Hypoproteinemia

Plasma protein fractions are used to treat hypovolemic (low blood volume) shock that occurs as the result of bums, trauma, surgery, and infections, or in conditions where shock is not currently present but likely to occur. Plasma protein fractions are also used to treat hypoproteinemia (a deficiency of protein in the blood), as might be seen in patients with nephrotic syndrome and hepatic cirrhosis, as well as other diseases or disorders. As with human pooled plasma, blood type and crossmatch is not needed when plasma protein fractions are given. 

Sodium is contraindicated in patients with hypernatremia, fluid retention, and when the administration of sodium or chloride could be detrimental. Sodium is used cautiously in surgical patients and those with circulatory insufficiency, hypoproteinemia, urinaiy tract obstruction, congestive heart failure, edema, and renal impairment. Sodium is a Pregnancy Category C drug and is used cautiously during pregnancy. 

Special risk patients Administer cautiously to patients with decompensated cardiovascular, cirrhotic, and nephrotic disease circulatory insufficiency hypoproteinemia hypervolemia urinary tract obstruction CHF and to patients with concurrent edema and sodium retention those receiving corticosteroids or corticotropin and those retaining salt. 

Disorder of protein metabolism could be noticed in 13% decrease of total protein content in blood serum. The observed hypoproteinemia was stipulated by 25% decrease of albumin fraction. The index showing correlation between the level of middle molecules and total protein was 65% higher in Group 2 indicating prevalence of protein degradation processes over their synthesis. The revealed disorders indicated the development of liver failure syndrome. Profound disorders were also registered in lipid metabolism. We determined the intensification of lipolysis by increase in the concentration of the main lipid fractions in blood serum. The level... 

Gastrointestinal system Increased appetite increased frequency of bowel movements hypoproteinemia Decreased appetite decreased frequency of bowel movements ascites... 

When given in larger than physiologic amounts, steroids such as cortisone and hydrocortisone, which have mineralocorticoid effects in addition to glucocorticoid effects, cause some sodium and fluid retention and loss of potassium. In patients with normal cardiovascular and renal function, this leads to a hypokalemic, hypochloremic alkalosis and eventually to a rise in blood pressure. In patients with hypoproteinemia, renal disease, or liver disease, edema may also occur. In patients with heart disease, even small degrees of sodium retention may lead to heart failure. These effects can be minimized by using synthetic non-salt-retaining steroids, sodium restriction, and judicious amounts of potassium supplements. 

Nephrotic syndrome is a clinical and laboratory syndrome defined by heavy proteinuria (exceeding 3.5 g/1.73 m2 of body surface area in adults, or 40 mg/hr/m2 in children), accompanied by hypoproteinemia (mainly hypoalbuminemia), hypercholesterolemia (in severe cases also hypertriacylglycerolemia), lipiduria, and edema. 

Hypoproteinemia may result in low levels of serum calcium, ceruloplasmin, and transferrin. Because losses of iron are at most 0.5-1.0 mg/24 hr, even with the heaviest proteinuria, other factors must operate to produce iron deficiency and microcytic hypochromic anemia. Although the copper-binding protein ceruloplasmin is lost in the urine in nephrotic subjects and its plasma levels are low, plasma and red cell copper concentrations are usually normal. Zinc circulates mainly bound to albumin and also to transferrin, and thus the reported reduction zinc concentration in plasma, hair, and white cells in nephrotic patients is not surprising. 

Diagnosis of nephrotic syndrome depends on the identification of both the clinical signs (edema) and laboratory disorders (proteinuria, hypoproteinemia, hypoal-buminemia, hyperlipidemia). Lipid and coagulation abnormalities that also must be monitored are described in detail in the appropriate sections. 

Both forms of PEM are associated with hy-percortisolemia.The level of cortisol in kwashiorkor is lower, however, than in marasmus, likely due to decreased adrenocortical function caused by low protein intake (and not adrenal failure). If a sufficiently high level of cortisol is not maintained, then adequate muscle protein is not mobilized to sustain hepatic protein synthesis. Indeed, hypoproteinemia, evident by the decreased serum albumin and transferrin levels, is more acute in kwashiorkor than marasmus. 

H16. Holman, H., Nickel, W. F., Jr., and Sleisenger, M. H., Hypoproteinemia antedating intestinal lesions, and possibly due to exce.ssive. serum protein loss into the intestine. Am. ]. Med. 27, 963-975 (1959). 

