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Albumin and Prealbumin: Caution Before Use

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Kirsten Diegel, RD, LDN
Temple University Hospital
Philadelphia, PA, USA

As a transplant Registered Dietitian my role is to optimize a patient's nutritional status before, during and after their transplant. In fact, nutrition plays a role in whether or not a patient can be listed for lung transplant. Currently, the International Society of Heart and Lung Transplantation (ISHLT) guidelines for lung transplantation identify Class II or III obesity (body mass index [BMI] ≥35.0 kg/m2) as absolute contraindications to lung transplant and "Class I obesity (BMI 30.0-34.9 kg/m2), particularly truncal (central) obesity and progressive or severe malnutrition" as relative contraindications to transplant [1]. While ISHLT does not specify which parameters to use to identify progressive and/or severe malnutrition, I find that physicians and surgeons focus their attention on serum albumin and serum prealbumin levels as an indicator of nutritional status.

Unfortunately, serum albumin and serum prealbumin are not good indicators of nutritional status. Historically, physicians have used serum albumin and more recently serum prealbumin as markers of nutritional status; however, this practice was established prior to the understanding of the inflammatory processes associated with both acute and chronic illness [2]. It is now understood that both albumin and prealbumin are negative acute-phase proteins meaning they decrease in response to inflammation, but not always predictably so. Research has found that malnourished individuals will likely exhibit normal visceral proteins (ASPEN slides) and that "literature available on adults comparing intake and albumin levels has shown inconsistent results" [3,4].

Currently, there is no single laboratory value that can accurately identify a suboptimal nutritional status. For a laboratory value to be effective at identifying malnutrition it must be sensitive only to changes in nutrition intake and the change in its value should happen over a short time period4. Serum albumin and prealbumin do not fit any of those criteria. It should be noted however, that research has found that serum albumin levels do correlate well with areas that should be considered in relation to transplant outcomes.

Preoperative serum albumin is associated with morbidity, mortality and surgical outcomes. Hypoalbuminemia has been linked to increased morbidity, mortality and increased surgical complications in some populations [5,6].

Clinicians should recognize that serum albumin and prealbumin are not indicators of nutritional status, and therefore, will not necessarily improve with nutritional interventions. Clinicians should use the following laboratory values as indicators of how ill a patient is, and to determine preoperatively whether a patient is at an increased risk for complications, morbidity and mortality following surgery.

Take Home Points for Clinicians

Hepatic serum proteins in patients with inflammatory conditions are not related to nutritional status and should not be used a marker for such

Preoperative serum albumin has been found to be related to morbidity, mortality, and surgical outcomes

Hepatic serum proteins are related to disease severity

An effective nutrition marker should be:

  • Only sensitive to changes in nutrition intake only
  • Change in level should happen in a short time in relation to change in nutrition status
  • Level should be directly related to adequate or inadequate intake

Nutritional status should be based upon assessing the patient's intake, a physical examination, and obtaining and tracking accurate, dry weight

Disclosure Statement: The author has no conflicts of interest to disclose.


  1. Weill D, Benden C, Corris PA, et al. A consensus document for the selection of lung transplant candidates: 2014-An update from the Pulmonary Transplantation Council of the International Society for Heart and Lung Transplantation. The Journal of Heart and Lung Transplantation. 2015;34(1):1-15.
  2. Fuhrman MP, Charney P, Mueller C. Hepatic Proteins and Nutrition Assessment. Journal of the American Dietetic Association. 2004;104(8):1258-1264.
  3. Fuhrman T. Nutrition Support Fundamentals and Review Course Week 1: Test Taking Tips, Nutrient Deficiencies and Malnutrition Assessment. Webinar presented by the American Society of Parenteral and Enteral Nutrition; July 2016.
  4. Banh, Le. Serum Proteins as Markers of Nutrition: What Are We Treating? Practical Gastroenterology. Edited by Carol Rees Parrish. 2006:46-64.
  5. Huckleberry, Yvonne. Nutritional support and the surgical patient. Am J Health-Syst Pharm. 2004:671-682.
  6. Gibbs, J., Cull, W., Henderson, W., Daley, J., Hur, K., & Khuri, S. Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity. Arch Surg. 1999;134: 36-42.

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