Total Protein and Albumin/Globulin (A/G) Ratio

How is it used?

Total protein and albumin tests are routinely included in the panels of tests performed as part of a health examination, such as a comprehensive metabolic panel (CMP), so they are frequently used to help evaluate a person's overall health status.

Additionally, since total protein can be low, increased, or the component globulin proteins altered with many different diseases and disorders, total protein and albumin tests may be ordered in a variety of settings to help diagnose disease, to monitor changes in health status, and as a screen that may indicate the need for various follow-up tests.

(For more information about proteins in the blood, see the "What is being tested?" section.)

Total protein measurements can reflect nutritional status and may be used to screen for and help diagnose kidney disease or liver disease, for example. Sometimes conditions are detected with routine testing before symptoms appear. If total protein is abnormal, further testing must be performed to identify which specific protein is abnormally low or high so that a specific diagnosis can be made. Some examples of follow-up tests include protein electrophoresis and quantitative immunoglobulins.

Some laboratories report total protein, albumin, and the calculated ratio of albumin to globulins, termed the A/G ratio. The A/G ratio is calculated from measured total protein, measured albumin, and calculated globulin (total protein - albumin). Because disease states affect the relative amounts of albumin and globulin, the A/G ratio may provide a clue as to the cause of the change in protein levels.

When is it ordered?

A total protein test is frequently ordered as part of a comprehensive metabolic panel (CMP) when an individual undergoes a routine health checkup. Total protein may also be ordered to provide general information about a person's nutritional status, such as when someone has undergone a recent, unexplained weight loss. It can be ordered along with several other tests to provide information when someone has symptoms that suggest a liver, kidney, or bone marrow disorder, or to investigate the cause of abnormal pooling of fluid in tissue (edema).

What does the test result mean?

Results of a total protein test are usually considered along with those from other tests of the CMP and will give the healthcare practitioner information on a person's general health status with regard to nutrition and/or conditions involving major organs, such as the kidney and liver. However, if results are abnormal, further testing is usually required to help diagnose the disease affecting protein levels in the blood.

• A low total protein level can suggest a liver disorder, a kidney disorder, or a disorder in which protein is not digested or absorbed properly. Low levels may be seen in severe malnutrition and with conditions that cause malabsorption, such as celiac disease or inflammatory bowel disease (IBD).
• A high total protein level may be seen with chronic inflammation or infections such as viral hepatitis or HIV. It also may be associated with bone marrow disorders such as multiple myeloma.
• A low A/G ratio may reflect overproduction of globulins, such as seen in multiple myeloma or autoimmune diseases, or underproduction of albumin, such as may occur with cirrhosis, or selective loss of albumin from the circulation, as may occur with kidney disease (nephrotic syndrome).
  • A high A/G ratio suggests underproduction of immunoglobulins as may be seen in some genetic deficiencies and in some leukemias.
• With a low total protein that is due to plasma expansion (dilution of the blood), the A/G ratio will typically be normal because both albumin and globulin will be diluted to the same extent.

Following an abnormal total protein result and depending on the suspected cause, more specific tests are typically performed to make an accurate diagnosis. Some examples include liver enzyme tests, renal panel, serum protein electrophoresis, or tests for celiac disease or IBD.

Is there anything else I should know?

Prolonged application of a tourniquet during blood collection can result in a blood sample with a falsely elevated total protein (higher than the actual concentration in the circulation).

Drugs that may decrease protein levels include estrogens and oral contraceptives.

Will a high protein diet raise my total protein level?

No, increasing your intake of protein will not increase your total protein test result.

What type of nutrition is recommended for optimal protein levels?

A well-balanced diet that follows the recommendations of the United States Department of Agriculture is summarized by the USDA Choose My Plate.

What are globulin proteins and how are they measured in blood?

Globulins are all the proteins in the blood other than albumin, and this group is comprised of hundreds of different types. These proteins are larger than albumin and are divided into alpha, beta and gamma globulins.

A protein electrophoresis test can be used to quantify the different groups of globulin proteins (see the article on Protein Electrophoresis and the table on Protein Groups). An immunofixation electrophoresis test can measure the different types of immunoglobulins (e.g., IgG, IgM, IgA) as can a quantitative immunoglobulins test.

Some globulin proteins can be measured directly using specific tests for the protein of interest. The tests are most valuable in instances where a specific protein is associated with a disease or condition. The specific protein tests may be ordered to provide information to the healthcare practitioner when particular signs and symptoms are present that suggest one of these diseases or conditions. A few examples of proteins associated with specific conditions are C-reactive protein (inflammation), fibrinogen (clotting disorders), ferritin (iron deficiency), and ceruloplasmin (Wilson disease).

Can protein be measured in samples other than blood?

Yes, a test for protein can be performed on many different types of body fluids. The purpose for testing and the meaning of results vary. For more details, see the article on Body Fluid Analysis and select the link for the fluid of interest.