evaluation of laboratory data in nutrition assessment cinda s. chima, ms, rd

Evaluation of Laboratory Data in

Nutrition Assessment

Cinda S. Chima, MS, RD

Laboratory Data and the NCP• Used in nutrition assessment (a clinical Used in nutrition assessment (a clinical

sign supporting nutrition diagnosis)sign supporting nutrition diagnosis)• Used in Monitoring and Evaluation of Used in Monitoring and Evaluation of

the patient response to nutritional the patient response to nutritional interventionintervention

Specimen Types• Serum: the fluid from blood after blood cells and Serum: the fluid from blood after blood cells and

clot removedclot removed• Plasma: fluid from blood centrifuged with Plasma: fluid from blood centrifuged with

anticoagulantsanticoagulants• Erythrocytes: red blood cellsErythrocytes: red blood cells• Leukocytes: white blood cellsLeukocytes: white blood cells• Other tissues: scrapings and biopsy samplesOther tissues: scrapings and biopsy samples• Urine: random samples or timed collectionsUrine: random samples or timed collections• Feces: random samples or timed collectionsFeces: random samples or timed collections• Less common: saliva, nails, hair, sweatLess common: saliva, nails, hair, sweat

Interpretation of Routine Medical Laboratory Tests

• Clinical Chemistry PanelsClinical Chemistry Panels• Basic metabolic panelBasic metabolic panel• Comprehensive metabolic panelComprehensive metabolic panel

• Complete blood countComplete blood count• UrinalysisUrinalysis• Hydration statusHydration status

Clinical Chemistry Panels: Basic Metabolic Panel (BMP)

Also called Chem 7Also called Chem 7

IncludesIncludes• Electrolytes: Na+, K+, Cl-, HCO3 or Electrolytes: Na+, K+, Cl-, HCO3 or

total CO2total CO2• GlucoseGlucose• CreatinineCreatinine• BUNBUN

Basic Metabolic Panel Charting Shorthand

BMPBMP

NaNa ClCl BUNBUN

glucoseglucose

K+K+ CO2CO2 CreatinineCreatinine

Clinical Chemistry Panels:Comprehensive Metabolic Panel

Includes Includes • BMP except CO2BMP except CO2• AlbuminAlbumin• Serum enzymes (alkaline phosphatase, AST Serum enzymes (alkaline phosphatase, AST

[SGOT], ALT [SGPT][SGOT], ALT [SGPT]• Total bilirubinTotal bilirubin• Total calciumTotal calcium

Phosphorus, total cholesterol and triglycerides Phosphorus, total cholesterol and triglycerides often ordered with the CMPoften ordered with the CMP

Clinical Chemistry Panels: Complete Blood Count (CBC)

• Red blood cellsRed blood cells• Hemoglobin concentrationHemoglobin concentration• HematocritHematocrit• Mean cell volume (MCV)Mean cell volume (MCV)• Mean cell hemoglobin (MCH)Mean cell hemoglobin (MCH)• Mean cell hemoglobin concentration (MCHC)Mean cell hemoglobin concentration (MCHC)• White blood cell count (WBC)White blood cell count (WBC)• Differential: indicates percentages of different Differential: indicates percentages of different

kinds of WBCkinds of WBC

Clinical Chemistry Panels: Urinalysis

Specific gravitySpecific gravity 1.010-1.025 mg/ml1.010-1.025 mg/ml

pHpH 6-8 (normal diet)6-8 (normal diet)

ProteinProtein 2-8 mg/dl2-8 mg/dl

GlucoseGlucose Not detectedNot detected

KetonesKetones NegativeNegative

BloodBlood NegativeNegative

BilirubinBilirubin Not detectedNot detected

UrobilinogenUrobilinogen 0.1-1 units/dl0.1-1 units/dl

NitriteNitrite NegativeNegative

Leukocyte esterageLeukocyte esterage Negative Negative

Types of Assays• Static assays: measures the actual level of Static assays: measures the actual level of

the nutrient in the specimen (serum iron, the nutrient in the specimen (serum iron, white blood cell ascorbic acid)white blood cell ascorbic acid)

• Functional Assays: measure a Functional Assays: measure a biochemical or physiological activity that biochemical or physiological activity that depends on the nutrient of interest (serum depends on the nutrient of interest (serum ferritin, TIBC)ferritin, TIBC)• (Functional assays are not always (Functional assays are not always

specific to the nutrient) specific to the nutrient)

