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ABSTRACT
The decision by nephrologists, renal dietitians, federal agencies, health care payers, large dialysis organizations, and the research community to embrace serum
albumin as an important index of nutrition and clinical performance is based on
numerous misconceptions. Patients with analbuminemia are not malnourished and
individuals with simple malnutrition are rarely hypoalbuminemic. With the possible
exception of kwashiorkor, a rare nutritional state, serum albumin is an unreliable
marker of nutritional status. Furthermore, nutritional supplementation has not
been clearly shown to raise levels of serum albumin. The use of serum albumin as
a quality care index is also problematic. It has encouraged a reflexive reliance on
expensive and unproven interventions such as dietary supplements and may lead
to adverse selection of healthier patients by health care providers. The authors
offer a rationale for considering albumin as a marker of illness rather than nutrition.
Viewed in this manner, hypoalbuminemia may offer an opportunity to improve
patient well-being by identifying and treating the underlying disorder.
J Am Soc Nephrol 21: 223230, 2010. doi: 10.1681/ASN.2009020213
DETERMINANTS OF SERUM
ALBUMIN
General Population
ISSN : 1046-6673/2102-223
223
224
Data courtesy of the US Renal Data System: USRDS 2008 Annual Data Report Special Data Request: Atlas of End-Stage Renal Disease in the United States, Bethesda, National Institutes of Health, National
Institute of Diabetes and Digestive and Kidney Diseases, 2008.
3.2 0.7
3.2
2.7
3.7
3.1 0.7
3.2
2.7
3.6
3.1 0.7
3.2
2.6
3.6
3.1 0.7
3.2
2.7
3.6
3.1 0.7
3.2
2.7
3.6
3.1 0.7
3.2
2.7
3.6
3.1 0.7
3.2
2.7
3.6
3.1 0.7
3.2
2.7
3.6
3.2 0.7
3.2
2.8
3.7
3.2 0.7
3.2
2.8
3.7
3.2 0.7
3.2
2.8
3.7
28.5 7.6
27.1
23.2
32.3
28.2 7.5
26.7
23.0
31.9
27.8 7.3
26.4
22.8
31.4
27.6 7.2
26.3
22.7
31.2
27.5 7.2
26.1
22.5
31.0
27.2 7.1
25.8
22.4
30.6
2005
2004
2003
2002
2001
2000
27.0 7.0
25.8
22.2
30.5
26.5 7.0
25.3
21.8
29.8
26.0 6.9
24.9
21.5
29.4
25.6 6.7
24.6
21.2
28.9
25.5 6.6
24.4
21.1
28.7
1999
1998
1997
1996
BMI (kg/m2)
mean SD
median
25th percentile
75th percentile
Serum albumin (g/dl)
mean SD
median
25th percentile
75th percentile
Year
Parameter
2006
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Table 1. Trends in serum albumin and BMI levels in the US ESRD population: 1996 through 2006
SPECIAL ARTICLE
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cating inadequate nutrition as a causative factor. Studies that did find a relationship between serum albumin and
diet all used normalized protein catabolic rate to estimate protein intake43;
however, normalized protein catabolic
rate does not measure caloric consumption and has a number of other important limitations.44 Furthermore, the estimated amount of protein intake in all
these studies far exceeds the amount typically associated with hypoalbuminemia.
In summary, a plethora of corroborative clinical evidence in the general population and in patients with CKD demonstrates that serum albumin is an
insensitive indicator of malnutrition,
possibly excepting the very rare circumstance of kwashiorkor-like states, and
that even severe protein and caloric restriction do not cause serum albumin
levels to fall.
CAN NUTRITIONAL
INTERVENTIONS RAISE SERUM
ALBUMIN LEVELS?
BMI (kg/m )
Body composition (kg)
total weight (% of baseline)
active body mass (% of baseline)b
fat mass (% of baseline)
Serum albumin (g/dl)
End of Study
21.7 1.7
16.4 0.9
SPECIAL ARTICLE
SERUM ALBUMIN AS A
RESEARCH, CLINICAL, AND
QUALITY CARE INDEX
Serum albumin is a commonly used research tool, being cited in more than one
quarter of the scientific publications that
include the terms dialysis and nutrition. Widespread hypoalbuminemia in
the dialysis population in the United
States has been used to support the concept that malnutrition is the preeminent
nutritional concern46,47 despite evidence
demonstrating that overnutrition, not
malnutrition, now predominates (Table
1). Of note, the effect of excess adiposity
on clinical outcomes remains controversial in CKD. Moreover, the severe degree
Albumin as a Nutritional Marker
225
226
44/Japan/HD
40/India/HD
45/Netherlands/HD
40/United States/
HD
28/Mexico/PD
Hiroshige et al.,64
2001
Kloppenberg et al.,66
2004
Gonzalez-Espinoza et
al.,68 2005
C: dietary
counseling
I: 1 to 2 supplement
cans per day
C: usual care
I: oral protein
supplement
C: usual care
I: strategies to lower
dialysis/nutritional
barriers
C: matched placebo
I: amino acid
granules
C: dietary
counseling
I1: home-prepared
supplement
I2: commercial
supplement
C: regular-protein
diet
I: high protein diet
I1: high-protein/
energy diet
I2: standard diet
I3: low-protein/
energy diet
C: matched placebo
I: amino acid tablets
Group
Interventions
180/United States/
HD
47/United States/
HD PD
22/Germany/HD
N/Location/Dialysis
Modality
Kuhlmann et al.,62
1999
Study
52
24
29 (mean)
C: 28
I: 29
C: 25
I: 23
NA
C: 25
I: 24
C: 17
I1: 18
I2: 17
80
C: 18
I: 19
PD: C, 23; I, 24
HD: C, 25; I,
31
I1: 18
I2: 22
I3: 22
BMI (kg/m2)
52
12
12
Study
Length (wk)
C: 3.40
I: 3.40
C: 2.66
I: 2.40
C: 3.01
I: 3.11
C: 4.77
I: 4.19
C: 3.4 0
I1: 3.40
I2: 3.40
C: 3.27
I: 3.31
I1: 4.14
I2: 4.08
I3: 4.19
Baseline
No
C: 0.14
I: 0.41 (P 0.05)
No
No
C: 0.03/mo
I: 0.04/mo (P 0.03)
C: 0.06
I: 0.21 (P 0.01)
No
No
Yes
Yes
No
Blinded
Study?
No significant change in
either group
C: 0.1
I1: 0.6
I2: 0.5 (P 0.001)
I1: 5.14
I2: no change
I3: no change (no
significant change in
any group)
PD: C, 0.02; I, 0.04
(NS)
HD: C, 0.04; I, 0.26
(P 0.02)
C: no increase
I: increase
End
Table 3. Effects of randomized oral nutritional interventions on serum albumin levels in dialysis patients
Nonnutritional
interventions
also included
Intervention also
included high
versus regular
dialysis dosage
Patients with
diabetes
excluded
NS effect on
combined
groups
(P 0.08)
Mean dialysis
vintage 6 to 7 yr
Comments
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227
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Normal range
ACKNOWLEDGMENTS
YES
NO
Hypoalbuminemia may
reflect malnutrition
NO
YES
Continue nutritional
supplementation
CONCLUSIONS
DISCLOSURES
None
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