Nutritional Assessment - 2 Flashcards
Considerations of pre-albumin in renal disease?
Kidney often excretes prealbumin, thus will reflect a higher value
When there a drop in visceral protein, what is it most often associated with?
Major blood loss and inflammation from surgeries, NOT indicative of nutritional status
Albumin half-life?
14-20 days
Mild depletion albumin?
28-35
Moderate depletion of albumin?
21-27
Severe depletion of albumin?
<21
Mild depletion of TIBC?
36-44
Moderate depletion of TIBC?
22-35
Severe depletion of TIBC?
<22
Half-life of pre-albumin?
1-3 days
Mild depletion of pre-albumin?
0.13-0.20
Moderate depletion of pre-albumin?
0.07-0.13
Severe depletion of pre-albumin?
<0.07
Mild depletion of TLC? Elderly?
1.5-1.8 1.2-1.8
Moderate depletion of TLC? Elderly?
0.9-1.5 0.8-1.19
Severe depletion of TLC? Elderly?
<0.9 <0.8
When are albumin, and other visceral proteins decreased?
-Inflammation -Infection -Liver disease -Protein losing states -Surgery, stress, catabolic states, malnutrition, corticosteroid therapy
In what inflammation state is pre-albumin increased?
-Corticosteroids -CKD due to less excretion
What is low albumin associated with?
Increased risk of morbidity and mortality
When does TLC increase?
-AIDS -Malignancies -immunosuppressive drugs
Patient is admitted well nourished for unexpected bowel surgery, Post-op he has a fever, and on POD 8 he is NPO for the past 8 days. Albumin = 19 g/L, what is your impression?
-Recall that 1/2 life of albumin is 14-30 days, thus it has not been enough time for albumin to be reflective of nutritional status -Likely due to fever, inflammation and post-catabolic state post Sx. -Initiate post-op nutrition to ret bowel until PO intake can resume
Patient presents w/ albumin of 36 g/L and TLC of 1.2. Impression in 40 y/o?
-Albumin reflective of mild malnutrition -Mild deficit of TLC -Thus, indicative of mild malnutrition
Patient presents w/ albumin of 36 g/L and TLC of 1.2. Impression in 80 y/o?
-Albumin good for age -Mild deficit of TLC -Nutritional status likely OK, reflective of aging and not nutritional status
Pre-albumin/trasnthyretin 1/2 life?
2-3 days
Which has a larger body pool size, pre-albumin or albumin? What is the significance?
-Albumin > Pre-albumin -This means that pre-albumin could rapidly change
Discuss the sensitivity of pre-albumin
-Decreases in malnutrition quickly -Increase quickly with adequate kcal -May help confirm low-protein intake with adequate energy -Negative APP
When may the ebb & flow phases indicate about nutritional status?
-Not reflective -The ebb phase (eliciting of hormones/inflammation_ will cause a sharp decrease, whereas flow phase will return to normal
When are low values of pre-albumin observed?
-Liver diseases -Sepsis (inflammation, infection) -Protein-losing enteropathies (IBD, cancer) -Acute catabolic states (trauma, surgery)
What may increase pre-albumin?
-CKD (less catabolism) -Corticosteroids
Why may someone with IBD, but on glucorticoids may display normal pre0albumin, despite being malnourished?
-IBD decrease pre-albumin -Glucocorticoids increase pre-albumin
What is the order of protein utilization during malnutrition?
lean mass -> visceral proteins –> organ mass
Which study showed that pre-albumin is not a nutritional indicator, but rather of the diseased state?
-Obeserved the biochemistry fo two groups of ICU patients on TPN, where group one had increased pre-albumin and the other had decreased pe-albumin. -However the two groups had similar weight, BMI, energy intake, protein intake, no differences in mortality, hospital or ICU stay
Half life of RBP?
2 hours
RBP is synthesized in the ___ and degraded in the ____
liver kidney
When is RBP high?
-Kidney disease
When is RBP low?
-Liver disease -Vitamin A deficiency
RBP is sensitive to ____ but not to low protein intake, thus it is not ____
-PEM -protein specific
What can RBP help us interpret?
-Confirm low protein intakes with adequate energy -Low values coincide with RBO -Similar to pre-albumin, follow RBP for recovery with nutritional support
What is ferritin?
The storage form of iron, which will be mobilized within the context of iron deficiency
When is ferritin important to interpret ?
-GI issues -Blood losses -Suspected anemia
When does ferritin increase?
-Infection -inflammation -Trauma -Iron overload -Viral hepatitis
Does increased ferritin mean decreased iron status?
No, must interpret against other marker, such as CRP and RBC panel
Half life of ferritin?
72 hous
if both HMG and ferritin are low, more likely indicative of what?
Nutritional status
Elevated ferritin?
>310
Normal ferritin?
21-310
Low ferritin?
<10
What is transferrin?
transport protein for iron, which will increase within the context of iron deficiency, with less saturation but increased TIBC
half-life of transferrin?
8-9 days
Arrange the body pool sizes of the following visceral proteins from largest to smallest: -Transferrin -Albumin -Pre-albumin
Albumin –> Transferrin –> Prealbumin
When is transferrin low?
-PEM -Sensitive to PEM and refeeding
What is transferrin affected by?
-Liver disease -Protein losing enteropathies -hemodilution
What is the normal range of CRP?
