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![Page 1: Blood tests in the assessment of nutritional status - an ... · PDF fileBlood tests in the assessment of nutritional status - an overwiew Lars Ellegård Dept. of clinical nutrition](https://reader034.vdocuments.net/reader034/viewer/2022051601/5abdf9897f8b9a8e3f8c6f41/html5/thumbnails/1.jpg)
Blood tests in the assessment of nutritional
status - an overwiew
Lars Ellegård
ESPEN Congress Gothenburg 2011
Assessment or nutritional status – what are we measuring ?
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Blood tests
in the assessment of
nutritional status
- an overwiew
Lars Ellegård
Dept. of clinical nutrition
Sahlgrenska University Hospital
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Development of
malnutrition
Intake lower than required
Decreasing deposits
Biochemical changes
Anatomical and functional changes
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The slope of malnutrition
Malnutrition
Cell mass
Visceral protein synthesis
Organ dysfunction
Immun defense
Infections
MODS
MORS + inflammation
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Malnutrition & disease
Disease
Anorexia Low dietary
intake
Catabolism
Waste of
Tissue
Waste of
fat >> muscles
Waste of both
fat and muscles
Protein synthesis Protein degradation
Inflammation
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Nutritional status
Screening Weight & BMI
Weight curve
Apetite
Nutritional assessment Dietary intake
Body composition
Function
Biochemical indices
Protein/energy intake
Specific deficiencies
Comorbidity
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Factors affecting the
interpretation of blood tests
Medical
Disease
Inflammation/
trauma/ malignancy
Weight loss
Constitutional
Age, sex, genetics
Behavioral
Physical activity
Dietary intake
Pharmacological
Drugs
Technical
Contamination
Sampling errors
Accuracy & precision
Sensitivity & specificity
Physiological
Homeostasic regulation
Circadian variation
Endocrine variation
Interaction between nutrients
Easier to get than to interpret!
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Serum values
in relation to physiology
Synthesis Elimination
Dehydration
Overhydration
[x]= amount
volume
Redistribution
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Serum samples
in relation to total body water
0
10
20
30
40
50
60
70
80
90
100 %
TBW
BF+BM
ICW
ECW
PV
InterCW
[Albumin] 40g/l ≈ 140g in PV
[Albumin] 15 g/l ≈ 180g in PV
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ESR Erythrocyte
sedimentation rate
ESR= mm sedimentation of
erythrocytes in 1 hr
Fibrinogen
Immunoglobulins
Albumin
Erythrocyte count
ESR
General index of inflammation
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Biochemical indices
decreasing with low protein/
energy intake or malnutrition
Index half life relative cost
S-albumin [t½=20 d] 1
S-transferrin /TIBC [t½=8 d] 1
S-Orosmucoid [t½=5 d] 2
S-Prealbumin/transthyretin [t½=1-2d] 3
S-IGF-1 insulin like growth factor [t½=1 d] 7
S-RBP retinol binding protein [t½=0.5 d] 2
Lymphocyte count 1
S-Creatinine, K, Mg, PO4, (glucose) (Na) (Ca2+ ) 1
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Biochemical indices
for nutrition assessment/PEM
S-albumin
≈35-50g/l normal range
> 50g/l dehydration?
< 35g/l malnutrition, overhydration, inflammation
< 25g/l leakage (GI/renal/burns), cirrhosis,
malignancy
Hypoalbuminic edema rare > 20g/l
Albumin transports Ca, Mg, Zn, Se, as well as bilirubin,
lipids, FFA, drugs…
whose serum levels will decrease during inflammation,
in parallell with albumin
More prognostic than nutritional index!
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Biochemical indices
to assess nutritional status/PEM
S-transferrin/TIBC
≈45-70μmol/l normal range (≈2-4g/l)
Low TIBC: protein malnutrition, alcoholism,
inflammation
High TIBC Iron deficiency, estrogen, 17-α-AAS
S-orosomucoid
≈0.55-1.05g/l normal range
Low: protein losses, malnutrition
High inflammation
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Biochemical indices
to assess nutritional status/PEM
S-transthyretin/prealbumin
≈0.3g/l normal range
High TT/PA uraemia, dehydration, alcoholism
Low TT/PA Fasting, malnutrition/
malabsorption, inflammation,
pregnancy, cirrhosis, overhydration
Quick response to nutrition support,
but insensitive to adapted starvation.
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Biochemical indices
to assess nutritional status/PEM
S-RBP retinol binding protein
≈60mg/l normal range
High RBP uraemia, alcoholism
Low RBP malnutrition/malabsorption,
Vit A deficiency, cirrhosis,
Quick response to nutrition support/ recent dietary
intake, but insensitive to adapted starvation.
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Biochemical indices to assess
specific nutritional status
Vitamins:
Fat soluble: S- A, D, E (K as INR)
Water soluble: S-B12,S/B- folate (S/WBC-C, B1, B6…)
Electrolytes
(t)U-Na, U-K, U-Cl
Protein
tU-N: Low: Starvation / chronic inadequate intake
High: Excess dietary protein,
catabolism/inflammation
tU-urea (≈80% of U-N), tU-creatinine (≈2kg muscle/mmol)
Minerals
tU-Mg, (tU-Ca),tU-I2, S-Zn, S-Se, S-Ferritin/ Fe+TIBC
(t)U-Na<10 mmol/l = Na-depletion
Low urine excretion values indicate depletion
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Biochemical indices as
acute phase reactants (APR)
Positive APR:
CRP [t½ 0.8d]
Orosmucoid
Fibrinogen
Ferritin
Negative APR:
Albumin
Prealbumin/
transthyretin
RBP
Transferrin /TIBC
Fe
IGF1
Abnormal indices could be driven by inflammation
rather than malnutrition – allways check CRP!
Kushner NEJM 1999
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Ellegård et al Ann Surg
1997:225:89-96
Serum levels of IGF-1
in SBS patients during 4 days
of nutrition therapy
on a metabolic ward
0
50
100
150
200
250
300
Pre-MW Post-MW
IGF-1 ug/l
P<0.05
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Plank, Ellegård & Hill unpublished
0
5
10
15
20
25
30
35
40
45
50
-3 4 11 18 25
CR
P m
g/l
Serum levels of IGF-1 and CRP
in major abdominal surgery
0
50
100
150
200
250
300
-3 4 11 18 25
ug
/l
Days
Op
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Effects of inflammation on serum
levels of vitamins and minerals
O
Blood test Reference CRP<15 CRP> 100 mg/l
Fe 18-30umol/l - 40% -60-90%
Zn (Ca, Mg) 11-17umol/l -10% -40-60%
Se 0,8-2 umol/l -10% -40-60%
Cu 10-24 umol/l +10% + 30%
Vit A 1-2,8 umol/l -40% -40%
Vit E 15-40 umol/l = -30%
Vit B12 110-600pmol/l = = (no change)
Folate 5-30nmol/l = =
β-carotene 90-300ug/l -50% -90%
Galloway, P. McMillan, D C. Sattar, N. Ann Clin Biochem 2000:37:289-97
Effect of the inflammatory response on trace element and vitamin status
Albumin-
bound!
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Summary
• Malnutrition could be detected by several
biochemical indices
• Most of these (serum) indices are severely
affected by acute or chronic inflammatory
responses
• Biochemical indices of malnutrition must
be related to the extent of APR, e g by CRP
• If APR is present, malnutrition might better
be diagnosed by antropometry/ body
composition methods
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