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

Kwashiorkor and Marasmus

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

AA structural& functional POOL

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

Key Words

• Hospital malnutrition• Kwashiorkor• Marasmus• Hepatic proteins• Nutritional assessment• Albumin