Malnutrition Cascade

CPT: 84305
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Test Details

Use

The malnutrition cascade is intended to aid physicians in the etiology-based diagnosis of malnutrition in patients with identified nutritional risk (compromised intake or loss of body mass).

Methodology

See individual test components.

Additional Information

Adults whose diets do not provide enough nutrients-including calories and protein-required for appropriate tissue repair and maintenance experience undernutrition, or malnutrition.1 It was reported that "malnutrition is a major contributor to increased morbidity and mortality, decreased function and quality of life, increased frequency and length of hospital stay, and higher health care cost."1 Parameters used to diagnose malnutrition reflect both nutrition intake and severity and duration of disease. Another proposal in diagnosing malnutrition in adults is based on etiology, which will integrate the present understanding of inflammatory responses to disease and trauma.2 The Academy of Nutrition and Dietetics, along with the American Society for Parenteral and Enteral Nutrition (ASPEN), have adopted patient-specific definitions based on etiologies, including social and environmental circumstances and chronic and acute illness.1 Diagnosis categories include: (1) starvation-related malnutrition, or chronic starvation without inflammation; (2) chronic disease-related malnutrition, highlighted by mild-to-moderate chronic inflammation; and (3) acute disease or injury-related malnutrition, where inflammation is acute and severe.1

Cascade Steps and Interpretation

1. The cascade starts with testing for the levels of Insulin-like Growth Factor-1 (IGF-1), as it was reported to be a sensitive indicator of malnutrition independent of classical nutritional markers like serum proteins,4 and renutrition is reported to be associated with an increase of serum IGF-1.3-8 If the IGF-1 result is equal to or above its age-/gender-specific lower limit, testing will stop and the interpretive comment will read: "Not suggestive of energy and/or protein deprivation."

2. If the IGF-1 result is less than its age-/gender-specific lower limit, the cascade will reflex to Step 2 — testing for Serum Albumin. Serum albumin is reported to be a marker of long-term (more than two weeks) malnutrition due to its long biological half-life.9,10 If the serum albumin result is equal to or above its age-/gender-specific lower limit, the cascade will reflex to Step 4 (Serum Transferrin). If the serum albumin result is below its age-/gender-specific lower limit, the cascade will reflex to Step 3 — testing for C-Reactive Protein (CRP).

3. Testing for C-Reactive Protein (CRP) will aid in assessment of the presence and degree of inflammation as outlined by ASPEN recommendations.1

a. If the CRP result is greater than 100 mg/L,11 testing will stop and the interpretive comment will read: "Suggestive of long-term energy and/or protein deprivation (more than two weeks) due to acute disease or injury-related malnutrition (like major infection, burns, trauma, closed head (injury)."1,10

b. If the CRP result is between 5 mg/L and 100 mg/L,11 testing will stop and the interpretive comment will read: "Suggestive of long-term energy and/or protein deprivation (more than two weeks) due to chronic disease-related malnutrition (like organ failure, pancreatic cancer, rheumatoid arthritis, sarcopenic obesity)."1,10

c. If the CRP result is less than 5 mg/L, testing will stop and the interpretive comment will read: "Suggestive of long-term energy and/or protein deprivation (more than two weeks) due to starvation-related malnutrition (like pure starvation, anorexia nervosa)."1,11

4. Testing for Serum Transferrin will aid in further evaluation of the patient, as it is reported to be a marker of mid-term malnutrition due to its biological half-life.9,10 If the transferrin result is greater than or equal to its age-/gender-specific lower limit, the cascade will reflex to Step 5 (Serum Prealbumin). If the transferrin result is below its age-/gender specific lower limit, the cascade will reflex to Step 3 — (CRP).

a. If the CRP result is greater than 100 mg/L, testing will stop and the interpretive comment will read: "Suggestive of mid-term energy and/or protein deprivation (more than eight days) due to acute disease or injury-related malnutrition (like major infection, burns, trauma, closed head injury)."1,9,10

b. If the CRP result is between 5 mg/L and 100 mg/L,11 testing will stop and the interpretive comment will read: "Suggestive of mid-term energy and/or protein deprivation (more than eight days) due to chronic disease-related malnutrition (like organ failure, pancreatic cancer, rheumatoid arthritis, sarcopenic obesity)."1,9,10

c. If the CRP result is less than 5 mg/L, testing will stop and the interpretive comment will read: "Suggestive of mid-term energy and/or protein deprivation (more than eight days) due to starvation-related malnutrition (like pure starvation, anorexia nervosa)."1,9,10

5. Testing for serum prealbumin will aid in the assessment of short-term malnutrition, as it is reported to be a marker for this condition.10 If the prealbumin result is equal to or greater than its age-/gender-specific lower limit, the cascade will reflex to Step 6 — (Serum Retinol-binding Protein[RBP]). If the prealbumin result is less than its age-/gender-specific lower limit, the cascade will reflex to Step 3 — (CRP).