Chronic intoxication with vitamin A has been reported to cause variously hypercalcemia, hyperglycae-mia, increased alkaline phosphatase, hypoproteinemia, hypoprothrombinemia, increased sulfobromphthalein retention, raised serum transaminases, low serum ascorbic acid, reduced protein content of the cerebrospinal fluid, raised urinary hydroxyproline, and hypercalciuria (SED-8, 800) (14). It is not always clear, however, whether these deviations are a cause or an effect of hypervitaminosis A. 

However, in the horse, the administration of a highly concentrated formula of hypertonic saline-dextran 70 resulted in clinically apparent intravascular hemolysis and hemoglobinuria (Moon et al 1991). Whether less-concentrated formulas are suitable for the horse remains to be investigated. The combination of an alternative colloid, hetastarch (lOml/kg), and hypertonic saline (4 ml/kg) may be an appropriate solution for the resuscitation of horses that are both hypovolemic and dehydrated. Clinical experience suggests that hypertonic-saline-hetastarch is particularly useful in horses with marked hypovolemia and hypoproteinemia, such as those with severe colitis, but this has not been formally evaluated in experimental studies or clinical cases. 

The use of colloids has recently been advocated for the resuscitation of hypovolemic horses and for the treatment of severe hypoproteinemia (McFarlane 1999). Colloids have two advantages over crystalloids that makes them attractive for fluid therapy. Firstly, because of their persistence in the circulation, a three to six times lower volume of a colloid solution is required to produce the same resuscitative effect as a crystalloid solution (Rackow et al 1987). This is particularly useful in acute resuscitation of severely dehydrated horses or in the field where large amounts of crystalloids may be difficult to transport. Secondly, the administration of colloids can increase colloidal oncotic pressure, in contrast to the administration of large volumes of crystalloids, which decreases the colloidal oncotic pressure (Jones et al 1997,2001). 

Systemic inflammatory response syndrome, hypoproteinemia, if hydroxyethyl starch unavailable Horses previously transfused... 

Hypoalbuminemia should be treated when acute or if there are clinical signs. Although it is advisable to treat all horses with a plasma total solids concentration of <4.0 g/dl, a few horses with chronic hypoproteinemia can have plasma total solids concentrations of 3.5-4.0g/dl with no apparent clinical signs. The treatment options for hypoalbuminemia include hetastarch and fresh or fresh frozen equine plasma. 

Amino acids Provide protein, calories, and fluid and are administered to patients who have hypoproteinemia. 

Triamterene is about 45 to 70% bound to plasma proteins.2 91 Influence of disease on binding of triamterene to plasma proteins has been studied.92 Plasma from uremic patients had a decreased binding of triamterene. Hypoproteinemia and hypoalbuminemia decreased the binding fraction. Drug binding was impaired by cirrhosis also.92... 

Values less than approximately 10 mmo /L or greater than about 20 mmol/L may indicate error. Elevated values may be found in patients with renal failure, diabetic acidosis, cardiac failure, anoxia, and other conditions (see Chapter 46). Low values occur in hypoproteinemia and with intravenous hydration. The capabilities of AG control procedures have been studied by Cembrowski and co-workers,who recommend that the average AG of groups of eight or more patients be used to provide a more sensitive statistical control. 

The total protein concentration of serum obtained from a healthy ambulatory adult is 6.3 to 8.3 g/dL and 6.0 to 7.8 g/dL from an adult at rest. The two general causes of alterations of serum total protein are a change in the volume of plasma water and a change in the concentration of one or more of the specific proteins in the plasma. Decrease in the volume of plasma water (hemoconcentration) is reflected as relative hyperproteinemia concentrations of all the individual plasma proteins are increased. Hyperproteinemia is noted in dehydration caused by inadequate water intake or excessive water loss as in severe vomiting, diarrhea, Addison s disease, or diabetic acidosis. Hemodilution (increase in plasma water volume) is reflected as relative hypoproteinemia concentrations of aU the individual plasma proteins are decreased. Hemodilution occurs with water intoxication or salt retention syndromes, during massive intravenous infusions, and physiologically when a recumbent position is assumed. A recumbent position decreases total protein concentration by 0.3 to 0.5 g/dL and many individual proteins including albumin by up to 10%. 

Of the individual serum proteins, albumin is present in such high concentrations that low levels of this protein alone may cause hypoproteinemia. Hypoalbuminemia is very common and has many causes. Mild hyperproteinemia may be caused by an increase in the concentration of specific proteins normally present in relatively low concentration, as, for example, increases in APR and polyclonal immunoglobulins as a result of infection. Marked hyperproteinemia may be caused by high levels of the monoclonal immunoglobulins produced in multiple myeloma and other malignant para-proteinemias. 

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