Nutritional status is the current body status, of a person

or a population group, related to their state of nourishment 2. Indirect Methods

(the consumption and utilization of nutrients). - use community indices that reflect the
community nutritional status/needs.
- determined by a complex interaction between
• Ecological variables including agricultural crops
internal/constitutional factors and external
production
environmental factors:
• Economic factors e.g. household income, per
• Internal / constitutional factors: age, sex, nutrition,
capita income, population density, food
behavior, physical activity and diseases.
availability and prices
• External / environmental factors: food safety,
• Cultural and social habits
cultural, social and economic circumstances.
• Vital health statistics: morbidity, mortality and
An ideal nutritional status occurs when the supply of other health indicators e.g., infant and under-
nutrients conforms to the nutritional requirements or fives mortality, Utilization of maternal and child
needs. Nutrient intake Requirements health care services, fertility indices and sanitary
conditions
Diets are rated in quality according to the balance of
nutrients they provide, and not solely on the type of food Direct Methods of Nutritional Assessment
eaten or the amount of caloric intake.
1. Anthropometric Methods
People can have an optimal nutritional status or they can
Anthropometry is the measurement of body height,
be under-, over- and/or malnourished. Severe underweight
weight & proportions.
(Under-nourished) Healthy baby (Optimal nutritional
- an essential component of clinical examination of
status) Morbid Obesity (Over-nourished)
infants, children & pregnant women.
The nutritional status of an individual has consequences: - These measurements are compared to the reference
data (standards) of the same age and sex group, in
• An optimal nutritional status is a powerful factor order to evaluate the nutritional status.
for health and well being . It is a major, modifiable - Although they indicate the nutritional status in
and powerful element in promoting health, general, still they are not used to identify specific
preventing and treating diseases and improving the nutritional deficiencies.
quality of life. - They are used to evaluate both under & over
• Malnutrition may increase risk of (susceptibility nutrition.
to) infection and chronic diseases : - The measured values reflect the current nutritional
- undernutrition may lead to increased status & don’t differentiate between acute & chronic
infections and decreases in physical and mental changes.
development
- overnutrition may lead to obesity as well as to Other anthropometric Measurements
metabolic syndrome or type 2 diabetes. 1. Mid-arm circumference
2. Skin fold thickness
Purpose of nutritional assessment 3. Head circumference
1. Identify individuals or population groups at risk of 4. Head/chest ratio Hip/waist ratio
becoming malnourished Measurements for adults Height measurement
2. Identify individuals or population groups who are - The subject stands erect & bare footed on a
malnourished stadiometer with a movable head piece. The head
3. To develop health care programs that meet the piece is leveled with skull vault & the height is
community needs which are defined by the recorded to the nearest 0.5 cm.
assessment
4. To measure the effectiveness of the nutritional Weight measurement
programs & interventions once initiated - Use a regularly calibrated electronic or balanced-
beam scale. Spring scales are less reliable. Weigh in
Methods of Nutritional Assessment Nutrition light clothes, no shoes. Read to the nearest 100 gm
1. Direct Methods (0.1kg)
- deal with individual & measure objective criteria Nutritional Indices in Adults
Anthropometric methods
Biochemical laboratory methods 1. The international standard for assessing body size in
Clinical methods adults is the body mass index (BMI).
Dietary evaluation methods
1
Evidence shows that high BMI (obesity level) is Low risk moderate high
associated with type 2 diabetes & high risk of Men <0.95 0.95-1.00 >1.00
cardiovascular morbidity & mortality Women <0.80 0.80-0.85 >0.85

BMI = Weight (kg)/ Height (m²) i.e. waist measurement > 80% of hip measurement for
Ex: Weight = 68 kg, Height = 165 cm (1.65 m) BMI = 68 women and > 95% for men indicates central (upper body)
÷ (1.65) 2 = 24.98 kg/ m² obesity and is considered high risk for diabetes & CVS
disorders. A WHR below these cut-off levels is considered
Interpretation of BMI for adults low risk.
For adults 20 years old and older, BMI is interpreted using Body Mass Index for Children and Teens
standard 7777eight status categories that are the same for criteria used to interpret the meaning of the BMI number
all ages, and for both men and women. for children and teens are different from those used for
adults. For children and teens, BMI age- and sex-specific
percentiles are used for two reasons: The amount of body
fat changes with age. The amount of body fat differs
between girls and boys.

