Y Hpc TP. Hb Chi Minh * Tap 21 * So 5 * 2017 Nghien a i u Y hpc
DANH GIA N 5 N G DO ALBUMIN VA PREALBUMIN TRONG TAM SOAT SUY DINH D U O N G 6 NGLTCJI L 6 N
Tr'dn QuocHuy*, Lam VinhNien**
TOMTAT
Ma dau: Suy dinh duong anh hu&ng deh site khoe benh nhdn luc nhap vien. Co nhieu chi so sinh hoc dugc dimg dephdt hien som suy dinh duang. Tim him gid tri ciia cdc chi so sinh hoc trong tam sodt suy dinh duang se ho trg viic phdt hien vd dieu trj suy dinh duang & benh nhdn.
M\ic tieu- Ddnh gid nong do albumin vd prealbumin mdu trong tam sodt suy dinh duong & ngu&i l&n v&i chuan tham chieu SGA.
Boi tugng vd phuang phap nghien c&u: Nghiin cim mo td cat ngang trin benh nhdn m&i nhap vien trong thin gian thdng 11/2016 din 03/2017 tgi benh vien Dgi hoc Y Dugc Thanh pho Ho Chi Minh.
Ket quk Trong 250 benh nhdn nghiin dm dm chung toi dugc ddnh gid tinh trgng dinh duong cho thay ty lebinh nhdn co riong do albumin < 35 g/l chian 16,8% vd prealbumin < 0,15 g/l chiim 20,4%. DiBn cat lorn trie suy dinh duong vai riong do albumin Id 39,7 g/l co do nhgy 54.46%. do dgc hieu 81,88% vd cua prealbumin la 0,167 g/l CO do nhay 46,43%, do dgc hiiu 92,03%.
Ket luan: Nong dp albumin & diem cat 39,7 g/l vd prealbumin 0,167 g/l cd the dugc sie dung nham h& trg torn sodt suy dinh duong. Trong do prealbumin giiip phdt hiin tinh trgng suy dinh du&ng s&m han so vol albumin.
Tit khoa: tom sodt dinh dmng, albumin, prealbumin ABSTRACT
VALIDITY OF SERUM ALBUMIN AND PREALBUMIN IN ADULTNUTRTHON SCREENING Tran (^uoc Huy, Lam Vinh Nien * Y Hoc TP. Ho Chi Minh * Vol. 21 - No 5 - 2017:61 - 67 Introduction: Nutrition status has been proved to affect treament results. Several biological indices has been suggested for early recognition of malnutrition. Investigation the validity of biological indices will give suppori to identify and manage malnutrition in patients.
Objective: To investigate the validity of albumin and prealbumin in malnutinton screening in adults, using SGA as reference.
Method: Cross-sectional study on newly hospitalized patients from October, 2016 to March, 2017 in University Medical Center of Ho Chi Minh City University of Mediane and Pharmacy.
Results: In 250 patients recruited in the study, 16.8% had albumin concentration less than 35 g/l, and 20.4% had prealbumin less than 0.15 g/l. At malnutrition exclusion cut-off point of albumin of 39.7 g/l, the sensitivity was 54.46%, and specificity 81.88%. At malnutrition exclusion cut-off point of albumin of 0.167 g/l, the sensitivity was 46.43%, and specificity 92.03%.
Conclusion: Albumin and prealbumin cut-off points at 39.7 g/l 0.167 g/l, respectively, can be used to screen malnutrition in patients. Prealbumin may help discover malnutrition earlier than albumin.
Keywords- nutrition screening, albumin, prealbumin
* Tnrong Dai hpe Tra Vinh ** Dai hpe Y Dupe TP. HCM
Tdc gid lien lac: TS. BS Lam Vinh Nien DT: 0988846972 Email. nien@ump edu vn
N g h i e n cthi Y hpc Y Hpc TP. Ho Chi M m h * Tap 21 * So 5 * 2017 D A T V A N D E
Suy dinh duong la tinh Pang thieii hut nang lupng, protein va cac vi chat dinh duong thiet yeu Pong ca the, anh huong bat Ipi len mo va eo the (hinh dang, co the, kich thuoe, thanh phan), chPc nang eo the va eae ket qua lam sangi^^^'.
Hien nay suy dinh dirong van eon ia mot van de ton dpng Pong eae benh vien chua duoc chii trgng nhieu tren cac benh nhan nam vien.
