Protein/Calorie Malnutrition
I have a patient who meets criteria for severe protein-calorie malnutrition according to ASPEN criteria yet has normal protein and albumin levels. The doctor is agreeing with 'malnutrition' but not protein malnutrition because of the lab values. Am I wrong to say the lab values don't negate presence of p/c malnutrition? I actually don't see a code for severe malnutrition that is not protein/calorie. Thoughts?
Thank you,
Betty
Comments
Pre-albumin Levels may be increased in the setting of renal dysfunction, corticosteroid therapy, or dehydration
https://www.medscape.com/viewarticle/474066_6.
Albumin has a half life that is generally regarding as being too long to be of much use within the time frame of an average hospitalization, but could provide some pre-admit baseline. No single lab can determine the presence of absence of the nutritional status of a patient, particularly during an acute illness and up to 20% to 50% of all hospitalized patients have some degree of malnutrition.
Here is an interesting study which concludes: "In otherwise healthy patients who are chronically or acutely undernourished, serum albumin and prealbumin levels have no value as “markers of nutritional status” that can identify undernutrition and the need for feeding. These serum measures remain normal until starvation is obvious by history (eg, prolonged fasting), physical examination (eg, BMI below 12), or both."
https://www.amjmed.com/article/S0002-9343(15)00354-X/pdf
There is also an interesting commentary that identifying patients who exhibit markers of malnutrition and identifying patients who would actually BENEFIT from increased nutritional therapy are two different things. IE....outcomes are not statistically improved for some sub sets of obviously malnourished patients such as cancer and dementia vs standard care. "We hypothesize that low serum albumin and prealbumin levels, in contrast, identify a group of patients who will be unable to benefit from nutrition support." which i thought very interesting in this debate. They actually postulate that the since diagnosis usually = treatment, the diagnosis is unnecessary in these groups since increased focus on treatment will have no impact...something which i sort of disagree with. "In patients with significant injury or illness, nutritional assessment is complex because of the similarities between inflammatory illness and undernutrition; there is no reason to believe that these measures identify patients who could benefit from nutrition support. Meaningful nutrition assessment of patients who are sick can be developed only when clinical trials of nutrition support show benefit for particular groups of patients.".. That line of thinking does not take into account the fact that it HAS been shown to be a huge predictor of outcomes with regards to risk of mortality but i digress.
The summary reiterates, "In summary, in healthy patients, serum albumin and prealbumin levels are useless as markers of nutritional status: they fail to identify those who are starving."
Keep in mind that GLIM criteria does acknowledge inflammatory and acute disease processes (two things known to reduce protein stores) in the risk assessment of outcomes in nutritional at risk patients.