hypoalbuminemia: serum albumin <25 g/L

{Poor nutrition is a chronic problem often linked to poverty, poor nutrition understanding and practices, and deficient sanitation and food security.[3] Malnutrition and its consequences are immense contributors to deaths and disabilities worldwide.[4] Promoting good nutrition helps children grow, promotes human development and eradication of poverty.[3]}








Malnutrition results from inadequate intake or abnormal GI assimilation of dietary calories, excessive energy expenditure, or altered metabolism of energy supplies by an intrinsic disease process.

Both outpatients and inpatients are at risk for malnutrition if they meet one or more of the following criteria:

  • Unintentional loss of >10% of usual body weight in the preceding 3 months

  • Body weight <90% of ideal for height (Table 6-1)


    Men Women
    Heighta Weighta Height Weight Height Weight Height Weight
    145 51.9 166 64.0 140 44.9 161 56.9
    146 52.4 167 64.6 141 45.4 162 57.6
    147 52.9 168 65.2 142 45.9 163 58.3
    148 53.5 169 65.9 143 46.4 164 58.9
    149 54.0 170 66.6 144 47.0 165 59.5
    150 54.5 171 67.3 145 47.5 166 60.1
    151 55.0 172 68.0 146 48.0 167 60.7
    152 55.6 173 68.7 147 48.6 168 61.4
    153 56.1 174 69.4 148 49.2 169 62.1
    154 56.6 175 70.1 149 49.8    
    155 57.2 176 70.8 150 50.4    
    156 57.9 177 71.6 151 51.0    
    157 58.6 178 72.4 152 51.5    
    158 59.3 179 73.3 153 52.0    
    159 59.9 180 74.2 154 52.5    
    160 60.5 181 75.0 155 53.1    
    161 61.1 182 75.8 156 53.7    
    162 61.7 183 76.5 157 54.3    
    163 62.3 184 77.3 158 54.9    
    164 62.9 185 78.1 159 55.5    
    165 63.5 186 78.9 160 56.2    

    aValues are expressed in cm for height and kg for weight. To obtain height in inches, divide by 2.54. To obtain weight in pounds, multiply by 2.2.

    Source: Adapted from GL Blackburn et al: Nutritional and metabolic assessment of the hospitalized patient. J Parenter Enteral Nutr 1:11, 1977; with permission.

  • Body mass index (BMI: weight/height2 in kg/m2) <18.5


wo forms of severe malnutrition can be seen: marasmus, which refers to generalized starvation that occurs in the setting of chronically decreased energy intake without systemic inflammation, and kwashiorkor, which refers to selective protein malnutrition due to decreased protein intake and catabolism in the setting of acute, life-threatening illnesses or chronic inflammatory disorders. Aggressive nutritional support is indicated in kwashiorkor to prevent infectious complications and poor wound healing.


The major etiologies of malnutrition are starvation, stress from surgery or severe illness, and mixed mechanisms. Starvation results from decreased dietary intake (from poverty, chronic alcoholism, anorexia nervosa, fad diets, severe depression, neurodegenerative disorders, dementia, or strict vegetarianism; abdominal pain from intestinal ischemia or pancreatitis; or anorexia associated with AIDS, disseminated cancer, heart failure, or renal failure) or decreased assimilation of the diet (from pancreatic insufficiency; short bowel syndrome; celiac disease; or esophageal, gastric, or intestinal obstruction). Contributors to physical stress include fever, acute trauma, major surgery, burns, acute sepsis, hyperthyroidism, and inflammation as occurs in pancreatitis, collagen vascular diseases, and chronic infectious diseases such as tuberculosis or AIDS opportunistic infections. Mixed mechanisms occur in AIDS, disseminated cancer, chronic obstructive pulmonary disease, chronic liver disease, Crohn’s disease, ulcerative colitis, and renal failure.