2. Waist circumference is measured at the level of the

umbilicus to the nearest 0.5 cm.
- The subject stands erect with relaxed abdominal Underwater weighing- hydrodensitometry
muscles, arms at the side, and feet together. The For: body composition analysis, obesity research, athletic
measurement should be taken at the end of a performance, cachexia, Sarcopenia, eating disorders.
normal expiration. To perform hydrostatic weighing, a person is first weighed
- predicts mortality better than any other in the air while standing on a regular scale.
anthropometric measurement. While sitting on a special scale, they are lowered
• Level 1 is the maximum acceptable waist underwater and asked to expel all the air from their lungs
circumference irrespective of the adult age, and and remain motionless while the underwater weight is
there should be no further weight gain. measured
• Level 2 denotes obesity and requires weight • This procedure is repeated three times and averaged.
management to reduce the risk of type 2 diabetes & DEXA – Dual Energy X-ray Absorptiometry
CVS complications. BodPod –Air displacement plethysmography

Male Female
Level 1 >94cm >80cm
Level 2 >102cm >88cm

3. Hip Circumference is measured at the point of

greatest circumference around hips & buttocks to
the nearest 0.5 cm.
- The subject should be standing.
- Both measurements (Waist and hip) should be taken
with a flexible, non-stretchable tape in close contact
with the skin, but without indenting the soft tissue. Advantages of Anthropometry
Interpretation of Waist / Hip ratio (WHR) • Objective with high specificity & sensitivity
Ideal value (health and fertility): men: 0.9 • Measures many variables of nutritional significance
women: 0.7 (Ht, Wt, MAC, HC, skin fold thickness, waist & hip
High risk WHR= > 0.80 for females; > 0.95 for males ratio & BMI).

2
 • Readings are numerical & gradable on standard LIVER FUNCTION TEST
growth charts Component Abbrev Normal
• Readings are reproducible. Bilirubin Bili <21 µmol/l
• Non-expensive & need minimal training Alkaline phosphatase ALP 30-130 IU/l
Limitations of Anthropometry ɣ–glutamyl transpedtidase GGT 11-55 IU/l
• Inter-observers errors in measurement Alanine aminotransferase ALT 15-45 IU/l
• Limited nutritional diagnosis Aspartate aminotransferase AST 15-42 IU/l
• Problems with reference standards, i.e. local versus Albumin Alb 35-50 g/l
international standards. Globulin Glob 20-40 g/l
• Arbitrary statistical cut-off levels for what Total protein TP 60-80 g/l
considered as abnormal values. Haemoglobin Hb 135-185 g/l
Mean cell volume MCV 78-100 fl
2. Initial Laboratory Assessment
White cell count WCC 4-11 x109/l
Laboratory tests based on blood and urine can be Platelets Plts 140-400 x109/l
important indicators of nutritional status, but they are Prothrombin time PT 9-12 s
influenced by non-nutritional factors as well. International normalized ratio INR 0.9-1.2
- Lab results can be altered by medications, hydration Urea Urea 2.5-7.8 mg/dl
status, and disease states or other metabolic Creatinine Creat 60-110 µmol/l
processes, such as stress.
C-reactive protein CRP <5 mg/l
- As with the other areas of nutrition assessment,
biochemical data need to be viewed as a part of the
whole.
Hemoglobin estimation is the most important test &
useful index of the overall state of nutrition. Beside
anemia it also tells about protein & trace element
nutrition. Stool examination for the presence of ova
and/or intestinal parasites Urine dipstick & microscopy
for albumin, sugar and blood
Specific Lab Tests Measurement of individual nutrient in
body fluids (e.g. serum retinol, serum iron, urinary iodine,
vitamin D) Detection of abnormal amount of metabolites
in the urine (e.g. urinary creatinine/ hydroxyproline ratio)
Analysis of hair, nails & skin for micro-nutrients.
1.) Complete Blood Count (CBC) - anemia and infection
2) Liver Function Tests (LFTs) - Hepatic Dysfunction
3.) Kidney Function Tests (KFIs) - Renal Impairment
4.) Electrolyte Panel - Fluid and electrolyte balance
5.) Glucose and Lipid Profiles - Metabolic disorders
6.) Vitamin & Mineral Levels -Deficiencies(Vit. D &Iron)

