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population
1. Dylan Harris, MB MRCP1
2. Nadim Haboubi, MD FRCP2
1.
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Malnutrition is a state in which a deficiency, excess or imbalance of energy, protein and other
nutrients causes adverse effects on body form, function and clinical outcome.1 To justify
screening for this state in the elderly, four criteria must be satisfied: malnutrition must be a
frequent cause of ill-health in this population; it must have a negative effect on outcomes; a
simple, reliable, valid and acceptable screening test must be available to detect those who are
malnourished or at risk of malnutrition; and there must be benefit from nutritional
intervention in those identified by screening. In this review we consider whether these
conditions are satisfied by tests of various kinds.
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community at high or medium risk of malnutrition. The prevalence was reckoned at 20%
among those in residential accommodation and up to 40% in those admitted to hospital.13 The
College identified nutritional screening as an integral part of clinical practice.
The economic cost of preventable malnutrition to the National Health Service has been
estimated at 260 million a year.14
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Anthropometry
Skinfold thickness can be measured with standardized callipers but requires a skilled
technique. Several different sites can be usedsubscapular, supra-iliac, biceps, triceps, thigh,
calf. The distribution of skinfold thickness varies with ageing and between sexes and between
ethnic groups.23
Use of arm circumference depends on the assumption that the mass of the muscle group is
proportional to its protein content and also reflects total body muscle mass.23 Mid-upper arm
circumference is a helpful indicator of malnutrition applicable in ill patients (normal 23 cm
males, 422 cm females).28
Anthropometric indices are simple and inexpensive to obtain,29 but have to be interpreted in
the light of age, gender and ethnicity.27 Furthermore, some are unreliable in conditions that
cause limb oedema.
Biochemical markers
Serum proteins synthesized by the liver have been used as markers of nutritionalbumin,
transferrin, retinol-binding protein and thyroxine-binding prealbumin.6 Of these, serum
albumin has been most widely adopted because it predicts mortality and other outcomes (for
example, perioperative complications) in older people. Nutritional state, however, is not the
only factor affecting these proteins, others being inflammation and infection. This limits their
usefulness, especially in the acutely ill.5,6,16 In addition, the long half-life of albumin means
that serum albumin does not respond to short-term changes in protein and energy intake.16
Transferrin is a more sensitive indicator of early protein-energy malnutrition but is
unreliable in conditions including pregnancy, iron deficiency, hypoxaemia, chronic infection
and hepatic disease.16 A low total lymphocyte count signifies a poor prognosis and is
independent of low serum albumin.6,11 Malnutrition contributes to age-related immune
dysregulation, including decreased lymphocyte proliferation.10 A low total cholesterol has
also been correlated with risk of malnutrition3 and assessment of vitamin and trace element
status is also important (including thiamine, riboflavin, pyridoxine, calcium, vitamin D,
B12, folate and ferritin).
No biochemical marker on its own offers a satisfactory screening test. Their main value is in
more detailed assessment (particularly risk stratification of patients identified by screening)
and for monitoring.18
The Mini Nutritional Assessment (MNA) was developed to evaluate the risk of malnutrition in
the elderly in home-care programmes, nursing homes and hospitals. In theory it should be
better at identifying frail elderly patients at risk of undernutrition since it encompasses
physical and mental aspects of health;20,21,31 moreover, it detects risk of malnutrition at a time
when albumin levels and BMI are still normal.32 The score for screening is derived from six
componentsreduced food intake in the preceding three months; weight loss during the
preceding three months; mobility; psychological stress or acute disease in the preceding three
months; neuropsychological problems; body mass index.20
The MNA has predictive validity for adverse health outcome, social functioning, mortality
and rate of visits to the general practitioner as well as length of hospital stay, likelihood of
discharge to a nursing home and mortality.20,21 A score of 11 or more on the screening
component of the MNA offers strong evidence that malnutrition is absent.33 The MNA has
also shown itself practical and reliable.19,21,34
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CONCLUSION
The importance of nutrition is now specified in documents such as the UK National Service
Framework for older people but there is no consensus on methods of detection.
Anthropometry and biochemical markers have drawbacks, and the choice falls on screening
tools employing combinations that can be applied without specific skills or training.
In a particular hospital or community, there is much to be said for use of a single such tool,
and one that attracts wide support is MUST, supported by the British Dietetic Association,
the British Association for Parenteral and Enteral Nutrition, the Royal College of Nursing,
the Registered Nursing Homes Association and the Royal College of Physicians.
Sumber: http://jrs.sagepub.com/content/98/9/411.full
status than albumin, and its concentration closely reflects recent dietary intake rather than
overall nutritional status (5). Because of this short half-life, however, the concentration of
prealbumin falls rapidly as a result of the fall in its synthetic rate when there is a
reprioritization of synthesis toward acute-phase proteins such as C-reactive protein (CRP),
fibrinogen, or 1-acid glycoprotein. Moreover, prealbumin concentration in plasma, like that
of albumin, is affected by changes in transcapillary escape. Hence, interpretation of plasma
prealbumin is difficult in patients with infections, inflammation, or recent trauma (4). Despite
this difficulty, interest in prealbumin as a potential marker of nutritional status in certain
groups of patients led to the First International Congress on Transthyretin in Health and
Disease in 2002 (6).