Assessment of Nutrient Pool

Assessment of Hydration Status

• Dehydration: a state of negative fluid balance Dehydration: a state of negative fluid balance caused by decreased intake, increased losses, or caused by decreased intake, increased losses, or fluid shiftsfluid shifts

• Overhydration or edema: increase in extracellular Overhydration or edema: increase in extracellular fluid volume; fluid shifts from extracellular fluid volume; fluid shifts from extracellular compartment to interstitial tissuescompartment to interstitial tissues• Caused by increase in capillary hydrostatic Caused by increase in capillary hydrostatic

pressure or permeabilitypressure or permeability• Decrease in colloid osmotic pressureDecrease in colloid osmotic pressure• Physical inactivityPhysical inactivity

• Use laboratory and clinical data to evaluate ptUse laboratory and clinical data to evaluate pt

Hypovolemia

Isotonic fluid loss from the extracellular space Isotonic fluid loss from the extracellular space caused bycaused by

• Fluid loss (bleeding, fistulas, nasogastric drainage, Fluid loss (bleeding, fistulas, nasogastric drainage, excessive diuresis, vomiting and diarrhea)excessive diuresis, vomiting and diarrhea)

• Reduced fluid intakeReduced fluid intake• Third space fluid shift, when fluid moves out of Third space fluid shift, when fluid moves out of

the intravascular space but not into intracellular the intravascular space but not into intracellular space (abdominal cavity, pleural cavity, space (abdominal cavity, pleural cavity, pericardial sac) caused by increased permeability pericardial sac) caused by increased permeability of the capillary membrane or decrease on plasma of the capillary membrane or decrease on plasma colloid osmotic pressurecolloid osmotic pressure

Symptoms of Hypovolemia

• Orthostatic Hypotension (caused by change in Orthostatic Hypotension (caused by change in position)position)

• Central venous and pulmonary pressures Central venous and pulmonary pressures • Increased heart rateIncreased heart rate• Rapid weight lossRapid weight loss• Decreased urinary outputDecreased urinary output• Patient cool, clammyPatient cool, clammy• Decreased cardiac outputDecreased cardiac output• Ask the medical team!!Ask the medical team!!

Treatment of Hypovolemia

• Replace lost fluids with fluids of similar Replace lost fluids with fluids of similar concentrationconcentration

• Restores blood volume and blood pressureRestores blood volume and blood pressure• Usually isotonic fluid like normal saline or Usually isotonic fluid like normal saline or

lactated Ringer’s solution given IVlactated Ringer’s solution given IV

Hypervolemia

• Excess of isotonic fluid (water and sodium) Excess of isotonic fluid (water and sodium) in the extracellular compartmentin the extracellular compartment

• Osmolality is usually not affected since Osmolality is usually not affected since fluid and solutes are gained in equal fluid and solutes are gained in equal proportionproportion

• Elderly and those with renal and cardiac Elderly and those with renal and cardiac failure are at riskfailure are at risk

Causes of Hypervolemia

• Results from retention or excessive intake of Results from retention or excessive intake of fluid or sodium or shift in fluid from fluid or sodium or shift in fluid from interstitial space into the intravascular spaceinterstitial space into the intravascular space

• Fluid retention: renal failure, CHF, cirrhosis of Fluid retention: renal failure, CHF, cirrhosis of the liver, corticosteroid therapy, the liver, corticosteroid therapy, hyperaldosteronismhyperaldosteronism

• Excessive intake: IV replacement tx using Excessive intake: IV replacement tx using normal saline or Lactated Ringer’s, blood or normal saline or Lactated Ringer’s, blood or plasma replacement, excessive salt intakeplasma replacement, excessive salt intake

Causes of Hypervolemia

• Fluid shifts into vasculature caused by Fluid shifts into vasculature caused by remobilization of fluids after burn tx, remobilization of fluids after burn tx, administration of hypertonic fluids, use of administration of hypertonic fluids, use of colloid oncotic fluids such as albumincolloid oncotic fluids such as albumin

Symptoms of Hypervolemia

• No single diagnostic test, so signs and symptoms No single diagnostic test, so signs and symptoms are keyare key

• Cardiac output increases Cardiac output increases • Pulse rapid and boundingPulse rapid and bounding• BP, CVP, PAP and pulmonary artery wedge BP, CVP, PAP and pulmonary artery wedge

pressure risepressure rise• As the heart fails, BP and cardiac output dropAs the heart fails, BP and cardiac output drop• Distended veins in hands and neckDistended veins in hands and neck