3
 • Vitamin A Deficiency
• Beriberi Vitamin B1 (Thiamine) deficiency
• Vitamin B2 Deficiency (Ariboflavinosis)
• Pellagra Vitamin B3 ( Niacin) Deficiency
Clinical-4 D’s: Dermatitis, Diarrhea, Dementia,
Death
• Scurvy (Vitamin C Deficiency)
• Rickets (Vitamin D deficiency)
• Goitre (Iodine deficiency disorder)
• Marasmus Kwashiorkor Protein energy
malnutrition
• Protein-energy malnutrition (PEM)
• Marasmus
• Kwashiorkor
Advantages of Biochemical Methods
• It is useful in detecting early changes in body
metabolism & nutrition before the appearance of
overt clinical signs.
• It is precise, accurate and reproducible.
• Useful to validate data obtained from dietary
methods e.g. comparing salt intake with 24-hour
urinary excretion.
Limitations of Biochemical Methods
• Time consuming & Expensive
• They cannot be applied on large scale
• Needs trained personnel & facilities

3. Clinical assessment
- It is an essential feature of all nutritional surveys.
- It is the simplest & most practical method of
ascertaining the nutritional status of a group of
individuals.
- It utilizes a number of physical signs, (specific & non
specific), that are known to be associated with
malnutrition and deficiency of vitamins &
micronutrients.
- Good nutritional history should be obtained
- General clinical examination, with special attention
to organs like hair, angles of the mouth, gums, nails,
skin, eyes, tongue, muscles, bones & thyroid gland.
- Detection of relevant signs helps in establishing the
nutritional diagnosis
CLINICAL EXAMINATION
1.) General Appearance - overall nutritional status
2.) Muscle Mass - Muscle wasting or atrophy
3.) Body Fat Distribution - Central, Peripheral, or
visceral fat
4.) Edema - Fluid Retention or dehydration
5. Hair, skin, and Nail Changes

Examples of illnesses caused by improper nutrient

consumption

• Vitamin-A deficiency Xerophthalmia Bitot’s spot

4
 • Mini-Nutritional Assessment (MNA)2
- Sensitivity: 98.9 % ; Specifity: 94.3 %;
Diagnostic accuracy: 97.2 %
Clinical assessment ADVANTAGES
- Fast & Easy to perform
- Inexpensive
- Non-invasive
LIMITATIONS
- Did not detect early cases

4. Dietary assessment
Nutritional intake of humans is assessed by five
different methods:
1. 24 Hours Dietary Recall
- A trained interviewer asks the subject to recall all
food & drinks taken in the previous 24 hours.
- It is quick, easy & depends on short-term memory,
but may not be truly representative of the person’s
usual intake