Clinical Features

  • General: weight loss, temporal and proximal muscle wasting, decreased skin-fold thickness

  • Skin, hair, and nails: easily plucked hair (protein); sparse hair (protein, biotin, zinc); coiled hair, easy bruising, petechiae, and perifollicular hemorrhages (vit. C); “flaky paint” rash of lower extremities (zinc); hyperpigmentation of skin in exposed areas (niacin, tryptophan); spooning of nails (iron)

  • Eyes: conjunctival pallor (anemia); night blindness, dryness, and Bitot spots (vit. A); ophthalmoplegia (thiamine)

  • Mouth and mucous membranes: glossitis and/or cheilosis (riboflavinniacin, vit. B12, pyridoxine, folate), diminished taste (zinc), inflamed and bleeding gums (vit. C)

  • Neurologic: disorientation (niacin, phosphorus); confabulation, cerebellar gait, or past pointing (thiamine); peripheral neuropathy (thiaminepyridoxine, vit. E); lost vibratory and position sense (vit. B12)

  • Other: edema (protein, thiamine), heart failure (thiamine, phosphorus), hepatomegaly (protein)

Laboratory findings in protein malnutrition include a low serum albumin, low total iron-binding capacity, and anergy to skin testing. Specific vitamin deficiencies also may be present.

For a more detailed discussion, see Dwyer J: Nutritional Requirements and Dietary Assessment, Chap. 95e; Russell RM and Suter PM: Vitamin and Trace Mineral Deficiency and Excess, Chap. 96e; and Heimberger DC: Malnutrition and Nutritional Assessment, Chap. 97, p. 459 in HPIM-19.




Content 9


Severe malnutrition causes widespread organ dysfunction and increases perioperative morbidity and mortality rates. Nutritional repletion may improve wound healing, restore immune competence, and reduce morbidity and mortality rates in critically ill patients. This chapter does not provide a complete review of nutrition in the patient undergoing surgery or with critical illness, but rather offers the framework for providing basic nutritional support in such patients. We consider, for example, whether enteral nutrition (EN) or parenteral nutrition (PN) will best meet the needs of an individual patient. This chapter also briefly reviews the conditions under which the ongoing nutritional needs of patients may come into conflict with anesthetic preferences and dogmas, such as the duration that patients must not receive EN before undergoing general anesthesia.


Negative Effects of Malnutrition on Clinical Outcome
  • Greater susceptibility to infectious complications
  • Reduced immune competence
  • Poor skin integrity
  • Delayed wound healing
  • Higher incidence of surgical complications
  • Prolonged need for mechanical ventilation
  • Increased mortality
  • Extended length of stay, higher health care costs

As the interplay between nutritional status and illness has become better understood, nutritional assessment has taken on greater importance in clinical care. By integrating nutritional assessment into the evaluation of all patients, clinicians not only identify malnutrition but also uncover risk factors for chronic disease and unfavorable clinical outcome, determine nutritional requirements, recognize people likely to benefit from nutritional support, and establish a framework for developing a therapeutic plan.


Content 11

A 74-year-old woman is hospitalized in the surgical intensive care unit after undergoing an emergent colectomy for ischemic colitis related to vascular disease. At the time of surgery, she had experienced a bowel perforation. She is currently postoperative day 10 and remains intubated and sedated with evidence of ongoing multiorgan system failure. She requires norepinephrine infusion continuously at a rate of 10 μg/min. She has acute renal failure and is on continuous venovenous hemodialysis. Her blood cultures were positive for Escherichia coli, and she is being treated with cefepime 2 g IV every 8 hours and metronidazole 500 mg every 8 hours. She has a colostomy in her right lower quadrant, but the surgeons were unable to primarily close her abdomen due to the bowel perforation. She has returned to the operating room for reexploration and wash out of the peritoneum. Since admission, her fluid balance is positive more than 30 L. She has marked anasarca and has not been fed since admission, although the team plans to initiate total parenteral nutrition today. Which statement is most likely true regarding her nutritional state?


Aggressive nutritional support should be avoided.


Immune function is not affected.


The albumin is less than 2.8 g/dL.


The body mass index will be less than 18.5 kg/m2.


The nutritional state does not confer any increased mortality risk for this patient.