Symptoms of Hypervolemia

• Anasarca: severe, generalized edemaAnasarca: severe, generalized edema• Pitting edema: leaves depression in skin when Pitting edema: leaves depression in skin when

touchedtouched• Pulmonary edema: crackles on auscultationPulmonary edema: crackles on auscultation• Patient SOB and tachypneicPatient SOB and tachypneic• Labs: low hematocrit, normal serum sodium, Labs: low hematocrit, normal serum sodium,

lower K+ and BUN (or if high, may mean renal lower K+ and BUN (or if high, may mean renal failure)failure)

• ABG: low O2 level, PaCO2 may be low, ABG: low O2 level, PaCO2 may be low, causing drop in pH and respiratory alkalosiscausing drop in pH and respiratory alkalosis

Treatment of Hypervolemia

• Restriction of sodium and fluid intake Restriction of sodium and fluid intake • Diuretics to promote fluid loss; morphine Diuretics to promote fluid loss; morphine

and nitroglycerine to relieve air hunger and and nitroglycerine to relieve air hunger and dilate blood vessels; digoxin to strengthen dilate blood vessels; digoxin to strengthen heart heart

• Hemodialysis or CAVHHemodialysis or CAVH

Dehydration

• Excessive loss of free waterExcessive loss of free water• Loss of fluids causes an increase in the Loss of fluids causes an increase in the

concentration of solutes in the blood (increased concentration of solutes in the blood (increased osmolality)osmolality)

• Water shifts out of the cells into the bloodWater shifts out of the cells into the blood• Causes: prolonged fever, watery diarrhea, failure Causes: prolonged fever, watery diarrhea, failure

to respond to thirst, highly concentrated feedings, to respond to thirst, highly concentrated feedings, including TFincluding TF

Symptoms of Dehydration

• ThirstThirst• FeverFever• Dry skin and mucus membranes, poor skin turgor, Dry skin and mucus membranes, poor skin turgor,

sunken eyeballssunken eyeballs• Decreased urine outputDecreased urine output• Increased heart rate with falling blood pressureIncreased heart rate with falling blood pressure• Elevated serum osmolality; elevated serum Elevated serum osmolality; elevated serum

sodium; high urine specific gravitysodium; high urine specific gravity

Treatment of Dehydration

• Use hypotonic IV solutions such as D5WUse hypotonic IV solutions such as D5W• Offer oral fluids Offer oral fluids • Rehydrate graduallyRehydrate gradually

Laboratory Values and Hydration: BUNLab TestLab Test Hypo-Hypo-

volemiavolemiaHyper-Hyper-volemiavolemia

Other factors influencing Other factors influencing resultresult

BUNBUN

Normal: Normal: 10-20 10-20 mg/dlmg/dl

IncreasesIncreases DecreasesDecreases Low: inadequate dietary Low: inadequate dietary protein, severe liver protein, severe liver failurefailure

High: prerenal failure; High: prerenal failure; excessive protein intake, excessive protein intake, GI bleeding, catabolic GI bleeding, catabolic state; glucocorticoid state; glucocorticoid therapytherapy

Creatinine will also rise Creatinine will also rise in severe hypovolemiain severe hypovolemia

Adapted from Charney and Malone. ADA Pocket Guide to Nutrition Assessment, 2004.

Laboratory Values and Hydration Status: BUN:Creatinine RatioLab TestLab Test Hypo-Hypo-


Other factors Other factors influencing resultinfluencing result

BUN: BUN: creatinine creatinine ratioratio

Normal: Normal: 10-15:110-15:1

IncreasesIncreases DecreasesDecreases Low: inadequate dietary Low: inadequate dietary protein, severe liver protein, severe liver failurefailure

High: prerenal failure; High: prerenal failure; excessive protein intake, excessive protein intake, GI bleeding, catabolic GI bleeding, catabolic state; glucocorticoid state; glucocorticoid therapytherapy


Laboratory Values and Hydration: HCTLab TestLab Test Hypo-Hypo-



Hemato-Hemato-critcrit

Normal: Normal:

Male: Male:

42-52%42-52%

Female: Female: 37-47%37-47%

IncreasesIncreases DecreasesDecreases Low: anemia, hemorrhage Low: anemia, hemorrhage with subsequent with subsequent hemodilution (occurring hemodilution (occurring after approximately 12-24 after approximately 12-24 hours)hours)

High: chronic hypoxia High: chronic hypoxia (chronic pulmonary (chronic pulmonary disease, living at high disease, living at high altitude, heavy smoking, altitude, heavy smoking, recent transfusion) recent transfusion)


Laboratory Values and Hydration: Alb, Na+Lab TestLab Test Hypo-Hypo-



Serum Serum albuminalbumin

Low: malnutrition; acute Low: malnutrition; acute phase response, liver phase response, liver failurefailure

High: rare except in High: rare except in hemoconcentrationhemoconcentration

Serum Serum sodiumsodium

Typical-Typical-ly ly can be can be normal normal or or

, normal , normal or or

Serum sodium generally Serum sodium generally reflects fluid status and not reflects fluid status and not sodium balancesodium balance


Laboratory Values and Hydration StatusLab TestLab Test

normalnormal

Hypo-Hypo-volemiavolemia

Hyper-Hyper-volemiavolemia


Serum Serum osmolalityosmolality

(285-295 (285-295 mosm/kg)mosm/kg)

Typically Typically but can be but can be normal or normal or

Typically Typically but can but can be normal be normal or or

Urine sp. Urine sp. GravityGravity

1.003-1.0301.003-1.030

Urine Urine osmolality osmolality (200-1200 (200-1200 mosm/kg)mosm/kg)

Low: diuresis, Low: diuresis, hyponatremia, sickle cell hyponatremia, sickle cell anemiaanemia

High: SIADH, azotemia, High: SIADH, azotemia,


Laboratory Values and Hydration Status

Lab TestLab Test Hypo-Hypo-volemiavolemia

Hyper-Hyper-volemiavolemia


Serum Serum albuminalbumin

Low: malnutrition; acute Low: malnutrition; acute phase response, liver phase response, liver failurefailure

High: rare except in High: rare except in hemoconcentrationhemoconcentration

Serum Serum sodiumsodium

Typically Typically can be can be normal or normal or

, , normal normal or or


Hypokalemia (K+< 3.5 mEq/L)

• ↑ ↑ renal losses (diuresis)renal losses (diuresis)• ↑ ↑ GI losses (diarrhea, vomiting, fistula)GI losses (diarrhea, vomiting, fistula)• K+ wasting meds (thiazide and loop K+ wasting meds (thiazide and loop

diuretics, etc)diuretics, etc)• Shift into cells (anabolism, refeeding, Shift into cells (anabolism, refeeding,

correction of glucosuria or DKA)correction of glucosuria or DKA)• Inadequate intakeInadequate intake

Hyperkalemia (K+>5.0 mEq/L)

• Decreased renal excretion as in acute or Decreased renal excretion as in acute or chronic renal failurechronic renal failure

• Medications, e.g. potassium sparing Medications, e.g. potassium sparing diuretics, beta blockers, ACE inhibitorsdiuretics, beta blockers, ACE inhibitors

• Shift out of cells (acidosis, tissue necrosis, Shift out of cells (acidosis, tissue necrosis, GI hemorrhage, hemolysis)GI hemorrhage, hemolysis)

Serum Calcium

• Normal serum 9.0-10.5 mg/dL (includes Normal serum 9.0-10.5 mg/dL (includes ionized calcium and calcium bound to ionized calcium and calcium bound to protein, primarily albumin, and ions)protein, primarily albumin, and ions)

• Ionized calcium: 4.5-5.6 mg/dLIonized calcium: 4.5-5.6 mg/dL• Normal levels maintained by hormonal Normal levels maintained by hormonal

regulation using skeletal reservesregulation using skeletal reserves• Ionized calcium is more accurate, especially Ionized calcium is more accurate, especially

in pt with hypoalbuminemia; evaluate in pt with hypoalbuminemia; evaluate before repleting Ca+before repleting Ca+

Charney and Malone, 2004, p. 89

Hypocalcemia (serum calcium <9.0 mg/dL; ionized Ca+ <4.5 mg/dL)• HypoalbuminemiaHypoalbuminemia• HypoparathyroidismHypoparathyroidism• HypomagnesemiaHypomagnesemia• Renal failure, renal tubular necrosisRenal failure, renal tubular necrosis• Vitamin D deficiency or impaired Vitamin D deficiency or impaired

metabolismmetabolism

Hypercalcemia (serum calcium >10.5 mg/dL; ionized Ca+ >5.6 mg/dL)