2. Food Frequency Questionnaire

Validated screening test - in this method the subject is given a list of around
100 food items to indicate his or her intake
• MNA - Mini Nutritional Assessment (frequency & quantity) per day, per week & per
• MNA-S (Short Form) month.
• SGA - Subjective Global Assessment - It is inexpensive, more representative & easy to
• PG-SGA (Patient Generated) use.
• NRS - Nutritional Risk Screening - Limitations: Long questionnaire Errors with
• MUST - Malnutrition Universal Screening Tool estimating serving size. Needs updating with new
• Nottingham questionnaire commercial food products to keep pace with
changing dietary habits.
Recommended Patient Screening Tools
Based on guidelines of the:
3. Diet history
1.) European Society for Clinical Nutrition and
- aims to discover the usual food intake pattern of
Metabolism (ESPEN)
individuals over a relatively long period of time.
2.) American Society for Parenteral and Enteral
It is an interview method composed of two parts.
Nutrition (ASPEN)
- The first part establishes the overall eating
• Nutritional Risk Screening 2002 (NRS 2002)2
pattern and includes a 24hr recall: questions such
- Hospitalized patients
as “What did you have for breakfast yesterday?”
• Subjective Global Assessment (SGA)3
It covers 3 areas: coupled with “What do you usually have for
1. Medical History breakfast?” following through the entire day in
Weight change this way.
Dietary intake change
Gastrointestinal symptoms - Subjects are asked to estimate portion sizes in
Functional capacity household measures with the aid of standard
2. Physical examination
Loss of subcutaneous fat
spoons and cups, food photographs or food
Loss of muscle mass models.
Presence of oedema, ascites - The second part is known as the cross-check.
3. Subjective global assessment
A - Well nourished - This is a detailed list of foods that are checked
B - Mildly/Moderately Malnourished with the subject.
C - Severely Malnourished - Questions concerning food preferences,
The individual items are not point scored as the assessment is subjective. The results
of the medical history and physical examination are summarized in the „Subjective purchasing and the use of each food serve to verify
Global Assessment"
and clarify information given in the first part.
• Malnutrition Universal Screening Tool (MUST)2 - Questions about purchasing can also provide a
- Hospital and community settings check on portion estimates.
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 - Its advantage is that it estimates nutrient intakes • Plasma: liquid component of blood (water, blood
over a long period of time. proteins, inorganic electrolytes, clotting factors)
- Its disadvantages are that it takes about one hour • Erythrocytes: red blood cells
of careful questioning, and the interviewer must • Leukocytes: white blood cells
be a nutritionist or dietitian experienced in • Other tissues: scrapings and biopsy samples
obtaining diet histories. • Urine: random samples or timed collections
- The most common fault of an inexperienced • Feces: random samples or timed collections
interviewer is probably that of suggesting • Less common: saliva, nails, hair, sweat, breath tests
answers.
Routine Medical Laboratory Tests
4. Food Diary • Clinical chemistry panels
- Food intake (types & amounts) should be o Basic Metabolic Panel
recorded by the subject at the time of o Comprehensive Metabolic Panel
consumption. The length of the collection period • Complete Blood Count
range between 1-7 days. Reliable but difficult to • Urinanalysis
maintain. • Hydration Status
• Serum Proteins
5. Observed Food Consumption • Vitamin D
- The most unused method in clinical practice, but
it is recommended for research purposes. Basic Metabolic Panel
- The meal eaten by the individual is weighed and Glucose Chloride
contents are exactly calculated. Calcium BUN
- This method is characterized by having a high Sodium Creatinine
degree of accuracy but expensive & needs time & Potassium CO2 (bicarbonate)
efforts.
Comprehensive Metabolic Panel
Interpretation of Dietary Data Glucose Albumin
Calcium Total Protein
1. Qualitative Method - Using the food pyramid &
Sodium ALP
the basic food groups method. Different nutrients are
Potassium ALT
classified into 5 groups (fat & oils, bread & cereals, CO2 (bicarbonate) AST
milk products, meat-fish-poultry, vegetables & fruits) Chloride Bilirubin
- Determine the number of servings from each group BUN (blood urea Mag, phos, lipid panel may
& compare it with minimum requirements. nitrogen) also be ordered along with
Comp panel
2. Quantitative Method- The amount of energy &
Creatinine