Suy dinh duong gay anh huong nghiem trpng doi qua trinh phuc hoi sue khoe va lam tang ehi phi y te, tang nguy eo nhiem khuan, cham lanh vet thuong, tang hien ehiing sau phau thuat, keo dai thfri gjan nam vien, ty le biai chiing cao^^'.
Viec danh gia tinh trang dinh duong eho timg ea the rat can thiet trong (hue Pen lam sang. Co nhieu nghien cPu cho thay benh nhan nam vien CO van de ve dinh duang (nghi ngcr suy dinh duong hoac suy dinh duong nang) chi&n ty 1$ ttr 20 - 50%. Dieu tri dinh duong thieh hpp eo the lam giam ty le benh tat va tii vong, giam chi phi dieu tri cho benh nhan<^.
De can thi^p dinh duong diing va hieu qua, viec danh gia tinh trang dinh duong rat quan trpng. Tren lam sang co nhieu each de danh gia dinh duong bao gom viec khai tiKac benh sir, ehe dp an uong, kham thue the, do luong cac chi so nhan trac va cae xet nghiem sinh hoa ho trp tir do phat hien benh nhan suy dinh duong hoac co nguy ca bi suy dinh duong<*"-"'. Nhin chung cae phuong phap nay deu eo u u va nhupc diem rieng, khong co phuong phap nao la hoan hao. Cac phucmg phap nay co s p khae biet dang ke ve tinh gia Pi, dp tin eay, tinh de sii dung va dupe chap nhgn, trong do phuong phap xet nghiem sinh hoa giup tam soat nguy eo suy dinh duong khong ton nhieu thai gian, de dang thpc hien
doi voi nhiing nhan vien khong co ky nang ve dinh duong.
Tai Viet Nam da co mpt so nghien ciiu ve si^
thay doi albumin mau 6 benh nhan suy dinh duong tuy nhien chua eo nghien cuu nao danh gia dong bp ve sp thay doi ciia ca prealbumin va albumin Do vay chiing toi tien hanh nghien ciiu nay nham "Danh gja nong dp albumin va prealbumin mau trong ^ m soat suy dinh duong d nguoi Ion.
Mpc tieu
Danh gja nong dp albumm va prealbumin mau trong tam soat suy dinh duong a nguoi Ion voi chuan tham chieu SGA.
D6I TUONG NGHIEN ctfu Doittrpng
Benh nhan nhap vien trong vong 24 deh 48 gio tai eae khoa lam sang
Tieu chuan chgn vdo
Lon hon 18 tuoi (trii berth niian mac cac benh eap tinh, cap ciiu)
Mau nghi&i cuu
"= V
Trong do
Z: tri so'tie phan phoi chuan cc xdc suSi sai t&m logi 1 = 0,05 P- tn so mong muon ti li d: sai so cho phep
Dpa tren nghien ciiu ciia Luu Ngan Tam, Nguyen Thi Quynh Hoa (2009)"2). Lay P = 0,45; d
= 0,07, tinh dupe n = 194.
Phmmg phap nghien cuti M6 ta cat ngang
62
Y Hpc TP. H o Chi Minh * Tap 21 * So 5 * 2017 N g h i ^ cihi Y hpc
Phuang phdp ddnh gid tong tki dtd quan - SGA®
Bdngl
Phan t)^nh sO- 1.Thay(J6ic3nn$ng:
canning 6 thing tnF6caay: kg, % Tliay ddi cdn n$ng trong 2 tuan: a iang a Khdng ddi n Giam cdn 2. iJJvng i n vdo (so v6i binh thu^g)
D Khdng thay doi
aCdthayd&:tho'igian (tuin) Lo^i thi>c dn:
n Long • S^t n It nSng lu^ng n Nhm hoan toSn 3. Tii$u chi>ng ctia d? day - nj$t (kto dai tr6n 2 tuin).
