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For many years clinicians have relied on serum proteins, such as albumin and pre-albumin, as markers of nutritional status. However, current research indicates that there is little data to support this practice. Albumin and pre-albumin (transthyretin) are acute phase proteins. The advent of the inflammatory process - including infection, trauma, surgery, burns, and other wounds - elicits the acute phase response. During this acute phase response, these proteins decline and are called negative acute phase reactants.
Albumin is a visceral protein and has a large body pool, distributed between the vascular and interstitial spaces. Only 5 % is synthesized daily. Albumin functions as a carrier protein, and assists in maintaining oncotic pressure. Corticosteroids, insulin, thyroid hormone, and dehydration all increase albumin levels. During inflammation, cytokines increase, especially interleukin-6, which is responsible for the production of acute phase proteins. This increased cytokine production results in albumin being pulled from the intravascular spaces and circulating to the liver until the inflammatory process resolves
Pre-albumin, also a visceral protein, acts as a transport protein for thyroxine and as a carrier for retinal binding protein. Due to the short half-life of pre-albumin (2-3 days), it is assumed to be a better indicator of nutritional repletion. However, it is affected by the same inflammatory process as albumin and decreases during the acute phase response. A pre-albumin level declines with infection, hyperglycemia, dialysis, liver disease, and surgery. Pre-albumin may be elevated with corticosteroids and acute renal failure, as it is degraded by the kidneys
Multiple studies, either randomized, interventional, or prospective cohort studies, fail to demonstrate a relationship between nutritional status and serum protein levels. Declining intake does not correlate with declining serum protein levels, nor does increased nutritional intake result in improved values. Low levels of albumin and pre-albumin are indicators of morbidity and mortality, and increased levels may reflect the improvement in the overall clinical status of the individual
The focus of nutritional care should be on risk factors like unintended weight loss, undernutrition, declining food/fluid intake, and slow wound healing. Individuals with any of these risk factors will benefit from a comprehensive nutrition assessment, as well as aggressive interventions including weight monitoring and oral intake
As a clinician, ask yourself the following questions
- Is the individual actually receiving the nutrition care prescribed?
- Are the supplements ordered, delivered, and consumed?
- Is the feeding tube running at the ordered rate for the number of hours ordered?
- Answering these questions will directly aid in providing nutrition assessments and interventions.
overall clinical assessment to judge if nutritional needs are being met for wound healing - on average only 60% of an 8oz supplement is consumed and interruption of tube feeding has been shown to correlate with poor outcomes.
However, past medical history albumin, pre-albumin, appetite, wound bed status can be useful in assessing the level of inflammation - and trending the labs values and help to determine if the nutritional intervention and wound care is working to modulate inflammation. Our approach includes a "high protein, anti-inflammatory" nutritional regimen along with "sooner rather than wait and see" debridement.
We get baseline laboratory values as part of a detailed nutritional assessment with follow up to check for compliance with recommendations. When these levels start to improve - increased visceral proteins, normal blood sugars, improving appetite, cleaner wound - we see this as a measure of resolving inflammation with decreased insulin resistance - normalization of nutrient utilization. We can then consider transition to a more standard (i.e. less expensive) intervention