Fischer

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JerrahAnn
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171428
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Fischer
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2012-09-17 09:59:25
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Fischer
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  1. Issues with Lab Data
    • Availability of tests in clinical practice
    • Reliability of test in predicting malnutrition
    • Range of normal values sometimes varies, depending on laboratory
    • Some dependent on age & gender
  2. Static Assays
    • Actual level of nutrient
    • Examples: Serum iron or vitamin D
  3. Functional Assays
    • Physiological activity that depends on nutrient status
    • Examples: Serum ferritin in blood reflects iron storage
  4. Net Protein Loss
    • Starts off somatic, followed by visceral protein loss
    • Loss of >30% body protein
    • -Decreased immunity and muscle strength
    • -Increased mortality
  5. Protein-Calorie Malnutrition
    • Serum albumin
    • Serum transferrin
    • Serum prealbumin
    • All are:
    • -Synthesized in liver
    • -Altered by hydration state
    • -Negative acute phase respondents
  6. Albumin, Transferrin, Prealbumin
    • Often are maintained at normal levels  during protein deprivation
    • -But can be used as one indicator of nutrition status when inflammation not present
    • Can serve as indicators of patients who are most at risk of developing nutrition deficits and need extensive nutrition monitoring 
  7. Acute Stress
    Monitored by c-reactive protein and erythrocyte sedimentation rate
  8. C-Reactive Protein
    • Increases early in acute stress
    • Proportional to amount of stress
    • A positive acute phase protein
    • Occurs within hours 
    • Hs-CRP: high-sensitivity CRP being used as predictor of coronary and stroke events
    • •Not a marker of acute stress
  9. Erythrocyte Sedimentation Rate
    >100 mm/hr has a 90% predictive value for serious underlying disease 
  10. Nitrogen Balance
    • Measures balance between nitrogen intake from protein and nitrogen loss
    • N intake (g/24h) - (urinary urea N
    • [g/24h] + 3-5 g/24h)
    • Can see dramatic negative values- nitrogen is being excreted faster than being taken in
    • Visceral protein
    • Have to get an accurate urine sample
    • -0 + or – 2
    • The persons renal function must be normal in order to
    • work
    • -IF it’s diminished there are factors that you can use
    • to fix it
  11. Urinary Creatinine/Height Index
    • Rate of creatinine formation is proportional to muscle mass
    • 24 hour collection used
    • Creatine is found in the muscles as creatine phosphate
    • -Continuously degraded to creatinine
    • -Only works when renal system is working properly
    • Won’t see very often
    • Used in large medical centers that are involved in
    • research studies
  12. Urinary 3-Methylhistidine
    • A marker of breakdown of myecin and actin
    • Also reflects muscle mass
  13. Immune Function
    • Total lymphocyte count
    • Delayed cutaneous hypersensitivity
  14. Total Lymphocyte Count
    • <1500/mm3
    • If a person has an infection, lymphocyte count goes up
  15. Delay Cutaneous Hypersensitivity
    • A test that looks at the skin reaction to various antigens
    • -Like a TB test
    • -If a person is malnourished, the immune response won’t occur (red bump)
  16. Comprehensive Metabolic Panel
    • Use to screen for nutrition related health conditions and monitoring MNT
    • Look for nutrition-specific laboratory data
    • Has the electrolytes, serum glucose, serum creatinine, albumin, BUN & urea, enzymes, bilirubin, calcium, phosphorus and cholesterol & total triglycerides
    • Should be done on a fasting patient
  17. Metabolic Panel: Serum Glucose
    • Fasting Normal = 70-99.9 mg/dL
    • >100-125 mg/dL = Increased risk for diabetes
    • >126 mg/dL = Diabetes mellitus
    • Also increases with pancreatitis, trauma, some meds like glucocortocoids
    • Use Hemoglobin A1c to reflect glucose control for previous 2-3 months, Normal = < 5.7%; A1c of 6.5% or higher is a criteria for diagnosis of diabetes mellitus
  18. To Monitor Renal Function
    • Blood Urea Nitrogen
    • Creatinine
    • Both increase with renal disease, and decrease with low protein diets and with negative nitrogen balance
  19. To Monitor Liver Function
    • AST (SGOT):Aspartate aminotransferase
    • ALT (SGPT) Alanine aminotransferase
    • Alkaline Phosphatase
    • GGT:gamma-glutamyl transferase
    • All increased in liver disease, but AST reflects damage in many organs and ALKp also reflects bone disease
  20. Metabolic Panel: Bilirubin
    • Byproduct of hemoglobin breakdown in liver
    • Increased with gallstones and biliary duct blockage
    • •Bile can’t leave liver, so it enters the bloodstream causing jaundice
    • Increased with some liver disease
    • Jaundice results from increase
  21. Metabolic Panel: Total Calcium
    • Very tightly regulated
    • Total Ca = protein-bound and free Ca
    • Increase in hyper-parathyroidism, malignancy, excessive Vitamin D
    • Decrease in D deficiency, renal disease, Mg deficiency 
    • Increase in albumin = increase in total Ca
    • Some cancers result in increase in calcium
    • 50% of calcium is bound to albumin in the bloodstream
    • -If protein is low, then you’ll have a lower calcium level
  22. Metabolic Panel: Total Phosphate
    • Increase in renal failure
    • Altered by hyper- and hypo-parathyroidism
  23. Metabolic Panel: Na+
    • Reflects total water balance
    • Dehydration= decreases