• HyperparathyroidismHyperparathyroidism• Some malignancies, especially breast, lung, Some malignancies, especially breast, lung,

kidney; multiple myeloma, leukemia, kidney; multiple myeloma, leukemia, lymphomalymphoma

• Medications: thiazide diuretics, lithium, Medications: thiazide diuretics, lithium, vitamin A toxicityvitamin A toxicity

• ImmobilizationImmobilization• HyperthyroidismHyperthyroidism


Serum Phosphorus (normal 3.0-4.5 mg/dL)• Serum phos a poor reflection of body stores Serum phos a poor reflection of body stores

because <1% is in ECFbecause <1% is in ECF• Bones serve as a reservoirBones serve as a reservoir

Hypophosphatemia (<3.0 mg/dL)

• Impaired absorption (diarrhea, Vitamin D Impaired absorption (diarrhea, Vitamin D deficiency, impaired metabolism)deficiency, impaired metabolism)

• Medications: phosphate binding antacids, Medications: phosphate binding antacids, sucralfate, insulin, steroids)sucralfate, insulin, steroids)

• Alcoholism, especially during withdrawalAlcoholism, especially during withdrawal• Intracellular shifts in alkalosis, anabolism, Intracellular shifts in alkalosis, anabolism,

neoplasmsneoplasms• Refeeding syndromeRefeeding syndrome• Increased losses: hyperparathyroidism, renal Increased losses: hyperparathyroidism, renal

tubular defects, DKA recovery, hypomagnesemia, tubular defects, DKA recovery, hypomagnesemia, diuretic phase of ATN diuretic phase of ATN


Hyperphosphatemia (>4.5 mg/dL)

• Decreased renal excretion: acute or chronic renal Decreased renal excretion: acute or chronic renal failure (GFR<20-25 mL/min); failure (GFR<20-25 mL/min); hypoparathyroidismhypoparathyroidism

• Increased cellular release: tissue necrosis, tumor Increased cellular release: tissue necrosis, tumor lysis syndromelysis syndrome

• Increased exogenous phosphorus load or Increased exogenous phosphorus load or absorption, phosphorus containing laxatives or absorption, phosphorus containing laxatives or enemas, vitamin D excessenemas, vitamin D excess

• AcidosisAcidosis

Hypomagnesemia <1.3 mEq/L (normal 1.3-2.1 mEq/L)• Decreased absorption: prolonged diarrhea, intestinal or Decreased absorption: prolonged diarrhea, intestinal or

biliary fistula, intestinal resection or bypass, steatorrhea, biliary fistula, intestinal resection or bypass, steatorrhea, ulcerative colitis; upper GI fluid loss, gastric suctioning, ulcerative colitis; upper GI fluid loss, gastric suctioning, vomitingvomiting

• Renal losses: osmotic diuresis, DM with glucosuria, Renal losses: osmotic diuresis, DM with glucosuria, correction of DKA, renal disease with magnesium wasting, correction of DKA, renal disease with magnesium wasting, hypophosphatemia, hypercalcemia, hyperthyroidismhypophosphatemia, hypercalcemia, hyperthyroidism

• AlcoholismAlcoholism• Inadequate intake: malnutritionInadequate intake: malnutrition• MedicationsMedications• Intracellular shift: acute pancreatitisIntracellular shift: acute pancreatitis• Refeeding syndromeRefeeding syndrome

Hypermagnesemia (>2.1 mEq/L)

• Acute or chronic renal failureAcute or chronic renal failure

Assessment for Protein-Calorie Malnutrition• Hormonal and cell-mediated response Hormonal and cell-mediated response

to stressto stress• Negative acute-phase respondentsNegative acute-phase respondents• Positive acute-phase respondentsPositive acute-phase respondents

• Nitrogen balanceNitrogen balance

Assessment for Protein-Calorie Malnutrition–cont’d• Hepatic transport proteinsHepatic transport proteins

• AlbuminAlbumin• TransferrinTransferrin• PrealbuminPrealbumin• Retinol-binding proteinRetinol-binding protein• C-reactive proteinC-reactive protein• CreatinineCreatinine

• ImmunocompetenceImmunocompetence

Hormonal and Cell-Mediated Response to Inflammatory Stress

• Acute illness or trauma causes Acute illness or trauma causes inflammatory stressinflammatory stress

