Jan 20, 2018
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Hypoalbuminemia: Malnutrition versus Inflammatory Response

Low serum albumin, a level less 3.4-3.5 g/dL, is most frequent in the elderly who are institutionalized and in those with advanced stages of a disease (i.e. terminal cancer).  Low serum albumin can be a predictor of mortality.  For every 10 g/L decrease in serum albumin level, mortality increases by 137% and morbidity by 89%.  No wonder when physicians see a low albumin, they often ask for a dietary consult.  Hypoalbuminemia can be caused by various conditions, including nephrotic syndrome, hepatic cirrhosis, heart failure, and malnutrition; however, most cases of hypoalbuminemia are caused by acute and chronic inflammatory responses.

The Academy of Nutrition and Dietetics does not even include albumin or prealbumin as defining characteristics of malnutrition because recent evidence analysis shows that serum levels of these proteins do not change in response to changes in nutrient intake.  Characteristics that make up a diagnosis of severe or non-severe malnutrition include at least two of the following: 1) reduced food and nutrient intake over time in relation to energy requirements; 2) significant weight loss over time; 3) loss of body fat and/or muscle mass; 4) fluid accumulation and; 5) reduced grip strength.

Inflammation, either acute or chronic, can cause a significant drop in serum albumin levels.  Inflammation is the body’s response to physical injury and/or the invasion of bacteria or viruses.  The immune system activates white blood cells and certain other chemicals, and then sends them to the point of invasion or injury.  Some people can develop acute inflammation with a burn or an infective process. These types of inflammation may last anywhere from minutes to days.  Others may have chronic inflammation, which persists long-term and in some cases may never stop such as with arthritis, dementia, or Crohn’s disease.

When inflammation occurs, the liver, where albumin is produced, must change from producing albumin to producing other proteins needed to fight the inflammation. Possible symptoms of hypoalbuminemia include generalized body swelling, swelling that occurs in one part of the body, muscle cramps or weakness, lack of appetite, and a buildup of fluid in the abdomen called ascites.

Some residents come in with such vague symptoms as malaise, fatigue and lack of appetite.  This could be the signs and symptoms of the inflammatory response.  Other signs and symptoms include fever, skin redness, joint swelling, headaches, chills, muscle stiffness, and fatigue.  Chronic inflammation is typically detected with lab tests including C-reactive protein, a protein that appears in increased amounts in people when inflammation is present.  This has become an important tool in diagnosing heart disease or risk of heart attack.  A complete blood count (CBC) and complete metabolic panel (CMP) may be ordered by the physician.  A high white blood count would be typical in inflammation along with a low albumin on the CMP.  Sodium level should be reviewed to see if it is low, in which case, the albumin level may be diluted due to over hydration.

So what does this all mean?  Should our nutrition departments ignore low albumin levels and leave the treatment of the inflammation to the physician?  Yes and no.  The physician will be treating the underlying causes of the low albumin.  All the parameters above, mentioned as characteristics of malnutrition, should be considered.  How is the resident eating?  Is intake meeting needs?  Has there been recent weight loss?  What are all the disease processes of this resident and how do they affect albumin levels?  Supplementation may be necessary to spare any protein production that may be occurring and calorie needs must be met.  If this is a resident who maintains a good BMI, is eating well, then all things considered, a low albumin may be an ongoing issue due to some chronic inflammatory response that is going on.  In either case, albumin and prealbumin are not necessarily indicators of malnutrition, but an extensive review by the dietitian of the resident’s overall plan of care is critical.

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