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Strategies to Improve Albumin in Patients on Peritoneal Dialysis
| The Issues in Renal Nutrition
in Nephrology Nursing department is designed to focus on nutritional
issues for nephrology patients. Address correspondence to: Susan Reams,
Department Editor, Nephrology Nursing Journal; East Holly Avenue/Box
56; Pitman NJ 08071-0056; (856) 256-2320. The opinions and assertions
contained herein are the private views of the contributors and do not
necessarily reflect the views of the American Nephrology Nurses'
Association. |
Albumin! Why do we care? Albumin is a visceral protein found in the
blood. It is used as an inexpensive marker of nutritional status.
Patients are told that albumin is an important measure of how well they
are doing nutritionally. And it is well known that low serum albumin is
strongly correlated with increased morbidity and mortality in patients
requiring chronic dialysis (Spiegel & Breyer, 1994).
Protein
Protein
from food is digested and reassembled into the proteins needed by the
body. To do this, the body must have all the amino acids it needs at
the same time. If a specific amino acid is not readily available, the
body will take apart another protein and redesign it to make what it
needs. If necessary, the body will break down its own proteins to get
the needed amino acids. The body has no way to store amino acids, so
new sources of protein must be provided daily. If any essential amino
acids are missing for protein synthesis, the remaining amino acids are
converted for use as energy or fat storage.
Proteins perform many roles essential to life, such as:
- Building, repairing, and maintaining body tissues.
- Making enzymes and hormones
- Regulating body processes.
- Transporting nutrients.
- Being involved in muscle contraction.
- Assisting in blood clotting.
- A component of antibodies.
Albumin
A number of factors can contribute to a low albumin level. These include:
- Increased needs for protein (e.g. “stress response” [catabolic stress]) brought on by illness, infection, and surgery.
- MIncreased protein losses, such as:
- urinary losses, i.e. nephrotic syndrome.
- loss of protein during peritoneal dialysis (PD) exchanges.
- Decreased appetite (fullness and glucose absorption from dialysis solution can diminish appetite).
- Inadequate dialysis/declining urine output.
- Psychosocial problems such as depression, loneliness, lack of family support, poor income.
- Drug/nutrient interactions.
- Abnormal metabolism.
Malnutrition
is prevalent among individuals on PD, yet patients may have few or no
visible symptoms. Malnutrition occurs when a person does not eat enough
protein and calories to compensate for protein losses. Adequate caloric
intake is needed to maintain energy stores and to optimize protein
metabolism. Common problems associated with a low albumin level include
difficulty fighting infection, poor wound healing, swelling, difficulty
removing fluid during dialysis, and decrease in muscle strength.
The
acceptable range for serum albumin is 3.5 to 5.1 g/dl, although this
may vary depending on the laboratory method used. The K/DOQI nutrition
guidelines recommend a serum albumin of 4.0 g/dl or greater (Kopple,
2001). The recommended protein requirement for people on PD is 1.2 to
1.3 grams protein/kg ideal body weight (IBW)/day (Kopple, 2001) with 50
to 70% from high biologic value (HBV) food sources. HBV protein sources
include eggs, beef, fresh pork, poultry, fish/seafood, wild game, lamb,
veal, or protein salads (e.g. tuna salad, egg salad, and chicken salad).
Case 1
A 55 kg patient on PD needs 66 to 72 grams of protein each day. The
patient needs 40 to 43 grams of HBV to provide 60% of this protein.
