Clinical Application of Albumin and Its Significance in Nutrition Therapy
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Abstract:
Albumin can quickly expand fluid and maintain a stable plasma colloid osmotic pressure in patients with hypovolemia.However,when various diseases cause the increase of the permeability of capillaries,albumin may not play such a role or even counteract.Considering the facts that albumin has a long half-life in human body,that it can be used only when it metabolizes into amino acids,and that it contains limited number of essential amino acids,its nutrition value is limited.However,albumin can improve the gut tolerance when patients with severe hypoalbuminemia undergo enteral nutrition supports.Keywords:
Hypoalbuminemia
Oncotic pressure
Hypovolemia
Serum Albumin
Human albumin
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Enteral administration
Basal (medicine)
Feeding tube
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Retinol binding protein
Nitrogen balance
Enteral administration
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Hypoalbuminemia
Marasmus
Serum Albumin
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Nutritional support is indicated when cirrhotic patients undergo surgery becasue they are malnourished, hypercatabolic and immunocompromised. However, the choice of nutrient may be problematic as the liver itself is the central organ of protein, fat and glucose metabolism. Branched chain amino acid‐enriched solution may be the choice of protein source, as it is anticatabolic and it stimulates liver regeneration. Excessive glucose is undesirable as it may suppress endogenous fat utilization, which may be the preferred pathway of metabolism after hepatectomy. Medium chain triglycerides are preferred to long chain triglycerides as they are readily utilized and are not deposited in the liver; however, the tendency of cirrhotic patients to accumulate free fatty acids and glycerol after infusion of triglycerides dictates their use intermittently. Clinical studies have shown that perioperative nutritional support is beneficial in cirrhotic patients undergoing major hepatectomy or liver transplantation. The judicious choice of nutrient, care of the catheter and a limitation of the fluid infused are all prerequisites for the efficient use of perioperative nutritional support, which is complementary to a technically perfect operation.
Liver Regeneration
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Spanner
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Protein-calorie malnutrition is present in a sizable proportion of dialysis patients. In CAPD patients, constant glucose absorption from dialysate may displace other calorie sources, such as protein, and may suppress the appetite, thus contributing to malnutrition. Use of amino acids in place of glucose as the osmotic agent has been studied extensively. Ultrafiltration and small-molecule clearance similar to that with glucose can be achieved with amino acid solutions, but nitrogenous waste produced by amino acids limits the extent to which they can replace hypertonic glucose. Side effects of CAPD with amino acids appear to be minor and easily manageable. Most studies have found at least some nutritional benefit of amino acid solutions in addition to that of lowering the glucose load. Short-term studies of amino acid solutions for dialysis indicate that they may improve protein nutrition in malnourished CAPD patients.
Ultrafiltration (renal)
Calorie
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The development of peptide-based enteral formulas is a significant milestone in the advancement of nutritional care of the nutritionally compromised patient. Although previously limited to specific gastrointestinal mucosal diseases, the use of peptide-based formulas has been extremely useful in the critically ill patient with impaired gastrointestinal absorption associated with hypoalbuminemia resulting from hypermetabolic states. Based on previous animal studies, several investigators have noted improved nitrogen absorption, greater nitrogen utilization, higher branched chain amino acid levels, and increased insulin secretion with the use of peptide-based formulas compared with intact protein or free amino acid diets. Recent studies have indicated an improved gastrointestinal tolerance with peptide-based diets, with the rate of absorption and the degree of tolerance dependent on the presence of small molecular weight peptides. In addition, we have found that the critically ill patient suffering from severe hypoalbuminemia frequently develops a protein-losing enteropathy, which can be attenuated by the use of a peptide-based formula. Thus, peptide-based formula may attenuate albumin turnover in the intestine and thus be efficacious in patients with a protein-losing enteropathy from a variety of etiologies (table 2). We therefore recommend that enteral support with a peptide-based diet is safe and extremely useful in the catabolic, critically ill patient or in patients with significant gastrointestinal malabsorption associated with a protein-losing enteropathy. Tolerance of these formulas is dependent on the catabolic state of the patient, with more catabolic patients needing higher concentrations of nitrogen in the form of peptides and/or supplemental parenteral branched chain amino acids.(ABSTRACT TRUNCATED AT 400 WORDS)
Enteral administration
Hypoalbuminemia
Etiology
Catabolism
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Recent investigations here and elsewhere have demonstrated that a pronounced negative nitrogen balance occurs in patients after intra-abdominal operation. 1 In most instances this nitrogen loss does not seriously affect the concentration of protein in the serum, but in patients with gastrointestinal cancer the development of significant hypoproteinemia is an almost uniform finding. 2 The gravity of postoperative hypoproteinemiais widely recognized, and any measures which would successfully prevent its occurrence should prove most useful. The development of postoperative hypoproteinemia in the patients with gastrointestinal cancer apparently is the result of numerous factors. Among these are that ( a ) frequently the patient is already hypoproteinemic when he comes to surgery, a fact which strongly suggests that his protein stores are depleted; 3 ( b ) the functional capacity of his liver is very much impaired 4 and therefore the fabrication of plasma albumin by this organ is likely to be limited; 5 ( c
Gastro-
Digestive tract
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Critically ill patients are characterized by acute changes in their metabolism, which are described by the term 'hypermetabolism'. In combination with anorexia, hypermetabolism leads to a negative energy and nitrogen balance. Consequently, wound healing can be inhibited, resistance is reduced, and (multiple) organ failure can occur. With the aid of nutritional support these consequences can be counteracted. During hypermetabolism protein breakdown is increased, and it is necessary to supply extra protein in the diet of critically ill patients. The amino acid glutamine is an important source of energy for enterocytes, and extra glutamine can improve the protective function of the intestinal mucosa. Branched amino acids serve as energy source during the acute phase. Arginine can reduce symptoms of encephalopathy by improving the conversion of ammonia to urea. Extra arginine in the diet also improves resistance. Because of the increased energy demand, diets for critically ill patients should be rich in fat. Moreover, extra n-3 fatty acids can improve immune function. A diet supplemented with extra zinc seems warranted because of its beneficial effect on wound healing and its inhibitory effect on protein breakdown. The enteral route is preferred because it protects the mucosal barrier of the gut, and it is less expensive and easier than the parenteral route. An enteral diet for critically ill patients is presented. Various factors that determine the choice of technique for enteral feeding are discussed.
Hypermetabolism
Enteral administration
Gastrointestinal function
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A total parenteral nutrition may particularly be used in patients with liver diseases, for comatous patients or postoperatively. By using central venous catheterization the practical application of high osmolar solutions, fat emulsions and amino acid mixtures is easy to be performed. Partial parenteral nutrition is needed mainly for decompensation of metabolic disturbances of amino acids in liver diseases. As carbohydrates particularly glucose is used, but because of the deranged glucose tolerance also fructose and glucose substitutes are given in mixed solutions. The infusion of fat emulsions partly covers the need of energy and on the other side prevents a lack of essential fatty acids. Recent investigations demonstrated that fat emulsions may be tolerated by patients with liver diseases and fat is utilized for energy metabolism. The changes of plasma amino acids in blood in patients with chronic liver diseases, especially in the stage with liver insufficiency, demands for a special amino acid solution. For the accomplishment of a total as well as for partial parenteral nutrition principles are given and relevant clinical problems are discussed.
Decompensation
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