and Iguchi, A. (Feb. 2007). Is serum albumin a good marker for malnutrition in the physically impaired elderly? Clinical Nutrition, 26. Retrieved from http://www.clinicalnutritionjournal.com/article/S0261-5614(06)00144-0/fulltext • Secker, D.J., and Jeejeebhoy, K.N. (Apr. 2007). Subjective Global Nutritional Assessment for Children. The American Journal of Clinical Nutrition, 85. Retrieved from http://ajcn.nutrition.org/content/85/4/1083.long • White, J.V., Guenter, P., Jensen, G., Malone, A., Schofield, M., the Academy Malnutrition Work Group, the A.S.P.E.N. Malnutrition Task Force, A.S.P.E.N. Board of Directors. (May 2012). Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteraland Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition). Journal of Academy of Nutrition and Dietetics, 112, 2212-2672. doi:10.1016/j.jand.2012.03.012 • Yamada, K., Furuya, R., Takita, T., Maruyama, Y., Yamaguchi, Y., Ohkawa, S., and Kumagai, H. (Jan. 2008). Simplified nutritional screening tools for patients on maintenance hemodialysis. The American Journal of Clinical Nutrition, 87. Retrieved from http://ajcn.nutrition.org/content/87/1/106.full