    • Overhydrated= increases
  24. Metabolic Panel: K+
    • Must maintain in a normal limit
    • Can have serious neurological, muscle problems, and death if high or low
  25. Metabolic Panel: Cl- & HCO3
    Important for acid base balance in the body
  26. LDL Cholesterol
    Normal: <100
  27. HDL Cholesterol
    Normal: <40
  28. Triglycerides
    • Normal: <150
    • High risk: >200
  29. Low Serum Cholesterol
    • < 80 mg/dL associated with increased risk of nutritional complications and mortality
    • When using as PEM assessment tool, be sure that person is not taking cholesterol-lowering drugs
  30. Metabolic Syndrome
    • Pre-risk for cardiovascular disease
    • Increased risk for illness
    • Risk factors:
    • Abdominal obesity
    • -Men: >40
    • -Women: >35
    • -Triglycerides: >150
    • HDL cholesterol
    • -Men: <40
    • -Women: <50
    • Blood pressure: >130/>85
    • Fasting glucose: >100
  31. A1C Test
    • Glucose in the serum can enter RBC and bind to hemoglobin (glycosylation)
    • –Higher average glucose levels = higher % of hemoglobin that will be glycosylated (or glycated)
    • People with diabetes need to keep their level below 7
  32. Anemia
    • Deficiency in size or number of erythrocytes or amount of hemoglobin they contain
    • Limits exchange of oxygen and CO2 between blood and tissue cells
  33. Hemogram
    • Complete blood count
    • White blood count
    • Differential blood count
  34. Complete Blood Count
    • Description of RBC
    • •Hemoglobin (Hg)
    • •Hematocrit (Hct)
    • •RBC count
    • •Mean cell volume (MCV)
    • •Mean cell hemoglobin (MCH)
  35. Differential Blood Count
    Classes of leukocytes (neutrophils, lymphocytes, monocytes, eosinophils, basophils)
  36. Microcytic
    • <80 fL (MCV)
    • Such as iron deficiency 
  37. Normocytic
    • 80-99 fL
    • If a person is anemic because of blood loss, they have fewer cells, but are normal size
  38. Macrocytic
    • >100 fL (>110 fL)
    • Such as folate deficiency
    • Such as B12 deficiency
  39. Classification of Anemia
    • Based on:
    • -Cell size
    • -Hemoglobin content
  40. Hemoglobin Content
    • Hypochromic (pale)
    • -Iron deficient
    • Normochromic (normal)
  41. Iron Deficiency Anemia
    • Production of microcytic red blood cells and diminished hemoglobin
    • –Decreased MCV, MCH
    • Last stage of iron deficiency
    • –Can result from
    • •Low iron intake
    • •Increased needs: growth, pregnancy
    • •Increased menstrual loss
  42. Stages of Iron Deficiency
    • Stage 1- moderate depletion of iron stores
    • Stage 2- severe depletion of iron stores
    • Stage 3- start seeing dysfunction of cell, iron depletion
    • Stage 4- anemia dysfunction, fatigue, anorexia, increased risk of infection, decreased exercise, abnormal cognitive development
    • Physical signs- pale skin, nails
  43. Tests for Iron Deficiency
    • Serum iron
    • Total iron-binding capacity
    • Transferrin saturation
    • Free-erythrocyte protoporphyrin
    • Serum ferritin
    • Serum transferrin receptor test
  44. Iron Deficiency: Serum Iron
    • A poor indicator of iron status because it does not change until stage 3 of deficiency
    • Not sensitive to early iron deficiency
  45. Iron Deficiency: Total Iron-Binding Capacity
    • Indirect measure of transferrin
    • Transport protein is synthesized in the liver, transferrin has binding sites for iron
    • Total capacity goes up
  46. Iron Deficiency: Transferrin Saturation
    • The measure of the % of the binding sites that have iron bound to them
    • Value will drop if you have less iron
  47. Iron Deficiency: Free-Erythrocyte Protoporphyrin
    • Will go up in iron deficiency
    • Zinc protoporphyrin will go up
  48. Iron Deficiency: Serum Ferritin
    • Readily available
    • Storage protein synthesized in the liver
    • If you have less iron, this will go down
    • One of the most sensetive indicators
  49. Iron Deficiency: Serum Transferrin Receptor Test
    • Sensitive indicator
    • The receptor that transferrin binds on to transfer iron from the serum to the hemoglobin
    • Tends to go up when iron is low
    • Not readily available in clinical practices
  50. Iron Deficiency: Stage 4
    • Erythrocytes start becoming microcytic and hypochromic
    • When someone has iron overload disease
    • -Transferrin saturation and serum ferratin go up
  51. B12 Deficiency Tests
    • Serum B12
    • Serum homocysteine
    • Methylmalonic acid (serum or urine)
    • Schilling test
  52. Serum B12
    • Readily available
    • Not very sensitive
    • Just a marker of B12
  53. Serum Homocysteine
    • Readily available
    • More sensitive
    • When B12 isn't present, this builds up
  54. Methymalonic Acid
    • Readily available
    • More sensitive
    • Urine is better than serum
    • Conversion of methylmalonyl CoA to Succinyl CoA requires B12
  55. Schilling Test
    • Used to measure B12
    • Given a dose of B12 to fill up the spaces
    • Not given often, just given to diagnosed pernicious anemia
  56. Folate Deficiency Tests
    • RBC folate
    • Serum folate
    • Serum homocysteine
  57. RBC & Serum Folate
    Readily available
  58. Folate Serum Homocysteine
    Will go up with deficiency
  59. Vitamin D
    • Serum 25-OH-Vitamin D is commonly used marker for D status
    • Deficiency = < 30 nmol/L
    • >50 nmol/L generally considered adequate for bone and overall health in healthy individuals
    • Optimal may be as high as 80 nmol/
    • >125 nmol/L may result in adverse effects
    • Divide nmol/L by 2.5 to get ng/mL

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