• Khdng c6 • Non a Bu6n nfln a 4. KhS nang sinh ho^it hang ngay
D Khong thay doi
a Thay doi: thdi gian (luan)
\jo^v. o H^n che sinh hoat n Di Igi ylu 5. B^h ly va nhu cau dinh du'dng lien quan:
Benh ty chinh:
Nhu ciiu chuyin h6a' • Khong • Nhg D Vi>a o Njng
D TiSu chSy
Nlim hoan toan t r ^ giirdng
Tham kham lam sang Binh t h u ^ g : 0; nh?: 1; viTa: 2; ning: 3
Mat Idp m& dLTdi da:
Teoco;
PhiichSn:
Bangbijng'
D SGA-A: tinh trgng dinh du'dng t6t
a SGA-B: suy dinh du'&ng hay nghi ngd suy dinh d u ^ g
• SGA-C: suy dinh du'ong
each phan logi
- SGA-A: CN dn ^nh hay tang can, I<h6ng cd chCmg cCr SDD trong thSm khSm ISm sang - SGA-B: mit can > 5% so vdi 2 tu^n t m ^ dSy, an ft, mki it i6p md du'di da.
- SGA-C: mAt can > 10%, c6 cac dIu chQ'ng SDD n$ng, kbm an k6m, hoac chi an diwyc tfii>c an Idng, E>inh lirpng albunun huyet thanh
Albumin la mpt tnmg hai thanh phan protein quan trpng nhat oia protein huyet Ihanh (gom albumin va globulin), chion khoang 50 - 60% lupng protein toan phan.
Albumin co tinh hoa tan eao va Ppng lupng phan tli vao khoang 66500 Dalton. Binh thuong albumin Pong huyet thanh khoang 35 - 50 g/l.
Albumin dupe tong hpp ^ gan tir cac add amin ngogi Iai ho§c san sinh trong eo the va co thoi gian ban hiiy khoang 18 - 20 ngay, vi vay cac anh huong eua chuy&i hoa len nong dp albumin can thoi gian lau han. Nong d$ albumin giam trong giai dogn cap sau chan thuang hay trong b?nh ly n$ng vi khi d6 gan im tien tong hpp cac
protein phan ling pha cap nhu CRP (C-reactive protein) thay eho tong hpp protein. Dong thoi, vi dupe tong hpp 6 gan nen albumin giam trong truong hpp suy gan hay do nong dp albumin dinh luong trong huyet thanh nen gia tri phu thupc vao tinh P?ng phan bo dich Pong co the*:^'.
Bdngl: Ddnh gid tinh trang dinh duong dua tren albumin huyel thanh (Gibbs 1999P
N&ng dO albumin/mau (g/l) 235 30-<35 25-<30
<25
Tinh tr^ng dinh du'dng BInh thu'dng Suy dinh d u ^ g nh?
Suy dinh du'dng tmng binh Suy dinh duong ngng
N g h i e n cim Y hpc Y Hpc TP. Hb Chi Minh * Tap 21 * S£» 5 * 2017 Dinh lupng Prealbumin huyet fhanh
Prealbiunin con co ten gpi khae la Pansihyretin la mpt protein giau tryptophan, trpng lupng phan tir la 54980 Dalton, dupe tong hop chii yeii a gan, eo chiic nang gan ket va van chuyen protein'^'. La mpt protein eo thai gian ban hiiy ngan khoang 2 ngay va ttianh phan tryptophan eao, lupng d p tru thap nen day la mpt thong so it bi tae dpng nhat khi co sp thay doi phan bo nuae trong ca the va la thong so thay doi som nhat so voi albumin trong phan anh tinh Pang dinh duong benh nhan tu do giiip theo doi hieu qua dieu tri Pong can thi?p dinh dirong cho benh nhan**-"'.
Bdng 3: Ddnh gid tinh trgng dirih duang dua tren prealbumin huyit thanh (Bernstein, 1995)"*>
Ndng dp Prealbumin/mau (gfl)
£0.15 0.11-< 0.15 0.05-< 0.11
<0.05
Tinh tf^ng suy dinh diPdng Binh thuong Suy dinh du^ng nhe Suy dinh du'dng tmng binh
Suy dinh du'd'ng n^ng KETQUA
Bdng 4: Tinh trgng dinh duong Die tinh
Binh thirdyng SDD nhe SDD tmng binh
SDD ngng Albumin/
huylt tiianh 208 (83,2)
26 (10,0) 14 (5,6) 3(1,2)
Prealbumin/
huylt thanh 199 (79,6) 25 (10.0)
17 (6,8) 9 (3,6)
SGA
138 (65,2) 74 (29,6) 38(15,2) Bang 5: Liin quan giu!a SGA vd gid tri trung binh albumin
Albumin
SQA 1 A
43,1 ±4,9 B 38.8 ±6,6
C 36,6 ±6,3 i Phan loai SGA xau dan a nhom suy dinh duang nhe-trung binh va suy dinh duang nang (SGA-B, SGA-C) ttii nong dp bxmg binh albumin mau eijng giam dan (38,8 g/l so voi 36,6 g/l).