specific nutrients in each food consumed can be
calculated using food composition tables & then
compare it with the recommended daily intake.
Laboratory Assessment and Nutrition Care Process
Objective measure: diagnose diseases, support nutrition
diagnoses, monitor medication effectiveness, and evaluate
NCP interventions. Many things are involved with
interpretation:
• Age
• Pt condition
• Medical condition
Interpretation with regard to nutrition can be tricky, but is
essential for the nutrition expert
Definition of Specimen Types
• Whole blood: Used when entire content of blood is
to be evaluated – no elements are removed
• Serum: The fluid obtained from blood after the
blood has been clotted and then centrifuged to
remove the clot and blood cells
6
Considerations regarding interpretation: Electrolytes Serum levels related to many factors
Hypocalcemia: 45% of serum calcium is bound to serum
1. Sodium (Na): 136 to 144 mEq/L
albumin. A one gram decrease in serum albumin results in
Hyponatremia: most common electrolyte abnormality in
~.8 mg decrease in serum calcium
hospitalized patients
Corrected calcium: measured serum calcium (4-serum
- Usually caused by excessive hypotonic IV fluid
albumin)
intake and/or gastrointestinal losses of sodium-rich
Ionized calcium (free calcium) is better measure of
fluids (gastric suctioning, diarrhea, high ileostomy
calcium status when albumin levels are low
output)
Hypercalcemia: rarely caused by excess calcium intake
- High serum glucose concentrations increase plasma
Common causes: malignancies, hyperparathyroidism,
osmolality to cause fluid shift from intracellular
immobilization
space to plasma – resulting in hyponatremia
Related to many factors including vitamin D status, renal
Hypernatremia: commonly the result of impaired water
function, phosphorus status, parathyroid function,
intake or relative water deficit
medications
2. Potassium: 3.5-5.5 mEq/L Serum Calcium = 8.1
(minimally affected by diet) Serum Albumin = 3.0
Hypokalemia: decreases can be seen in excessive GI Corrected Calcium = 8.1 + 0.8 (4.0-3.0) = 8.9
losses (diarrhea), intracellular shift during refeeding,
8. phosphorus (normal: 2.7-4.5 mg/dL)
medications (loop and thiazide diuretics increase K+
Serum phos a poor reflection of body stores because <1%
losses)
is in ECF
Hyperkalemia: decreased kidney function, medications
Bones serve as a reservoir
(potassium-sparing diuretics, cyclosporine, tacrolimus)
Hypophosphatemia: <2.7 mg/dL
- Never give potassium I.M or rapid I.V push.
- Impaired absorption (diarrhea, Vitamin D
- Never give more than 26.8meq/2gm KCI over 1
deficiency, impaired metabolism)
hour without any continuous ECG monitor.
- Medications: phosphate binding antacids,
- Do not just add the KCI solution to the hanging
sucralfate, insulin, corticosteroids)
I.V fluid bag. Fully invert it around 10 times to
- Alcoholism, especially during withdrawal
ensure proper mixing.
- Intracellular shifts such as in refeeding syndrome
- 1 tab(600mg) of( Slow K) gives around 8 mmol
- Increased losses: hyperparathyroidism, DKA
potassium.
recovery, hypomagnesemia
- Peripheral veins are damaged by a potassium
Hyperphosphatemia >4.5 mg/dLq
concentration greater than 30 mmol/L. For higher
- Decreased renal excretion: acute or chronic
concentrations, central lines are preferre
renal failure; hypoparathyroidism
Acid base disorders are usually caused by the patient’s
- Sign of excessive dietary intake in patients on
underlying diseases and clinical condition(s)
hemodialysis
3. Chloride: mEq/L - Increased cellular release: tissue necrosis, tumor
Hyperchloremic acidosis: may result from large and lysis syndrome
rapid infusion of normal saline fluids or significant - Increased exogenous phosphorus load or
bicarbonate losses from intestines or kidneys (can cause absorption, phosphorus containing laxatives or
chloride retention) enemas, vitamin D excess
9. Magnesium (normal: 1.3-2.5 mEq/L)
4. Bicarbonate or total Co2: 21-30mEq/L Magnesium homeostasis is maintained by the intestines,
Metabolic alkalosis (increase in bicarbonate): prolonged bone and the kidneys.
vomiting, high gastric fluid suctioning, potassium wasting Hypermagnesemia: decreased kidney function can cause
diuretic use magnesium accumulation
5. Blood Urea Nitrogen (BUN): 7-20mg/dL Hypomagnesemia: common causes include diarrhea,
Increased BUN: kidney disease, dehydration, excessive high ileostomy fluid losses, medications (loop and thiazide
protein catabolism diuretics, immunosuppressants)
Decreased BUN: liver failure, negative nitrogen balance, Adequate correction of hypomagnesemia essential for
pregnancy (2nd or 3rd trimester) correction of hypokalemia