<10 mg/L usually 1 mg/L
Discuss the + APP response of CRP after inflammation
Begins to increase within 46 hours after the initial tissue injury and will continue to increase several hundred fold within 24-48 hours
When does CRP increase? When does it decrease? What must happen to indicate healing?
-Elevated during the acute-phase response -Returns to normal with the restoration of tissue structure and function -Must come down to indicate healing
The rise of CRP is ____ an doubles every ___
exponential 8-9 hours
What is a direct and quantitative measure of the acute phase reaction?
CRP
Half life of CRP?
<24 hours
What is the ultimate measurement of protein metabolism?
Nitrogen balance
goal of nitrogen balance?
Reach zero nitrogen balance, +/- 2 g/day
What does measuring nitrogen balance require?
1) 24 hr urine collection 2) Diet intake assessment 3) Consideration of + 4 g output for random losses
How do we calculate nitrogen output?
24 hr urea mmol/35.7 = N output
How to we calculate nitrogen input?
24 hr protein intake g/ 6.25 = N input
N balance equation
Intake - (Output + 4 g)
When is anabolism indicated from nitrogen balance?
When NB is > 0 +/- 2 g/day
When may NB be realistic?
In the ICU setting, as urine catheters are often in palce
Why may measuring NB be preferential than visceral proteins with respect to protein status?
NB is less affected by fluid shifts than plasma proteins
You wish to calculate nitrogen balance on an ICU patient and have the following data available. They are receiving 1.8 L daily of TPN containing 4% AA consistently for the past 3 wk. What is your assessment?
1) 1.8 L AA: 1800 ml x 0.04 = 72 ml protein x 1 g/1ml = 72 g protein 2) Take 24 h urea from each week and divide by 35.7 to get to g N and add 4 g for other losses. 3) Calculate for each week, N balance = intake / output Week 1: -8.3 Week 2: -12.1 Week 3: -3.68 All -, but trend is approaching balance
___ of calcium is bound to albumin
60%
Low albumin may reflect low _____ and ____
-Serum calcium -Bilirubin As they are both bound to albumin
When we see low calcium, what may we want to look at to see if it is truly “low”?
See if albumin is low, because then the calcium would be low secondary to lwo albuin
Why do we need to measure corrected calcium if albumin is low?
Because measured total plasma Ca will change 0.8 mg/dL (0.20 mmol/L) for every 10 g/L change in albumin
Corrected calcium (mg/dl) =
measured Ca + 0.8 mg/dL x [(40 – albumin g/L)/10]
Corrected calcium (mmol/L) =
measured Ca + 0.2 mmol/L x [(40-albumin g/L)/10]
What type of calcium is the most physiologically important?
Ionized, as it is metabolically active
What other nutrients are bound to protein, and will be lower secondary to malnutrition?
-Zinc -Magnesium
Tl Ca is 1.9 mmol/L; albumin is 32 g/L —- Calculate corrected Ca.
Corrected Ca = 1.9 + 0.2 x (8/10) = 1.9 + 0.16 = 2.06 (Still low, but lower end of normal range of 2.1 mmol/L)
Consequences of high calcium
-Irregular heart rhythms -Calcification of soft tissue -Renal/heart failure
Consequences of low calcium?
-Cardiac issues, nerve transmission issues -Long-term: osteoporosis
WHO finding of anemia in the elderly?
8-44% prevalence
Why increased prevalence of anemia in the elderly?
-Kidney function declines, les EPO -Lack of appetite -Malabsorption
Anemia Hmg in women?
<12 g/dl or <120 g/L
Anemia Hmg in men?
<13 g/dl or <130 g/L
(T/F) Lower HmG is a normal consequence of aging
F -in the absence of disease, most older people maintain a normal red cell count, hemoglobin and hematocrit
What is anemia of chronic diseases?
-Results from extended periods of infection or inflammation -Certain chronic infections/inflammations can influence hematopoiesis
What are the impacts of decreased heameopatic function in AOCD?
-Shortened RBC life span -Sequestration of iron in inflammatory cells, resulting in a decreased amount of iron available to form RBC -May see microcytic anemia in inflammation
Examples of chronic infections which may cause AOCD?
-Tuberculosis -Infective endocarditis -Chronic UTI -Chronic fungal infections –> These infections will cause the sequestration of iron
Chronic inflammatory disorders which may cause AOCD?
-Osteoarthritis -Rheumatoid disease -Collagen vascular disease -Hepatitis -Decubitus ulcer
Malignancies which may cause AOCD?
-Metastic carcinoma -Hematologic malignancies -Lymphoma
Other diseases causing AOCD?
-PEM -Crohns disease -Ulcerative colitis -Celiac disease -Renal failure -Blood loss associated with chronic lesions
First stage of nutritional anemia?
-Depletion of iron stores -Decreased ferritin
Second stage of nutritional anemia?
-ID without anemia -Decrease transferrin sat, increased erythrocyte protoporphoryin
What is erythrocyte protoporphoryin?
Pre-cursor to Hbg
Third stage of nutritional anemia?
-IDA -Decreased hemoglobin and MCV (microcytic)
You have a patient who has had chronic blood loss and takes a supplement to help compensate. Her HCT % increase,They developed pneumonia in week 3. What is your assessment? Is iron status improving?
-Ferritin cannot be interpreted, as CRP is high and ferritin is sequestered within the context of inflammation
