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ESPEN Congress Brussels 2005
Key papers in the field of clinical nutritionDietitian
G. Rozen, Israel
Key Papers in Nutrition
ESPEN 2005 – BrusselsGeila S Rozen
Clinical Nutrition Dep.Rambam Medical Center
Weight loss from starvation after injury
Shils – modern Nutrition
Serum hepatic proteins levels were thought to be indicators of nutritional status
Nutritional status Assessment
Medical background
Physical +
Anthropometry
Lab Tests
Dietary Intake
Diet plan
Hepatic Proteins and Nutrition Assessment
M P Fuhrman, P Charney, M Mueller
JADA 2004; 104: 1258-1264
Hepatic proteinsCommonly refer to:Albumin, Pre-Albumin, Transferrin
The common assumptionis that albumin & pre-Albumin levels accurately reflect nutritional status of patient and amount of dietary protein consumed
Malnutrition - definitions
Total body waterExtra cellular water
Total body KTotal body protein
Serum Albumin & transport proteinsFatty liver infiltration
Serum BCAA
What about adults?What about Western culture MN?
• “western/Adult Kwashiorkor” Alcoholic cirrhosis, ICU - ?
• “western/Adult Marasmus”Anorexia Nervosa, sever illness
BUT, dose the critically ill patient have Kwashiorkor MN?
• ICU pt’s do not demonstrate the characteristics of Kwashiorkor
• Low protein diet studies fail to produce Kwashiorkor
• On the other hand: Aflatoxin poisoning, End stage liver disease, Sever infections, Oxidative stress ? seem to be etiologies of Kwashiorkor.
Protein distribution in body
• Muscle – 40%• Skin & Blood – 30%• Organs – 10%• Other tissue & components – 20%
Hepatic Protein – synthesized by hepatocyts,released into circulation, not stored to any extent.
12-25 g albumin are synthesized / day = 40% of total hepatic proteins
Hepatic Plasma Protein during Stress
Positive acute-phase proteins
25% increase
Negative acute-phase proteins
25% decrease
Factors effecting serum levels of Albumin, Pre-Albumin & transferrin
Increase• Intravascular volume deficit• Exogenous albumin infusion• Renal failure• Iron deficiency
Decrease• Intravascular volume excess• Recumbent posture• Extraneous loss of albumin• Liver disease• Pregnancy• Hypothyroid• Alcohol abuse• Nephrotic syndrome• Uremia• Corticosteroids• Malignancy• Trauma (including surgery)• Inflammation
Hepatic protein levelsDo not correlate with
Nitrogen Balance
But rather best correlate with
C-reactive protein levels
Hepatic proteins – practical use
• Hepatic proteins should not be used as indicators of nutritional status, rather of morbidity & mortality risk
• Good prognostic indicator
Mortality rate / month
AlbuminMg/dl
24%2.6-3.0
43%2.1-2.5
62% >2
Hepatic proteins – strategy of use
• As indicator of severity of disease that will accelerate nutritional depletion
• Those at risk to develop serious nutritional deficits, require aggressive nutritional intervention
• Failure of serum levels of hepatic proteins to increase does not indicate inadequate nutrition support, rather severity of primary problem, or development of secondary problems such as infection
Hepatic proteins – thought for future strategy of treatment
• Patients with low albumin = indicator of more on going inflammation process
? Should nutritional treatment contain anti inflammatory factors – Omega 3
? What about immune nutrition, and nutrogenomic data?
Thanks
• Lital Lahav – ICU clinical nutrition work group – Rambam Medical Center
For use of pictures:• Shils – Modern Nutrition in Health & Disease• Krause’s – Food, Nutrition & Diet Therapy
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