• Cytokines (interleukin-1, interleukin-6 Cytokines (interleukin-1, interleukin-6 and tumor necrosis factor) reorient and tumor necrosis factor) reorient hepatic synthesis of plasma proteinshepatic synthesis of plasma proteins

• Although protein-energy malnutrition can Although protein-energy malnutrition can occur simultaneously, interpretation of occur simultaneously, interpretation of plasma proteins is problematicplasma proteins is problematic

Hormonal and Cell-Mediated Response to Inflammatory Stress

• Negative acute-phase respondents Negative acute-phase respondents (albumin, transthyretin or prealbumin, (albumin, transthyretin or prealbumin, transferrin, retinol-binding protein) transferrin, retinol-binding protein) decreasedecrease

• Positive acute-phase reactants (C-reactive Positive acute-phase reactants (C-reactive protein, orosomucoid, fibrinogen) protein, orosomucoid, fibrinogen) increaseincrease

• The change in these proteins is The change in these proteins is proportional to the physiological insultproportional to the physiological insult

Nitrogen Balance Studies• Oldest biochemical technique for Oldest biochemical technique for

assessment protein statusassessment protein status• Based on the fact that 16% of protein is Based on the fact that 16% of protein is

nitrogennitrogen• Nitrogen intake is compared to nitrogen Nitrogen intake is compared to nitrogen

output, adjusted for insensible losses output, adjusted for insensible losses (skin, hair loss, sweat) (skin, hair loss, sweat)

Nitrogen Balance Studies

• Nitrogen balance in healthy adults is 0Nitrogen balance in healthy adults is 0• Nitrogen balance is positive in growing Nitrogen balance is positive in growing

children, pregnant women, adults gaining children, pregnant women, adults gaining weight or recovering from illness or injuryweight or recovering from illness or injury

• Nitrogen balance is negative during Nitrogen balance is negative during starvation, catabolism, PEMstarvation, catabolism, PEM

Nitrogen Balance Calculations

• Nitrogen balance = nitrogen intake (g/24 Nitrogen balance = nitrogen intake (g/24 hours) –(urinary nitrogen [g/24 hours) + 2 hours) –(urinary nitrogen [g/24 hours) + 2 g/24 hoursg/24 hours

• Use correction of 4 g/24 hours if urinary Use correction of 4 g/24 hours if urinary urea nitrogen is usedurea nitrogen is used

• Nitrogen intake = (grams protein/24 Nitrogen intake = (grams protein/24 hours)/6.25hours)/6.25

Nitrogen Balance Challenges• Urea nitrogen is highly variable as a Urea nitrogen is highly variable as a

percent of total nitrogen excretedpercent of total nitrogen excreted• It is nearly impossible to capture an It is nearly impossible to capture an

accurate nitrogen intake for patients accurate nitrogen intake for patients taking food potaking food po

• Most useful in evaluating the Most useful in evaluating the appropriateness of defined feedings, e.g. appropriateness of defined feedings, e.g. enteral and parenteral feedingsenteral and parenteral feedings

Visceral Proteins: Serum Albumin

• Reference range: 3.5-5.2 g/dlReference range: 3.5-5.2 g/dl• Abundant in serum, stable (half-life 3 weeks)Abundant in serum, stable (half-life 3 weeks)• Preserved in the presence of starvation Preserved in the presence of starvation

(marasmus)(marasmus)• Negative acute phase reactant (declines with the Negative acute phase reactant (declines with the

inflammatory process)inflammatory process)• Large extravascular pool (leaves and returns to Large extravascular pool (leaves and returns to

the circulation, making levels difficult to the circulation, making levels difficult to interpret)interpret)

• Therefore, albumin is a mediocre indicator of Therefore, albumin is a mediocre indicator of nutritional status, but a very good predictor of nutritional status, but a very good predictor of morbidity and mortalitymorbidity and mortality

Visceral Proteins: Plasma Transferrin• Reference range: 200-400 mg/dlReference range: 200-400 mg/dl• Half-life: 1 weekHalf-life: 1 week• Negative acute phase respondentNegative acute phase respondent• Increases when iron stores are depleted Increases when iron stores are depleted

so affected by iron status as well as so affected by iron status as well as protein-energy statusprotein-energy status

• Responds too slowly to be useful in an Responds too slowly to be useful in an acute settingacute setting

