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We read with great interest the April 2015 Practice Points article, "Clinical Order Sets: Defining Laboratory Tests for Pressure Ulcers," by Cathy Thomas Hess, BSN, RN, CWOCN. As thought and content experts in the field of nutrition and wound healing, we would like to clarify the use of albumin as a basic screening tool for nutritional status and its perceived direct relationship to the severity of protein deficiency. In addition, we would like to comment on the common conflation about prealbumin as a "better indicator of acute nutritional status changes than albumin."


Current research indicates that using negative acute phase reactants, such as albumin and prealbumin, to measure nutritional status is no longer appropriate. Negative acute phase reactants are affected by the presence of inflammation, stress, hydration status, and renal function. Cytokine mediators, interleukin 1[beta], interleukin 6, and tissue necrosis factor, redirect the liver to synthesize positive acute phase reactants, such as C-reactive protein and ferritin, rather than negative acute phase reactants. During this period of inflammation and/or stress, albumin is pulled from the extravascular space to the plasma and returned back to the extravascular space when inflammation declines. Albumin and prealbumin levels increase with dehydration and decrease with overhydration; this does not impact nutritional status.


Studies support that the entire class of hepatic proteins is a better indicator of morbidity and mortality than it is of nutritional status. This makes these hepatic proteins useful as indicators of illness severity. Hepatic protein levels do not accurately measure nutrition repletion, thus making them poor markers of malnutrition. The Academy of Nutrition Dietetics and the American Society of Enteral and Parenteral Nutrition's (ASPEN) 2012 article, "Characteristics recommended for the identification and documentation of adult malnutrition"1 defines an etiology-based approach to describe a standard set of diagnostic characteristics to define malnutrition. These characteristics include reduced energy intake, weight loss, and decline in muscle mass. The 2014 National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance Guidelines for the Prevention and Treatment of Pressure Ulcers do not recommend the use of laboratory tests of acute phase reactants as indicators of malnutrition based on the lack of research.


Registered dietitians are an integral part of the wound care team and can bring current information and research to light as the field is rapidly growing as more research is published. Registered dietitians are your best source of accurate and current nutrition information. Also featured in the April issue of Advances in Skin & Wound Care is the continuing education article, "The Role of Nutrition for Pressure Ulcer Management: National Pressure Ulcer Advisor Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance White Paper,"2 which provides additional information on this topic. This article offers a complete understanding of current nutritional recommendations for pressure ulcers.


-Nancy Collins, PhD, RDN, LD, FAPWCA, FAND


-Becky Dorner, RDN, LD, FAND


-Mary Ellen Posthauer, RDN, CD, LD, FAND


Nutrition Editorial Advisory Board, Advances in Skin & Wound Care


In response:


Thank you to the authors of the "Letter to the Editor" for their expert contributions regarding albumin, prealbumin, and nutritional status.


-Cathy Thomas Hess, BSN, RN, CWOCN




1. White JV, Guenter P, Jensen G, et al. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet 2012; 112: 730-8. [Context Link]


2. Posthauer ME, Banks M, Dorner B, Schols JMGA. The role of nutrition for pressure ulcer management: National Pressure Ulcer Advisor Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance white paper. Adv Skin Wound Care 2015; 28: 175-88. [Context Link]