Next Question

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The correct answer is C. You answered A.


The answer is C. Kwashiorkor is the term that describes acute disease- or injury-related malnutrition. In developed countries, the most common causes of kwashiorkor are trauma and sepsis. Pathophysiologically, the body has increased protein and energy requirements in these settings. However, intake is often reduced or absent for prolonged periods of time. Signs of kwashiorkor can develop within a period as short as 2 weeks. Body mass index is a poor predictor and is often normal. Acute weight loss is often masked by the development of edema. Easy hair pluckability, skin breakdown, and wound healing are common signs. On laboratory examination, there are marked decreases in serum proteins, including albumin <2.8 g/dL, transferrin <150 mg/dL, and total iron-binding capacity <200 μg/dL. Cellular immunity is impaired, with low lymphocyte counts and presence of anergy. Presence of kwashiorkor portends a poor prognosis and high mortality from the underlying medical condition. Surgical wounds exhibit poor healing and often dehisce. There is an increased risk of development of decubitus ulcers. Aggressive nutritional support is indicated. Use of enteral feeding in general can be difficult and may be contraindicated in this patient due to her surgical issues. Patients with kwashiorkor frequently exhibit gastroparesis with enteral feedings and also have an increased risk of gastrointestinal bleeding from stress ulcers.


What body mass index is likely to be lethal in males?

Next Question
You will be able to view all answers at the end of your quiz.

The correct answer is C. You answered A.

The answer is C.(Chap. 98e) It is important to understand the thresholds of body mass index (BMI) that indicate malnutrition. Normal BMI ranges between 20 and 25 kg/m2, and a patient is considered underweight with likely moderate malnutrition at a BMI of 18.5 kg/m2. Severe malnutrition is expected with a BMI of <16 kg/m2. In men, a BMI of <13 kg/m2 is lethal, whereas in women, the lethal BMI is <11 kg/m2.


A 21-year-old woman is admitted to the cardiac care unit after collapsing in her college dormitory. When emergency personnel arrived at her home, she was found to be in a torsades de pointes arrhythmia and was pulseless. She received cardiopulmonary resuscitation, defibrillation, and magnesium en route to the hospital. Upon arrival, her initial potassium is 1.2 mEq/L. Her physical examination is remarkable for an excessively thin appearance with lanugo hair on arms and chest. Her BMI is 14.6 kg/m2. Which of the following statements is true regarding this patient’s nutritional state?

Next Question
You will be able to view all answers at the end of your quiz.

The correct answer is E. You answered E.

The answer is E.(Chap. 97) The patient in this scenario has evidence of chronic starvation-related malnutrition, most likely related to anorexia nervosa. Starvation-related malnutrition that occurs without evidence of systemic inflammation is also known as marasmus and develops over months or years due to prolonged decreases in energy and protein intake. The patient exhibits a starved appearance with a low body mass index (<18.5 kg/m2). The diagnosis is based on diminished skinfold thickness, which reflects loss of fat stores and reduced arm circumference and demonstrates muscle wasting. In addition, temporal and interosseous muscle wasting is also commonly seen. Routine laboratory testing is not remarkably abnormal. Albumin may be low, but is typically not less than 2.8 g/dL. However, despite a morbid appearance, immunocompetence and wound healing are preserved. Because the process is a chronic and fairly well-adapted process, treatment should be planned in concert with a dietitian to slowly allow a return to normal body weight. Overly aggressive nutritional support can lead to life-threatening metabolic imbalances. When mortality occurs in anorexia nervosa, it is most commonly related to complications of the disease and rarely due to malnutrition itself. Indeed, suicide is a more common cause of death in the disease than malnutrition. In certain processes such as cancer or chronic obstructive pulmonary disease, a similar loss of fat and protein can occur in the setting of systemic inflammation resulting in a wasted appearance. This process is known as cachexia. The diagnostic criteria are similar with regard to skinfold thickness and arm circumference. However, due to the concomitant systemic inflammation, individuals with cachexia are more likely to have lower albumin levels and can be 



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