6. Creatinine: 0.6-1.2 mg/dL Clinical Chemistry Panels:

Increased: poor kidney function
Decreased: malnutrition Complete Blood Count (CBC)
- Red blood cells
7. Calcium: 8.6-10 mg/dL - Hemoglobin concentration
7
 - Hematocrit Urinalysis - Screening or diagnostic tool to detect
- Mean cell volume (MCV) substances or cellular material in the urine associated with
- Mean cell hemoglobin (MCH) different metabolic and kidney disorders
- Mean cell hemoglobin concentration (MCHC) Often involves visual examination, dipstick test, and
- White blood cell count (WBC) microscopic examination
- Differential: indicates percentages of different
kinds of WBC • Acidity (pH): Abnormal pH levels may indicate a
kidney or urinary tract disorder.
NUTRITIONAL ANEMIA
• Concentration. A measure of concentration, or
Classification of Anemia- need to distinguish
specific gravity, shows how concentrated particles are
Iron deficiency anemia
in your urine. Higher than normal concentration often
• Microcytic anemia: most often association with
is a result of not drinking enough fluids.
true iron deficiency
• Protein: larger amounts may indicate a kidney
- Important discriminating features are a low serum
problem.
ferritin concentration, an increased total iron
• Sugar: Any detection of sugar on this test usually calls
binding capacity (transferrin), and low serum iron
for follow-up testing for diabetes.
concentration
• Ketones: Positive in poorly controlled DM, fever,
• Macrocyctic anemia: generally due to deficient
anorexia, starvation
utilization of folate or B12 by the blood cells
o Pernicious anemia: not enough red • Bilirubin: product of red blood cell breakdown.
blood cells due to lack of B12 Bilirubin in urine may indicate liver damage or
o Megaloblastic anemia: folate deficiency disease.
Anemia of chronic disease: (normocystic) does not • Evidence of infection: If either nitrites or leukocyte
respond to iron supplementation esterase — a product of white blood cells — is
detected in your urine, it may be a sign of a urinary
Tests for Iron Deficiency Anemias tract infection
• Hemoglobin and hematocrit: below normal in • Blood: it may be a sign of kidney damage, infection,
all nutritional anemias. kidney or bladder stones, kidney or bladder cancer, or
- Not sensitive for iron, vitamin B12, or folate blood disorders
deficiencies
- Are sensitive to hydration status Types of Assays
• Serum Ferritin: Primary intracellular Fe-storage, • Static assays: measures the actual level of the nutrient
serum levels parallel iron stores in the specimen (serum iron, white blood cell ascorbic
- Increases during inflammatory response even acid)
when iron stores are not adequate Do not reflect the amount of that substance stored
- Not useful in anemia of chronic disease in the body
• Serum Iron: reflects recent iron intake, very Highly influenced by recent dietary intake
insensitive index of total iron stores • Functional Assays: measure a biochemical or
• Total Iron Binding Capacity (TIBC): physiological activity that depends on the nutrient of
- Increases when iron stores are depleted interest (serum ferritin, TIBC)
are not always specific to the nutrient (many
• Transferrin Saturation: decreased when iron stores
biologic and physiologic functions involved)
depleted; low vitamin B6 and low transferrin
This might be changes in the activities of enzymes
saturation seen in aplastic anemia
dependent on a given nutrient
Aplastic anemia develops when damage occurs to your
bone marrow, slowing or shutting down the production of
Assessment of Hydration Status:
new blood cells.
Total body water: fluid that occupies the intracellular and
extracellular spaces
Tests for Macrocytic Anemias from B vitamin
Deficiencies • Intracellular fluid compartment: fluid within the
Folate and B12 tests are not sensitive or specific to actual cells of the body (~2/3)
levels • Extracellular fluid compartment: Body’s internal
Mean corpuscular volume or mean cell volume (MCV) environment & the cell’s external environment (~1/3)
is the average volume of red cells. 2 parts: interstitial fluid and plasma
- Decreased in iron deficiency • Interstitial fluid: fluid in the spaces between cells
- Increased in setting of vitamin B12 / folate deficiency • Plasma: fluid portion of the blood