Vai nguong albumin ^ 35 g/I eo do nhay rat thap 29% va dp dae hieu 93%. Do do ehung toi da tim ra nguong mai. Tai diem eat 39,7 g/l vai chi so Youden (Youden index) J eao nhat 0,3634 CO dp nhay 54,46% va do dac hieu 81,88% Ihidh hop de phan biet tinh trang suy dinh duong tren
lam sang. Ve ducmg eong ROC voi dien tick 0,7342; khoang tin cay 95%: 0,67 - 0,79.
< 35 g/l
Hinh 1: Nong do albumin <35g/ldcdc phan nhom SGA. Su Ididc biet nay coy nghia thong ke (p<0,001) Bdng 6: EHan cat chi so albumin huyii thanh v&i ^ nhgy vd do dgc hieu.
Chi 36 albumin huylt thanh
(M
39,4 39,5 39,7 39,9 40,0
Dpnh^y
(%)
52,68 63,57 54,46 64,46 55,36
E}$ d^a hieu
(%)
81,88 81,88 81,88 80,43 79,71 Bang 7: Lien quan giiea S(2A vd gid tri trung binh prealbumin
Prealbumin
SQA A
27,8 ±8.8 B 20.2 ±10,0
C 17,6±11,2 Phan loai SGA xau dan a nhom suy dinh duong nh^trung binh va suy dinh duong nang (SGA-B, SGA-Q ttii nong dp Pung binh prealbumin mau ding giam dan (0,202 g/l so voi 0,175 g/l).
<0,15g/l
Hinh 2: Nong do prealbumin < 0,15 g/l & cdc phan nhom SGA. Su khac biet nay co y nghia thong ke (p<0,001)
Y Hoc TP. Hb Chi M i n h * T$p 21 * So 5 * 2017 Nghien cmi Y hpc V6i nguong prealbumin S 0,15 g/l co dp nhay
rat thap 38% va dp dac hieu 94%. Do do chiing toi da tim ra nguong moi. Tai diem cat 0,167 g/l voi ehi so Youden (Youden index) J eao nhat 0,3846 CO dp nh?y 46,43% va dp dac hieu 92,03%
thich hpp de phan biet tinh trang suy dinh duong tren lam sang. Ve duong cong RCX2 vai dien tich: 0,7346; khoang tin cay 95%: 0,67 - 0,79.
Bdng & Dion cat dii soprealbumin huyet thanh v&i do nhay vd do dgc hieu.
Ch! s6 prealbumin huylt thanl (3") 0,158 0,164 0,167 0,168 0,171
DQ nh9y
(%)
41,07%
44.64%
46,43%
46,43%
46,43%
D$ d$c hi^u
(%)
92,75%
92,03%
92,03%
91,30%
90,58%
BANLUAN Phan nhom dinh duong
Xet ve phan nhom dinh duang ehung eua nong d6 albumin cho tiiay eo 42/250 benh nhan CO nong dp albumin huyet thanh <35 g/l (suy dinh duong) chian ty le 16,8% thap han nghien Ciiu eua Luu Ngan Tam va epng su (2009) o benh nhan nhap vien la 31,9%<'^i va a b?nh nhan truoe phau thuat la 18,3%"^. Ngupc lai, ket qua cua ehiing toi gan giong ket qua cua Putwatana (18,9%)(i*). Ket qua nay cho thay ty le benh nhan CO albumin mau thap kha it, da so benh nhan co albumin Pong giai han binh thuong. Tuy nhien neii chiing ta can cii vao nong dp albumin nay ma cho rang ty le benh nhan suy dinh duong thap la khong chmh xac vi thai gian ban huy eua albumin trong mau la khoang 21 ngay, thai gian tong hpp ciing dai Pong khi mau nghien ciiu co nhung truteg hpp benh nhSn bi eSp tinh, tSng Pang truoe do tot nen eiing anh hudng len qua trinh tong hpp albumin. E)ieu nay cho fliay albumin khong phai la mpt xet nghiem nhay de phat hi?n tinh trang suy dinh duong tren lam sang, no phii hpp de danh gia tinh Pang dinh duong t5ng the han.
