CLI N IC AL QU ER I ES
Using albumin and prealbumin to assess nutritional status
I was taught that serum albumin
and prealbumin levels were accu-
rate indicators of nutritional sta-
tus and adequacy of nutritional
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support. Recently, however, I’ve
heard this is no longer considered
best practice. Can you provide an
update on this issue?—R.G., W.VA.
Susan H. Smith, DNP, RN, ACNS-
BC, replies: To better understand
why the role of these lab values in the
assessment of nutritional status has
changed, first consider some basic
physiology about proteins. Albumin
is the most abundant plasma protein.
Its essential role is to regulate passage
of water and solutes through the
capillaries by maintaining colloidal
Some patients may enter the clinical setting
with preexisting malnutrition; others develop
malnutrition during their illness.
oncotic pressure within the vascula-
ture.1 Plasma proteins have long been
considered integral to assessment of
nutritional status. During nutrient
deprivation, protein synthesis by the
liver is altered, resulting in low serum
protein levels. Reduced protein levels
are associated with poorer prognosis.2
Protein is an important macronutri-
ent for healing wounds, supporting
immune function and maintaining
lean body mass.3
Prealbumin, also called transthyre-
tin, is the precursor to albumin. Its
half-life is 2 to 4 days, whereas the
half-life of albumin is 20 to 22 days.4
Measuring prealbumin can help cli-
nicians detect short-term impairment
of energy intake and the effectiveness
of nutritional support efforts.2
During acute illness, infection, and
injury, a cytokine-mediated acute
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phase response occurs as a result of
inflammation.5 Inflammation and
illness increase vascular permeability,
and hepatic protein synthesis is repri-
oritized.3 Synthesis of C-reactive pro-
tein, fibrinogen, calcitonin, and other
proteins also occurs.5 As a result,
albumin and prealbumin levels are
reduced, not necessarily from poor
nutrition but because of acute patho-
physiologic events.6 Consequently,
measuring serum albumin and pre-
albumin levels may not give clini-
cians an accurate picture of the
patient’s nutritional status.
Understanding a patient’s nutritional
status is very important. Nutritional
imbalances result in malnutrition and
contribute to morbidity, mortality,
decreased function and quality of life,
and higher healthcare costs.7 Some
patients may enter the clinical setting
with preexisting malnutrition, while
others develop malnutrition during
their illness. The prevalence of malnu-
trition in the hospital setting ranges
from 20% to 50%.8
The risk of healthcare-acquired
conditions such as injury from falls,
infections, and pressure injuries can
be minimized with improved patient
nutrition. Nutrition interventions are
low cost and effective with a high
impact on patient outcomes.9
No single clinical or lab parameter
can be used to determine the com-
prehensive nutritional status of a pa-
tient, particularly during an illness.
Lab findings must be used in combi-
nation with other assessments to
identify the patient’s nutritional
state.5 The diagnosis of malnutrition
is made when two of the following
six characteristics are identified:
• insufficient caloric intake
• weight loss
• loss of muscle mass
• loss of subcutaneous fat
• localized or generalized fluid accu-
mulation
• diminished functional status as
measured by hand grip strength.6
Since 1996, The Joint Commission
requires screening all patients for risk
of malnutrition within 24 hours of
admission to an acute care facility.9
The Academy of Nutrition and Di-
etetics also recommends screening
patients to identify those who would
benefit from a more in-depth nutri-
tional assessment.7
Screening tools can help clinical
nurses and other caregivers identify
patients at greatest risk. Many have
excellent sensitivity and specificity
for identifying at-risk patients.9
Both the Society of Critical Care
Medicine and American Society for
Parenteral and Enteral Nutrition rec-
ommend the use of tools, such as the
Nutritional Risk Screening (NRS)
2002 and the Nutrition Risk in Criti-
cally ill (NUTRIC) assessment tools, for
critically ill patients. These tools ac-
count for nutrition status in relation
to disease severity, which is impor-
tant in this population.3 The NRS
2002 assesses body mass index,
weight loss, dietary intake, and ill-
ness severity.10 The NUTRIC assess-
ment includes age, APACHE II score,
sepsis-related organ failure assess-
ment (SOFA) score, patient comor-
bidities, ICU admission date, and
interleukin-6 (IL-6, if available).11
These tools can be embedded within
the electronic health record to pro-
vide automatic notification when a
April l Nursing2017 l 65
CLI N IC AL QU ER I ES
patient is at risk and improve com-
munication among team members.
Nurses play an important role in
early identification of malnutrition
through accurate and timely patient
screening of nutrition status.9 Pro-
viding optimal calories and protein
plays a vital role in recovery from
illness and patient outcomes,
including decreased morbidity,
mortality, and length of stay.12
Understanding how best to assess
nutritional status is a fundamental
way to ensure patients are protected
from harm associated with inad-
equate nutrition. ■
REFERENCES
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Biologic Basis for Disease in Adults and Children. 7th
ed. St. Louis, MO: Elsevier Mosby; 2014.
66 l Nursing2017 l Volume 47, Number 4
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
2. Caccialanza R, Palladini G, Klersy C, et al. Serum
prealbumin: an independent marker of short-term
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3. McClave SA, Taylor BE, Martindale RG, et al.
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4. Banks AD, Corbett JV. Laboratory Tests and Diag-
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assessment tutorial. JPEN J Parenter Enteral Nutr.
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albumin and prealbumin in calorically restricted,
nondiseased individuals: a systematic review. Am J
Med. 2015;128(9):123.e1-e22.
7. White JV, Guenter P, Jensen G, et al. Consensus
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nostic impact of disease-related malnutrition. Clin
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9. Tappenden KA, Quatrara B, Parkhurst ML, Malone
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Z; Ad Hoc ESPEN Working Group. Nutritional risk
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22(3):321-336.
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Identifying critically ill patients who benefit the
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Crit Care. 2011;15(6):R268.
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myths and misconceptions. Crit Care Med. 2014;
42(4):962-969.
Susan H. Smith is a CNS in critical care at Baylor
University Medical Center in Dallas, Tex.
The author has disclosed that she’s a paid speaker for
Abbott Nutrition and Masimo. She has disclosed no
other financial relationships related to this article.
DOI-10.1097/01.NURSE.0000511805.83334.df
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