A possible combination of these foods that would contribute 42 grams of HBV protein is:
1 egg = 7 grams protein
2 ounces beef = 14 grams protein
3 ounces chicken = 21 grams protein
Total 42 grams protein
The
rest of the protein (24 g) to total the minimum of 66 grams may be
obtained from low biological value (LBV) protein food sources: breads
and cereals, vegetables, fruit, and pasta. A combination of foods that
would contribute 24 grams of LBV protein is:
2 slices bread = 4 grams protein
1 whole bagel, small = 4 grams protein
2/3 cup noodles = 4 grams protein
fi cup carrots = 1 gram protein
1 cup broccoli = 2 gram protein
1/2 cup apple juice = 0.5 grams protein
3 Tbsp soft cream
cheese, fat-free = 4 grams protein
11/2 cups popcorn = 2 grams protein
5 vanilla wafers = 2 grams protein
fi cup fruit cocktail = 0.5 grams protein
Total = 24 grams protein
Case 2
An 82 kg patient on PD needs
98 to 107 grams of protein. The patient needs 59 to 64 grams of HBV
protein. A possible combination to obtain the HBV protein is:
1 egg = 7.0 grams protein
3 ounces fish = 21.0 grams protein
3 ounces chicken = 21.0 grams protein
2 ounces beef = 14.0 grams protein
Total 63.0 grams protein
A possible combination of foods for the remaining 35 grams of LBV protein is:
4 slices bread = 8.0 grams protein
1 cup hot cereal = 4.0 grams protein
5 vanilla wafers = 2.0 gram protein
1 cup pasta = 4.0 grams protein
1 cup noodles = 6.0 grams protein
1 cup cauliflower = 2.0 grams protein
1 cup green beans = 2.0 grams protein
1/2 cup apple juice = 0.5 grams protein
1 large apple = 1.0 gram protein
1 cup fruit cocktail = 1.0 gram protein
1 1/2 cup popcorn = 2.0 grams protein
1/2 cup nondairy creamer = 0.5 grams protein
1/2 cup rice = 2.0 grams protein
Total 35.0 grams protein
Improving Albumin Levels
There are a number of ways to improve albumin levels:
1. A variety of nutritional supplements contain differing amounts of protein.
- Liquid formulas such as Boost®,
Ensure®, and renal-specific formulas can provide between 8 and 18
grams of protein per 8-ounce can.
- Fortified puddings and protein bars are available.
- Protein powders such as Procel® and
ProMod® provide about 5 grams of protein per scoop. Protein powder
can be mixed with a variety of foods such as meat/seafood salads,
beverages, mashed fruits and vegetables, cookie mixes, and salad
dressings to boost protein intake without increasing the volume of
food.
- Many of the products have very little
taste or texture. For about $20 per month (the cost of 2 cans), protein
intake can be increased by 12 grams per day, roughly equivalent to 2
ounces of meat. One of the drawbacks is that patients need to add the
powder to foods during preparation, rather than just opening a can.
2. Watch for and treat depression because depression often reduces food intake.
3. Provide adequate dialysis. Uremia can cause
anorexia, nausea, vomiting, and sleeplessness. Simply focusing on the
numbers is not enough. It is important to regularly assess the patient.
4. Watch for and treat infection and
inflammation. Promptly treating peritonitis, exit site problems, and
wounds helps preserve albumin.
5. In the majority of patients, the dialysate
causes a feeling of fullness. Some individuals find eating while empty
is helpful. For many, eating smaller, more frequent meals is beneficial.
6. Some patients may benefit from the use of an appetite stimulant.
7. Intraperitoneal nutrition has been used to
effectively increase albumin levels in some patients; however, it is
expensive and not all insurance companies will pay for it.
Conclusion
Communication among the different disciplines is
vital to the overall health of individuals on PD. The team needs to
work together to maintain or improve each patient’s nutritional status.
Strategies to improve protein intake should be individualized and renal
dietitians can help in this area.
References
Kopple,
J. D. (2001). The National Kidney Foundation K/DOQI clinical practice
guidelines for dietary protein intake for chronic dialysis patients.
American Journal of Kidney Diseases, 38(4, Suppl. 1), S68-S73.
Spiegel, D.M., & Breyer, J.A. (1994).
Serum albumin: A predictor of long-term outcome in peritoneal dialysis
patients. American Journal of Kidney Diseases, 23(2), 283-285.
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