PhSn nhom dinh dudng theo prealbumin mau Pong nghien eiiu eua ehung toi so b$nh
nhan c6 prealbumin <0,15 g/l chi&n 20,4% tlufp so voi cac ket qua nghien eiiu khac nhu cua Nguyen Thiiy An la 55,7%<'5), Devoto va eong su (2006) ty le prealbumin < 0,17 g/l la 59%'*). Trong mpt nghien ciiu khae eiia Robinson va eong su ve tinh hieu qua eua viee danh gja tinh Pang dinh duong dua vao bang cau hoi va eae xet nghiem prealbumin, albumin cho thay viee danh gja thong qua xet nghiem prealbumin eo the cai thien sp nhan dien ciia nhung benh nhan can can thiep ve dinh duong va do do co the gjiip tang cuong cham soc benh nhan nhap vien"^.
Neil so sanh ket qua ciia prealbumin va albumin thi ta co the thay prealbumin co do nhay hon han so vdi albumin trong danh gia tinh trgng dinh duong. Prealbumin eo thai gian ban huy ngan hon so vdi albumin la 2 ngay va khong bi anh huong bai lupng nude trong CO the nen no phan anh chinh xac tinh trang dinh duang cua benh nhan nam vien.
Nong dp prealbumin mau giam eo the do suy dinh duong hay trong tinh trang viem. Giong nhu albumin, prealbumin mau giam thuong phan anh dp nang cua benh hon la tinh trang dinh duong. Tuy nhien hien nay khong phai phong xet nghiem nao ciing thue hien xet nghiem prealbumin, vi vay khong nhu albumin, prealbumin v i n chua dupe xem la mpt xet nghiem thuang qui trong tam soat suy dinh duong.
Tinh trang suy dinh duong theo phuong phap SGA ehiSn ty le 44,8%. Ket qua nay tuong duong voi ket qua cua Luu Ngan Tam va es 42,4%"^'. Nhimg lai cao hon so vod ket qua nghien a i u ciia Detsky (1987) eo ty le suy dinh duong la 31%'^'. Dieu nay cho ttiay sau vai thap nien, ty 1? suy dinh duong Pen lam sang van khong giam di ma ngay cang co xu hudng tang, trai ngupc lai vdi ty le suy dinh dirong tren cong dbng ngay cang giam, eo xu hirdng cai thien''").
So vdi hai phuang phap danh gia dinh duong bang xet nghiem albumin va prealbiunin thi phuang phap danh gia SGA eho ty le suy dinh dudng cao hon. Dieu nay ciing co ttie thay
N g h i e n c u u Y h p c Y Hpc TP. H b Chi M i n h * T^p 21 * So 5 * 2017 rang darix gia SGA liii chii yeii dua vao tren lam
sang theo mpt each chii quan ciia ngudi danh gia, do do ngudi danh gia phai cd chuyen mon ve dinh dudng. Trong khi do xet nghiem albumin va prealbiunin khdng can phai cd chuyen mon ky thuat eao, de dang thue hien d eae benh vien, phan anh d p doan tinh trang suy dinh dudng benh nhan sdm hon khi chua cd bieu hi$n lam sang. Tuy nhien nong dp albumin va prealbumin ngoai thay doi trong suy dinh dudng eon cd the thay doi trong cac benh ly khac. Do do can phM ket hpp lam sang va can lam sang cho chan doan chinh xac hon.
M5i tmmg quan giua SGA voi albumin va prealbumin
Khi so sanh nong dp trung binh ciia albumin va prealbumin giiia 3 nhdm SGA, ket qua cd su khae biet phan l o ^ SGA xau dan (SGA-B va C) thi nang dp albumin va prealbumin mau trung binh cung giam dan (38,8 g/l so vdi 36,6 g/I eua albumin va 0,202 g/l so vdi 0,175 g/l eiia prealbumin).
Neu so sanh eae nhdm albumin va prealbumin vdi phan loai SGA, ty le % nong do albumin < 35 g/l cang tang dan d cac nhdm SGA Kn lupt la 7,20%; 24,30% va 36,8%. Hay ty le prealbumin < 0,15 g/l Ian lupt la 5,80%; 32,40% va 50,0%. Vl vay ed the ndi tinh trang dinh dudng eang kem (hi nong dp albumin va prealbumin mau eang giam trong dd nong dp prealbumin giam manh hon so vdi albumin.