Visceral Proteins: Transthyretin (Prealbumin)

• Reference range: 19-43 mg/dlReference range: 19-43 mg/dl• Half-life: 2 daysHalf-life: 2 days• Negative acute-phase reactantNegative acute-phase reactant• Zinc deficiency reduces levelsZinc deficiency reduces levels• Due to short half-life, it is useful in Due to short half-life, it is useful in

monitoring improvements in protein-monitoring improvements in protein-energy status if baseline value is obtained energy status if baseline value is obtained near the nadir as inflammatory response near the nadir as inflammatory response waneswanes

Visceral Proteins: Retinol-Binding Protein• Reference range: 2.1-6.4 mg/dlReference range: 2.1-6.4 mg/dl• Half-life: 12 hoursHalf-life: 12 hours• Negative acute-phase proteinNegative acute-phase protein• Unreliable when vitamin A (retinol) status Unreliable when vitamin A (retinol) status

is compromisedis compromised• Elevated in the presence of renal failure, Elevated in the presence of renal failure,

regardless of PEM statusregardless of PEM status

Visceral Proteins:C-Reactive Protein

• Positive acute-phase reactantPositive acute-phase reactant• Increases within 4-6 hours of injury or illnessIncreases within 4-6 hours of injury or illness• Can be used to monitor the progress of the Can be used to monitor the progress of the

stress reaction so aggressive nutrition support stress reaction so aggressive nutrition support can be implemented when reaction is subsidingcan be implemented when reaction is subsiding

• Mildly elevated CRP may be a marker for Mildly elevated CRP may be a marker for increased risk for cardiovascular diseaseincreased risk for cardiovascular disease

Inflammation• hs-CRPhs-CRP• HomocysteineHomocysteine

Urinary Creatinine• Formed from creatine, produced in muscle Formed from creatine, produced in muscle

tissuetissue• The body’s muscle protein pool is directly The body’s muscle protein pool is directly

proportional to creatinine excretionproportional to creatinine excretion• Skeletal muscle mass (kg) = 4.1 = 18.9 x 24-Skeletal muscle mass (kg) = 4.1 = 18.9 x 24-

hour creatinine excretion (g/day)hour creatinine excretion (g/day)• Confounded by meat in dietConfounded by meat in diet• Requires 24-hour urine collection, which is Requires 24-hour urine collection, which is

difficultdifficult

Markers of Malabsorption• Fecal fatFecal fat• Fat-soluble vitaminsFat-soluble vitamins• Vitamin DVitamin D

Lipid Indices of Cardiovascular Risk

• Total cholesterolTotal cholesterol• LDLLDL• HDL: HDL2a, HDL2b, HDL2c, HDL3a, HDL: HDL2a, HDL2b, HDL2c, HDL3a,

HDLdbHDLdb• IDLIDL• VLDLVLDL• Lp(a)Lp(a)

Nutrition Diagnoses and Laboratory Indices• Nutrition-related labs can be used either as Nutrition-related labs can be used either as

diagnostic labels or a clinical signdiagnostic labels or a clinical sign

Examples of Nutrition Diagnostic Statements Related to Lab Values• Altered nutrition-related lab values (NC-Altered nutrition-related lab values (NC-

2.2) related to excessive intake of saturated 2.2) related to excessive intake of saturated fat and cholesterol and genetic factors as fat and cholesterol and genetic factors as evidenced by diet history and client history.evidenced by diet history and client history.

• Inappropriate intake of food fats (saturated Inappropriate intake of food fats (saturated fat and cholesterol) (NI-5.6.3) related to fat and cholesterol) (NI-5.6.3) related to frequent use of baked goods and fried foods frequent use of baked goods and fried foods as evidenced by diet history and elevated as evidenced by diet history and elevated LDL and TCLDL and TC

Examples of Nutrition Diagnostic Statements Related to Lab Values• Excessive carbohydrate intake related to Excessive carbohydrate intake related to

evening visits to Coldstone Creamery as evening visits to Coldstone Creamery as evidenced by HS blood glucose and diet evidenced by HS blood glucose and diet historyhistory

evaluation of laboratory data in nutrition assessment cinda s. chima, ms, rd

Documents

fluid shiftsdehydration

nutrient slide

white blood cellsleukocytes

fluid shifts overhydration

red blood cellserythrocytes

red blood cells leukocytes

co2creatinine slide

pt slide