8
The distribution of body water varies under different - The initial movement of fluid from the vascular
circumstances. It is usually remains fairly constant space into the interstitium reduces the plasma
Water consumed during the day (food, drink) is balanced volume, and consequently reduces tissue perfusion.
by water lost (urination, perspiration, feces, respiration) - In response to these changes, the kidney retains
sodium and water.
General Principles of disorders of water balance - Some of this fluid stays in the vascular space,
Disorders of water balance and sodium balance are returning the plasma volume toward normal.
common, but the pathophysiology is frequently However, the alteration in capillary hemodynamics
misunderstood results in most of the retained fluid entering the
Example: plasma sodium concentration is regulated by interstitium and eventually becoming apparent as
changes in water intake and excretion, not by changes in edema
sodium balance. Many factors affect serum albumin levels. more than
• hyponatremia is primarily due to the intake of water 50% is located extravascularly (outside of the blood
that cannot be excreted (too much water or vessels). Majority of the body’s albumin is distributed
overhydration) between the vascular and interstitial spaces
• hypernatremia is primarily due to the loss of water protein intake has very little effect on total albumin on a
that has not been replaced daily basis
• hypovolemia represents the loss of sodium and water Very little of the body’s albumin pool is comprised of
• edema is primarily due to sodium and water retention newly synthesized albumin. Hydration status being a
major factor
Hypovolemia Many factors affect serum albumin levels
- In a variety of clinical disorders, fluid losses reduce Albumin is a serum protein with a relatively large body
extracellular fluid volume, potentially pool size, and ~5% of which is synthesized in the liver
compromising tissue perfusion daily.
• Volume depletion results from loss of sodium and Many factors affect serum albumin levels. Serum
water from the following anatomic sites: proteins are affected by capillary permability, drugs,
• Gastrointestinal losses, including vomiting, impaired liver function, and inflammation among other
diarrhea, bleeding, and external drainage factors.
• Renal losses, including the effects of diuretics, Hydration status is a major factor with albumin
osmotic diuresis, salt-wasting nephropathies, and
Albumin: Negative Acute Phase Protein
hypoaldosteronism
Increased in: Dehydration, Marasmus, Blood
• Skin losses, including sweat, burns, and other transfusions, Exogenous albumin
dermatological conditions Decreased in: Fluid overload/ascites, Hepatic failure,
• Third-space sequestration, including intestinal CHF, Protein losing states, Nephrotic syndrome,
obstruction, crush injury, fracture, and acute Inflammation/infection/metabolic stress,
pancreatitis Burns/trauma/post-op, Kwashiokor, Cancer,
Edema (hypervolemia) Corticosteroid use.
- a palpable swelling produced by expansion of the Redistribution of albumin between the extravascular and
interstitial fluid volume. intravascular space occurs frequently. This is affected by
- A variety of clinical conditions are associated with infusion of large amounts of fluid
the development of edema: These are negative acute phase proteins, levels will be
• heart failure decreased during the acute phase response
• Cirrhosis Albumin has a long half life = days
• nephrotic syndrome
Vitamin D
An increase in interstitial fluid volume that could lead to
25HD (25-Hydroxyvitamin D)- The best laboratory
edema does not occur in normal subjects because of the
indicator of vitamin D
tight balance of hemodynamic forces along the capillary
- Vitamin D deficiency: < 20 ng/mL
wall and the function of the lymphatic vessels. For
- Vitamin D insufficiency: < 30 ng/mL
generalized edema to occur, two factors must be present:
- Vitamin D toxicity: > 150 ng/mL
- An alteration in capillary hemodynamics that
- Optimal serum 25 HD levels: 30 – 80 ng/mL
favors the movement of fluid from the vascular
space into the interstitium
- The retention of dietary or intravenously
administered sodium and water by the kidneys