Ca 2 xet ngiii^m albumin va prealbumin deu ed gia tri tot trong ch&i doan suy dinh dudng vi cd dien tich dudi duong cong ROC Ian lupt la 0,7342 va 0,7346.
Doi vdi albumin, tai diem eat 39,7 g/l cd dp nhay va dp dac hi|u (54,46% va 81,88%) eai thien hon so vdi nong dp cii. Hay prealbumin tai diem cat 0,167g/l cd dp nhay 46,63% va dp d|ie hieu 92,03%. Tai ngay diem cat cua albumin va prealbumin nay cd the dupe xem nhu la mpt dau moc de cai thien danh gja phan loai khong suy dinh dudng va suy dinh dudng.
Trong nghien eiiu chiing toi, so voi albumin tlu prealbumin c6 dp nhay va dp dgic hi^u eao han nen dupe xem nhu la mpt xet nghiem giiip sdm phat hien tinh Pang suy dinh dudng. EJieu nay giong nhu Pong nghien ciiu ctia Robinson va epng su nghien ciiu ve tinh hieu qua giiia bang cau hoi vdi prealbumin, albumin va protein gan ket Relinol trong sang Ipc dir\h dudng tren benh nhan nam v i ^ . Ket qua eho thay prealbumin ed dp nhay va dp d?c hieu eao hem han so vdi bang eau hoi Qua do cho thay prealbumin la mot Pong nhiing yeii to eo f nghia phan loai tinh trang dinh dudng Pong khi albumin va protein gan ket retinol thi khong eo y nghiaCT).
Nghien eiiu oia Young va epng sp ve danh gia tinh trang suy dinh dudng nang lupng protein dua tren cac chi so nhan trac (chu vi eo vong canh tay, lupng spt can), va nong dp protein huyet tucmg (prealbumin, albumin, protein gan ket retinol, transferrin, hemoglobin, so lupng te bao lymphocyte), ket qua cho tiiay trong cac ehi so nong dp protein huyet tuong chi ed prealbumin va transferrin tuong quan thuan manh vdi cac chi so dinh dudng eon lai trong do prealbumin la manh nhat. Con albumin ed moi tuong quan kem hay so vdi cac thdng so cdn 1^.
Cae so do nhan trac kem nhay hon so vdi su sut giam protein huyet tuong miie do nhe'^".
KET LUAN
Benh nhan ed nguy eo hay bi suy dinh dudng deu ed nong dp albumin va prealbumin mau giam thap hon so vdi nhiing benh nhan co tinh trang dinh dudng tot. Tai diem eat 39,7 g/l eua albumin hay 0,167 g/I ciia prealbumin giiip cai thien dupe dp nhay va dp dae hieu trong ehan doan suy dinh dudng. Trong dd xet nghiem prealbumin giup sdm phat hien tinh trang suy dinh dudng hon so vdi albumin.
TAI LI$U THAM K H A O
1 Banh L (2006), 'Serum Proteins as Markers of Nutnhon: What Are We Treating^". Practical gastroenferologi/, 43, pp.46-63.
Y Hpc TF. Hb Chi Minh * T^p 21 * S£» 5 * 2017 Nghien cuu Y hpc
Beck FK, Rosenthal TC (2002), ••Prealbumin; A Marker for Nutntioral Evaluation". American FamS.y Physician. 65, pp.1575 -2578.
Braunschweig C, Gomez S, Sheean P M (2002), 'Impact of Declines in Nutritional Status on Oulcomesin Adult Patients Hospitalized for i/kae T h a n 7 da}^''. laumal of the Attierican Dietetic Associatio, 100(11), pp.1316-1322.
Collins N, Friedrich L pOlO), •TJsmg Laboratory Data to Evaluate Nutntionai Status". Ostomy wound management, 56 {3),pp.l4-16.
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Gibbs J, Cull W, Henderson W, Daley J, Hur K, K h u n SF (1999), "Freoperalivc serum albumm level as a predictor of operative mortality and moit>idity'. Resuffs from the national surgiad risk study Archwes (f surgery, 134 p ) , pp36-^
[fensrud DD (1999), "Nutrition screening arid assessment", Med Clin North Am, 83 (6), pp.1525-1546,
Kniizenga HM, Tulder MWV, Seidell JC, IWjs A, Ader HJ, Van Bokhurst de van der Schueren MAE (2005), "Effectiveness and cost-efitectiveness of eaily scresiing and treatment of malnourished patients". Am j am Nutr. 82, pp.1082-1089.
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