Some studies have screened patients on the basis of their prealbumin on admission, with
values <100 mg/L being regarded as indicating severe risk of protein-energy malnutrition,
100170 mg/L moderate risk, and >170 mg/L no risk. This type of classification, however,
may often reflect severity of illness and the magnitude of the SIRS rather than nutritional
status. When screening protocols that use prealbumin have been compared with a 2-stage
process involving a screening questionnaire followed by an assessment by a professional
dietitian, the prealbumin protocols identified many more patients considered to be
malnourished (7)(8). The authors have tended to interpret this finding as showing the
increased sensitivity of prealbumin in detecting malnutrition, rather than the lack of
specificity of this test.
Nonetheless, these results do suggest a place for prealbumin measurement soon after
admission. In this issue of Clinical Chemistry, Devoto et al. (9) report their investigation of
the concordance of prealbumin measurement, made on day 3 after admission, with a Detailed
Nutritional Assessment (DNA) as a reference method to detect protein-energy malnutrition.
Intriguingly, they found excellent correlation of prealbumin with the DNA, in patients with
and without increased CRP (>5 mg/L). Devoto et al. (9) interpret this correlation as
indicating that prealbumin is a good screening tool for malnutrition, in both the presence and
absence of SIRS. Closer examination raises some concerns, however. First, the DNA score is
not affected only by nutritional statusit contains variables affected both by nutritional
status and by inflammation. Low albumin and low cholesterol, both of which are influenced
by SIRS, may account for up to 50% of DNA scores classified as malnourished. Thus, in
the group with increased CRP, it is not surprising that there is good concordance between
prealbumin and DNA. Similarly, because the DNA does contain true nutritional indicators
such as low nutritional intake or weight loss that lead to low prealbumin, it can be expected
that in patients without increased CRP, there would also be good concordance between DNA
and prealbumin concentration. Moreover, nearly half the patients in their study either had
undergone trauma or had an infection, so their CRP was probably stabilizing or decreasing on
treatment during the 3 days before prealbumin was measured. As noted below, an intake of as
little as 66% of the nutritional requirement could be associated with an increase in
prealbumin in such patients, and hence for many patients with an inadequate intake, the
prealbumin was already rising.
So, one-off measurements of prealbumin are of limited use in screening for malnutrition. A
better interpretation of the nutritional component could probably be achieved from 2
measurements, 3 to 5 days apart, to assess the trend both in prealbumin and in CRP.
What about prealbumin in monitoring adequacy of nutritional intake? In seriously ill patients,
very low prealbumin concentrations are typical and are inversely related to CRP (10).
metabolic demand decreases and oral nutritional intake increases, or active steps are taken to
ensure that their nutritional intake meets their ongoing metabolic demands.
A low prealbumin concentration can therefore be regarded primarily as a signal identifying
the at-risk patient who requires careful assessment and monitoring and for whom nutritional
support may be needed as part of the treatment plan. Nutritional assessment and monitoring
protocols should be developed in all hospitals treating patients with acute or chronic illness,
and these protocols should include assessment of adequacy of nutritional intake and possibly
serial measurements of plasma prealbumin and CRP concentrations.
Sumber: http://www.clinchem.org/content/52/12/2177.full
Source
Coram Health Care, St. Louis, MO, USA. fuhrmanp@coramhc.com
Abstract
Serum hepatic protein (albumin, transferrin, and prealbumin) levels have historically been
linked in clinical practice to nutritional status. This paradigm can be traced to two
conventional categories of malnutrition: kwashiorkor and marasmus. Explanations for both of
these conditions evolved before knowledge of the inflammatory processes of acute and
chronic illness were known. Substantial literature on the inflammatory process and its effects
on hepatic protein metabolism has replaced previous reports suggesting that nutritional status
and protein intake are the significant correlates with serum hepatic protein levels. Compelling
evidence suggests that serum hepatic protein levels correlate with morbidity and mortality.
Thus, serum hepatic protein levels are useful indicators of severity of illness. They help
identify those who are the most likely to develop malnutrition, even if well nourished prior to
trauma or the onset of illness. Furthermore, hepatic protein levels do not accurately measure
nutritional repletion. Low serum levels indicate that a patient is very ill and probably requires
aggressive and closely monitored medical nutrition therapy.
PMID:
15281044
[PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/15281044
Abstract
Surrogate nutrition markers are used to assess adequacy of nourishment and to define
malnutrition despite evidence that fails to link nourishment, surrogate markers, and outcomes.
Markers such as serum levels of albumin, prealbumin, transferrin, and IGF-1 and delayed
hypersensitivity and total lymphocyte count may be valid to help stratify risk. However, it is
not appropriate to consider these as markers of adequacy of nourishment in the sick patient.