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Parenteral nutrition: Albumin versus total proteins in the assessment of plasma calcium to adjust parenteral nutrition: A series of cases
Nutrición parenteral: albúmina versus proteínas totales en la valoración del calcio plasmático para ajustar la nutrición parenteral: a propósito de una serie de casos
Lorena García, María Fernández, Nuria Bengoa, Rosario Pintor, Francisco Arrieta
Corresponding author
arri68@hotmail.com

Corresponding author.
Hospital Universitario Ramón y Cajal, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Plasma calcium is the parameter most commonly used to determine patient calcium levels in clinical practice&#46; However&#44; in certain physiological conditions&#44; plasma calcium may not reflect the true clinical situation of the patient&#46; Calcemia &#40;blood calcium concentration&#41; is closely regulated in the body&#44; with total calcium values between 2&#46;2 and 2&#46;6<span class="elsevierStyleHsp" style=""></span>mmol&#47;l &#40;9&#8211;10&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; and ionic calcium values between 1&#46;1 and 1&#46;4<span class="elsevierStyleHsp" style=""></span>mmol&#47;l &#40;4&#46;5&#8211;5&#46;6<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41;&#46; Forty percent of circulating plasma calcium is bound to proteins &#40;mainly albumin&#44; but also to globulins&#41;&#44; 6&#37; is bound to phosphates&#44; citrate and bicarbonate&#44; and the remaining 54&#37; corresponds to ionic calcium&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> The total calcium values change when the plasma protein levels change&#44; while ionic calcium remains unchanged&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;3</span></a> Situations where calcemia can be strongly influenced by changes in plasma protein levels include volume overload&#44; malnutrition and nephrotic syndrome&#46; Hypoalbuminemia can also be found in patients with cancer or surgical complications &#40;bleeding&#44; fistula&#44; intestinal perforation&#44; etc&#46;&#41;&#46; In these cases&#44; we observe a decrease in total plasma calcium&#44; but not in ionic calcium&#44; a situation known as pseudohypocalcemia&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> There are other circumstances in which total calcium is hardly evaluable&#44; such as a reduced glomerular filtration rate and alkalosis&#44; since alterations in acid-base equilibrium cause H<span class="elsevierStyleSup">&#43;</span> ions to compete with Ca<span class="elsevierStyleSup">2&#43;</span> for the protein binding points&#44; though total calcium remains unchanged&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#8211;7</span></a> However&#44; when there are alterations in acid-base equilibrium&#44; the free calcium fraction is modified&#44; and the patients clinically manifest hypocalcemia due to a decrease in ionic calcium&#44; thereby underlining the importance of determining it through laboratory tests&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> Of note is the high frequency of hypoproteinemia in patients subjected to total parenteral nutrition &#40;TPN&#41; &#40;approximately 85&#37;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a>&#41;&#44; which points to the need for strict control in such cases&#46; When interpreting the biochemical parameters of a patient&#44; uncorrected plasma calcium is of no diagnostic value and must be confirmed by the measurement of ionic calcium as the gold standard&#46; When ionic calcium cannot be determined&#44; the total protein &#40;TP&#41; or albumin correction methods can be used &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;5</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">A series of cases are presented below&#44; corresponding to patients receiving TPN and followed-up on by the Nutrition Unit of Hospital Universitario Ram&#243;n y Cajal &#40;Madrid&#44; Spain&#41;&#46; An analysis is made of the best calcium adjustment method for the diagnosis of hypocalcemia&#44; using equations that correct the plasma calcium levels and afford estimates that are closer to the real concentration&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The indications of TPN were as follows&#58; case 1&#58; a 53-year-old woman operated upon due to a pelvic tumour&#59; case 2&#58; a 54-year-old male with perforation of the sigmoid colon and peritonitis&#59; case 3&#58; a 60-year-old woman with peritoneal pseudomyxoma and peritoneal carcinomatosis&#59; case 4&#58; a 72-year-old male with urothelial carcinoma&#44; chronic calcifying pancreatitis and acute lithiasic cholecystitis&#59; case 5&#58; a 79-year-old woman operated upon due to postsurgery eventration&#59; case 6&#58; a 56-year-old male with esophageal adenocarcinoma&#59; and case 7&#58; a 74-year-old male with a metal mitral valve prosthesis and annuloplasty&#44; pneumonia and respiratory distress syndrome&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Total plasma calcium&#44; TP and albumin were analysed with the ARCHITECT c16000 Abbot system &#40;the routine protocol in the laboratory of our hospital&#41;&#44; and TP and albumin correction methods were used&#46; Ionic calcium was determined by potentiometry &#40;GEM Premier 4000 gasometer&#41;&#46; In order for hypocalcemia to be symptomatic &#40;Trousseau and Chvostek signs&#41;&#44; calcium levels must be &#60;8<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; The above-mentioned patients had low calcium levels without clinical manifestations&#44; no history of hypocalcemia&#44; and were not receiving drugs capable of inducing hypocalcemia&#46; With correction&#44; plasma calcium was seen to exceed 8<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; Fifty-seven percent of the patients continued to show hypocalcemia after calcium correction for proteins&#44; but only 14&#37; showed hypocalcemia after correction for albumin&#46; On contrasting these values with those of ionic calcium&#44; all the calcium values were found to be normal &#40;pseudohypocalcemia&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Our study indicates that calcemia correction for albumin is more reliable for correctly diagnosing hypocalcemia&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> The cases presented reflect the influence of protein&#47;albumin upon the calcium levels&#44; as previously reported in the literature&#44; mainly in patients with renal failure&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> This may result in an incorrect diagnosis&#44; which in some cases could lead to the provision of TPN with more calcium than necessary&#46; Routine biochemical testing usually reports total calcium levels and protein-corrected levels&#44; but not albumin-corrected or ionic calcium levels&#46; However&#44; there is still controversy in the literature regarding the best method for measuring plasma calcium&#44; with significant differences in terms of costs and clinical sensitivity&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">We conclude that it is essential to accurately determine calcemia in patients receiving TPN as well as in all hospitalized patients in general&#46; It is therefore advisable to request albumin in the laboratory tests and&#44; in the event of doubt&#44; to determine ionic calcium&#44; particularly in patients with alkalosis and&#47;or altered renal function&#46; If albumin or blood gases are not immediately available&#44; the laboratory test results should be examined with caution&#44; especially if the reported calcium concentration is &#60;8<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; In such a case&#44; the clinical condition of the patient should be prioritised&#44; TPN being supplemented with calcium only in the presence of symptoms of hypocalcemia&#46; However&#44; while the study suggests that calcium correction for albumin is more useful in clinical practice&#44; and specifically for adjusting parenteral nutrition&#44; than correction for proteins&#44; studies involving larger samples are needed to consolidate these findings&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0035" class="elsevierStylePara elsevierViewall">The present study has received no specific support from public&#44; commercial or non-profit sources&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Garc&#237;a L&#44; Fern&#225;ndez M&#44; Bengoa N&#44; Pintor R&#44; Arrieta F&#46; Nutrici&#243;n parenteral&#58; alb&#250;mina versus prote&#237;nas totales en la valoraci&#243;n del calcio plasm&#225;tico para ajustar la nutrici&#243;n parenteral&#58; a prop&#243;sito de una serie de casos&#46; Endocrinol Diabetes Nutr&#46; 2019&#59;66&#58;272&#8211;274&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Plasma calcium levels&#44; total protein levels&#44; serum albumin levels&#44; corrections and ionic calcium corresponding to each of the patients analysed&#46;</p>"
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Article information
ISSN: 25300180
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos