hypoproteinemia



OVERVIEW

Definition.

Hypoproteinemia refers to a decrease in total plasma protein and albumin. Hypoproteinemia is generally defined as a decrease in total serum protein <60 g/L or serum albumin <35 g/L.

Clinically, serum albumin <35 g/L is often referred to as hypoalbuminemia.

Hypoproteinemia can be seen in various systemic diseases, such as severe illness in the elderly, severe infections, surgical trauma, malignant tumors, cirrhosis of the liver, nephrotic syndrome and so on.

Causes

Causes

Insufficient protein intake

Food in poor areas is mainly plant-based, and the quantity and quality of meat, eggs, milk and other high-quality proteins are insufficient.

Insufficient breast milk or hasty weaning during infancy, without adding other dairy products, and artificial feeding is mainly cereal, resulting in long-term protein deficiency.

Suffering from congenital diseases, such as cleft lip, cleft palate, pancreatic dystrophy, etc., which affect the intake of nutritious food.

Unable to eat or eating very little for a long time due to illness.

Reduced protein absorption

Sudden acute infection or after major surgery or severe trauma, which can occur within a short period of time.

Congenital diseases, such as congenital hypertrophic pyloric stenosis, which affect the digestion, absorption, and metabolism of nutritious food.

Decreased function of the liver to synthesize albumin

Liver diseases, such as cirrhosis, cause liver damage that affects hepatic protein synthesis and a sustained decline in albumin.

Increased rate of protein catabolism

Chronic wasting diseases, such as hyperthyroidism, malignant tumors, severe tuberculosis, etc., can lead to accelerated rate of protein catabolism and formation of hypoproteinemia.

Excessive protein loss

Chronic prolonged digestive diseases: such as chronic enteritis, bacterial dysentery, severe intestinal parasitosis, intestinal malabsorption syndrome, infantile hepatitis syndrome, etc., due to a large amount of diarrhea, which can lead to a large amount of protein loss from the digestive tract.

Chronic kidney disease: such as chronic nephritis, nephrotic syndrome, diabetic nephropathy, etc., there is a large amount of proteinuria, which can lead to protein loss from the urine.

Medical treatment: peritoneal dialysis treatment for end-stage renal disease, repeated puncture and drainage of pleural and peritoneal fluid, etc., which can lead to protein loss via body fluids.

Abnormal distribution of albumin

Severe infection, sepsis, intravascular albumin permeates the tissue interstitium in large quantities, resulting in hypoproteinemia.

Risk factors

Persons with one or more of the following risk factors are at high risk for hypoproteinemia.

Hepatic insufficiency.

Renal insufficiency.

Severe malnutrition.

Malignant tumors.

Advanced age.

Acute infections.

Symptoms

Hypoproteinemia is often one of the manifestations of various systemic diseases, and patients may present with edema, wasting, and fatigue.

Main Symptoms

Edema

Mild: lower extremity ankles.

Moderate: edema of the abdominal wall of the trunk, edema of the eyelids of the face, inability to open both eyes.

Severe: pleural effusion and abdominal effusion may occur.

Sunken edema.

Positively correlates with low plasma albumin.

Abdominal distension is often present with abdominal effusion and chest tightness and shortness of breath with pleural effusion.

Severe hypoproteinemia can cause pulmonary edema, which can lead to dyspnea and heart failure.

Other symptoms

Wasting

The patient has poor appetite, refuses to eat, wasting away day by day and losing weight significantly in a short period of time.

Skin, hair, finger (toe) nail changes

Skin is dry, lusterless, inelastic, hyperkeratotic and hardened, and hyperpigmented.

Hair is dry, brittle, fine, lusterless, easy to break and fall off, thinning, light color, curly hair will become straight.

Finger (toe) nails grow slowly, thin and brittle, easy to break.

Poor Mental Health

Dull and unresponsive, with little activity and dislike of socializing.

There are often symptoms of fatigue and weakness.

Sometimes moaning and irritability.

Complications

Water and electrolyte disorders

When vomiting and diarrhea occur, water and electrolyte disorders are easily caused.

Patients may present with thirst, convulsions, muscle weakness, fatigue, and irritability.

Susceptible to infection or contagion

Systemic immunocompromise makes the patient susceptible to infections and contagious diseases.

Patients may have respiratory and intestinal infections, causing fever and other symptoms.

Once infection occurs, it is easy to be prolonged.

Other nutritional deficiencies, anemia

If the protein is low for a long time, malnutrition, patients may develop vitamin A deficiency, manifested as dry and soft cornea, or even perforation.

Malnutrition patients, can also appear due to vitamin B deficiency caused by keratitis.

Malnutrition in children is often accompanied by nutritional anemia.

Pressure sores

Chronic low protein can lead to skin edema and low immunity, which can affect the supply of nutrients to the skin, making it more susceptible to damage and difficult to heal.

Patients may present with redness, swelling, blisters, ulcers and necrosis of the skin at the pressure site.

Consultation

Department of Medicine

Patients usually do not present with hypoproteinemia as a primary factor, but rather for other reasons, which are found to be associated with hypoproteinemia after laboratory tests.

Gastroenterology

Hypoproteinemia is most often complicated by digestive disorders, where protein deficiency is caused by impaired protein digestion, absorption and synthesis.

Prompt consultation is recommended in cases of loss of appetite, difficulty in eating, nausea and vomiting, abdominal pain and diarrhea, or a history of hepatitis.

Nephrology

When there is non-dissolving foamy urine, facial edema or generalized edema, timely consultation is recommended.

Emergency Medicine

In case of critical symptoms such as severe chest tightness, difficulty in breathing, etc., it is recommended to consult the emergency department or call 120 emergency number immediately.

Preparation

Preparation for medical consultation: registration, preparation of documents, common problems

Tips for seeking medical treatment

If you have underlying medical conditions, it is recommended that you consult the appropriate department and bring your past medical records with you.

Eat a regular diet and do not over-supply protein.

Fasting.

Preparation Checklist

Pay particular attention to the time of onset of symptoms, special manifestations, etc.

Have you recently had edema of the limbs or face?

Has there been recent lethargy, fatigue, weakness, loss of appetite, fever or other discomforts?

Has there been recent chest tightness, shortness of breath, or abdominal bloating?

Do you have a plant-based diet with little protein intake?

Are you suffering from cleft lip, cleft palate, pancreatic dystrophy?

Are there any chronic diseases of the liver or kidneys?

Are there any malignant tumors?

Has there been recent hemorrhage due to trauma?

Is there any dysphagia?

Test results in the last six months, which can be brought to the doctor’s office.

Laboratory tests: blood biochemistry, blood routine, urine routine, fecal routine + occult blood test, tumor markers test

Imaging examination: ultrasonography, CT and magnetic resonance examination of the corresponding parts of the body.

Pathologic examination: histopathologic biopsy, cytopathologic examination

Medications used in the last 3 months, if there is a medicine box or package, you can bring it to the doctor.

Protein-amino acid supplementation drugs: human albumin, amino acid preparations (oral hydrolyzed protein, etc.)

Diuretics: furosemide, spironolactone

Medications for underlying diseases: e.g., hepatitis B, cirrhosis antiviral therapy medications (entecavir, tenofovir)

Diagnosis

Diagnosis is based on

medical history

A history of wasting disease such as hepatic or renal insufficiency, tumors, etc.

History of sudden acute infection.

History of major surgery or severe trauma.

Clinical manifestations

There are often symptoms of malnutrition, emaciation, anemia, fatigue and weakness.

There are jaundice, vomiting blood, black stools, generalized edema and other manifestations.

Often immunocompromised and easily infected.

Children may have growth retardation.

Chronic illness is often present, and those who are anemic may have an anemic face (pale face, pale lips and tongue, and a tired expression).

Skin pigmentation, loss of luster and elasticity.

Those with a history of hepatitis may have liver palms, spider nevi, and enlarged liver and spleen.

In patients with a history of nephrotic syndrome and initiation of venous thrombosis, there may be tenderness in the renal region.

Laboratory Tests

Blood biochemistry

Routine blood tests

Tumor markers

Urine routine: If the result shows urine protein, urine occult blood, etc., it suggests that kidney disease may exist.

Stool routine + occult blood test: If the result shows positive occult blood, it suggests the possibility of gastrointestinal bleeding.

Imaging examination

Purpose: A non-invasive test to check for fluid in the plasma cavity (e.g., thoracic cavity, abdominal cavity).

Significance: Chest ultrasound can detect pleural fluid, abdominal ultrasound can detect abdominal fluid, etc., which can guide treatment.

Precautions: Fasting is required before abdominal ultrasound, and moderate urine holding is required before pelvic ultrasound.

Purpose: It is a radiological examination, which can check for cirrhosis and tumors.

Significance: It can detect lumps and clarify the location.

Precautions: Remove high-density or metal objects on the body, such as hard buckles on belts, etc., before the examination. Pregnant women are forbidden to do it, and children should be cautious.

Purpose: To locate tumors and other conditions.

Significance: It can detect lumps and clarify the location and nature of the lumps initially.

Precautions

Pathologic examination

Purpose: To clarify the nature of the effusion.

Meaning: It can detect tumor cells, clarify the amount of protein, and initially clarify the nature of the effusion.

Precautions

Purpose

Significance

Precautions

Differential Diagnosis

The diagnosis is clear with plasma protein testing, but the causes of hypoproteinemia need to be differentiated. Some common causes are identified below.

Malnutrition

Inadequate nutritional intake may be manifested by anemia, emaciation, low subcutaneous fat, etc. Hypoproteinemia may be present to exclude other diseases, and auxiliary tests such as micronutrient measurements, blood routine, blood biochemistry, etc. may help to clarify the diagnosis.

Cardia dystrophy

Intermittent food stagnation, obstructed feeling, difficulty in swallowing and other manifestations may cause insufficient intake of protein, resulting in hypoproteinemia. Auxiliary tests such as esophageal X-ray barium meal imaging and gastroscopy can help to clarify the diagnosis.

Cirrhosis

Patients often have a history of hepatitis, the function of liver synthesizing albumin decreases, there may be dyspepsia, jaundice, vomiting blood, ascites and other manifestations, and there may be hypoproteinemia, liver function test, ultrasound, abdominal CT and other auxiliary examinations can help to clarify the diagnosis.

Malignant tumor

Tumor patients in the late stage often show extreme emaciation, and it is still difficult to correct hypoproteinemia after supplementing a large amount of protein, and there may be elevation of corresponding tumor markers, and imaging examination may find tumor or occupancy. Pathologic examination can confirm the diagnosis.

Nephrotic syndrome

The main manifestations of nephrotic syndrome are “three highs and one low”, large amount of proteinuria, hypoalbuminemia, accompanied by edema and hyperlipidemia. The first two are necessary for diagnosis. Renal puncture biopsy can clarify the diagnosis.

Infection

Acute infection progresses rapidly, there may be obvious symptoms such as chills, fever, etc. Severe infection and sepsis may cause hypoproteinemia, and elevated infectious markers (e.g., C-reactive protein, procalcitonin) and cultured pathogens can help to clarify the diagnosis.

Treatment

Aim of treatment: correct hypoproteinemia, prevent and control infection and other complications, improve the nutritional status of patients and improve the quality of life.

Treatment principle: active treatment of primary diseases, protein supplementation, supplemented by drug therapy, puncture drainage when necessary.

General treatment

Treatment of primary disease

For patients diagnosed with hepatitis B virus infection and cirrhosis, antiviral and antifibrosis treatment is required.

For patients with confirmed nephrotic syndrome, treatment to protect renal function.

For patients with tumors, surgery, chemotherapy, radiotherapy and other treatments.

For patients with co-infections, anti-infection treatment.

Adjust diet

Supplement more high-quality protein.

Ensure the physiological requirement, the total calorie reaches 120~150kcal/(kg-d) at the highest, protein 2~4g/(kg-d).

Pay attention to supplying sufficient amounts of various vitamins and trace elements.

When the severely ill patients have poor digestion and refuse to eat, they can be fed temporarily by nasal or oral tube feeding, following the principles of small amount, multiple times and slowly.

Feed patiently according to the doctor’s instructions to prevent vomiting and choking.

Avoid forcing to eat when the appetite is poor, and try to eat when the mood is happy.

Rest

Seriously ill patients should rest in bed.

Long-term bedridden patients should turn over diligently to prevent pressure sores.

Pay attention to keep warm when the body temperature is low and the limbs are cold, but pay attention to prevent burns.

Medication

Protein supplementation

Common drugs: amino acid preparations (oral hydrolyzed protein, etc.), human albumin, etc.

Effects of medications

Precautions for medication

Nutritional support

Common drugs: medium/long-chain fat milk, compounded amino acids, etc.

Role of drugs: Supplementation of energy to ensure the amount of physiological needs.

Precautions for medication

Hormones promoting protein synthesis

Common drugs: recombinant human growth hormone (rh-GH).

Effects of drugs: Can promote protein synthesis in patients, and has obvious curative effects on hypoproteinemia in patients with severe burns.

Precautions: contraindicated in infectious shock, active tumors, acute respiratory failure in patients with acute and critical illnesses, proliferative or severe non-proliferative diabetic retinopathy.

Prognosis

Cure

Patients without chronic underlying disease generally improve with control of the primary disease.

Hypoproteinemia associated with chronic underlying disease may improve with symptomatic treatment (e.g., supplementation of human albumin, consumption of high quality protein).

If the primary disease is difficult to remove or is further aggravated, persistent hypoproteinemia may result.

Harmful effects

Symptoms such as edema, emaciation and poor mental health affect daily life, study and work.

Prolonged severe hypoproteinemia may aggravate the underlying disease, leading to a vicious circle.

It may be prone to complications of serious infections and infected diseases, and once infection occurs, it is easy to be prolonged.

Daily

Daily Management

Dietary management

Supplement more foods containing high quality protein, such as dairy, eggs, fish, meat, liver, poultry, blood and soybean products.

Ensure total energy intake, increase body weight and control body mass index (BMI) at 18.5-23.9.

Eat plenty of fresh vegetables and fruits, especially foods with high potassium content, such as fresh fruit juice and spinach.

Hygiene management

The living room should be sunny, fresh air and clean.

Keep the skin of the whole body clean, especially the skin of edematous limbs, to avoid the skin being damaged and difficult to heal.

Seriously ill patients should rest in bed. Feed patiently according to the doctor’s instructions to prevent vomiting and choking.

Avoid forcing to eat when the appetite is poor, and try to eat when the mood is happy.

Long-term bedridden patients should turn over diligently to prevent pressure sores.

When the body temperature is low and the extremities are cold, pay attention to keep warm, but pay attention to prevent burns.

Psychological support

Receive health education to understand the underlying disease, knowledge about hypoproteinemia, and correct misperceptions about the disease.

When there is emotional instability or psychological depression, talk to friends and relatives in time, or seek help from medical personnel.

If necessary, professional psychological counseling should be conducted to avoid affecting the therapeutic effect due to psychological problems.

Relatives of the patient need to pay attention to the patient’s psychological changes in daily life.

Exercise

While supplementing nutrition, start to increase physical activities, such as walking, sports activities, games, etc., to enhance cardiopulmonary function and muscle exercise.

Disease monitoring

Condition monitoring of the original disease and monitoring of physical recovery.

Regularly monitor weight, serum total protein, albumin and other indicators.

Children monitor height and head circumference.

Prevention

Follow a balanced dietary pattern with a variety of foods to ensure adequate nutritional intake.

Timely treatment of underlying diseases, early diagnosis and treatment.

Actively search for the cause of the disease, treat the original disease, and reduce protein loss and consumption.

Complete planned immunization to prevent infectious and contagious diseases.

Regular health monitoring for early detection and treatment.