a. If the CRP result is greater than 100 mg/L,11 testing will stop and the interpretive comment will read: "Suggestive of short-term energy and/or protein deprivation (more than two days) due to acute disease or injury-related malnutrition (like major infection, burns, trauma, closed head injury)."1,10

b. If the CRP result is between 5 mg/L and 100 mg/L,11 testing will stop and the interpretive comment will read: "Suggestive of short-term energy and/or protein deprivation (more than two days) due to chronic disease-related malnutrition (like organ failure, pancreatic cancer, rheumatoid arthritis, sarcopenic obesity.)" 1,10

c. If the CRP result is less than 5 mg/L, testing will stop and the interpretive comment will read: "Suggestive of short-term energy and/or protein deprivation (more than two days) due to starvation-related malnutrition (like pure starvation, anorexia nervosa)."1,10

6. Testing for serum RBP will aid in the assessment of acute malnutrition as it is reported to be a marker for this condition.9 If the RBP result is equal to or greater than its age-/gender-specific lower limit, the cascade will reflex to Step 3 — (CRP).

a. If the CRP result is greater than 100 mg/L,11 testing will stop and the interpretive comment will read: "Suggestive of acute disease or injury-related malnutrition (like major infection, burns, trauma, closed head injury)."1

b. If the CRP result is between 5 mg/L and 100 mg/L,11 testing will stop and the interpretive comment will read: "Suggestive of chronic disease-related malnutrition (like organ failure, pancreatic cancer, rheumatoid arthritis, sarcopenic obesity)."1

c. If the CRP result is less than 5 mg/L, testing will stop and the interpretive comment will read: "Suggestive of starvation-related malnutrition(like pure starvation, anorexia nervosa)."1

7. If the RBP result is less than its age/gender-specific lower limit, the cascade will reflex to Step 3 — (CRP).

a. If the CRP result is greater than 100 mg/L,11 testing will stop and the interpretive comment will read: "Suggestive of acute energy and/or protein deprivation due to acute disease or injury-related malnutrition (like major infection, burns, trauma, closed head injury)."1,9

b. If the CRP result is between 5 mg/L and 100 mg/L,11 testing will stop and the interpretive comment will read: "Suggestive of acute energy and/or protein deprivation due to chronic disease-related malnutrition (like organ failure, pancreatic cancer, rheumatoid arthritis, sarcopenic obesity)."1

c. If the CRP result is less than 5 mg/L, testing will stop and the interpretative comment will read: "Suggestive of acute energy and/or protein deprivation due to starvation-related malnutrition (like pure starvation, anorexia nervosa)."1,9

Specimen Requirements

Specimen

Serum

Volume

1.7 mL divided into two tubes

Minimum Volume

1.2 mL (Note: This volume does not allow for repeat testing).

Container

Red-top tube or gel-barrier tube

Collection

Separate serum from cells. Transfer separated serum to a plastic transport tube.

Storage Instructions

Refrigerate

Stability Requirements

Temperature

Period

Room temperature

3 days

Refrigerated

7 days

Frozen

14 days

Freeze/thaw cycles

Stable x3

Clinical Information

Special Instructions

Age and gender must be supplied for reflex to occur.

Footnotes

1. White JV, Guenter P, Jensen G, et al. Consensus Statement of the Acadamy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and and Documentation of Adult Malnutrition (Undernutrition). J Acad Nutr Diet. 2012 May;112(5):730-738.22709779
2. Mueller C, Compher C, Ellen DM, American Society for Parental and Enteral Nutrition (ASPEN) Board of Directors. ASPEN clinical guidelines: Nutrition screening, assessment, and intervention in adults. J Parenter Enteral Nutr. 2011 Jan;35(1):16-24.21224430
3. Alemany JA, Nindl BC, Kellogg MD, Tharion WJ, Young AJ, Montain SJ. Effects of dietary protein content on IGF-1, testosterone and body composition during 8 days of severe energy deficit and arduous physical activity. J Appl Physiol. 2008 Jul;105(1):58-64.18450989
4. Maggio M, De Vita F, Lauretani F, et al. IGF-1, the cross road of the nutritional, inflammatory and hormonal pathways to frailty. Nutrients. 2013 Oct 21;5(10):4184-4205.24152751
5. Donahue SP, Phillips LS. Response of IGF-1 to nutrition support in malnourished hospital patients: a possible indicator of short-term changes in nutritional status. Am J Clin Nutr. 1989 Nov;50(5):962-969.2816803
6. Fazeli PK, Klibanski A. Determinants of growth hormone resistance in malnutrition. J Endocrinol. 2014 Jan 27;220(3):R57-R65.24363451
7. Fazeli PK, Misra M, Goldstein M, Miller KK, Klibanski A. Fibroblast growth factor-21 may mediate growth hormone resistance in anorexia nervosa. J Clin Endocrinol Metab. 2010 Jan:95(1):369-374.19926712
8. Diagnosis of secondary malnutrition. In: Caballero B. Encyclopedia of Human Nutrition. 2nd ed. Elsevier Academic Press;2005.
9. Haider M, Haider S. Assessment of protein-calorie malnutrition. Clin Chem. 1984 Aug;30(8):1286-1299.6430595
10. Assessment of Malnutrition and Nutritional Therapy Approaches in Cancer Patients. In: Kumar NB. Nutritional Management of Cancer Treatment Effects. 2012 Berlin, Heidelberg: Springer-Verlag;2012.
11. Dechaphunkul T, Martin L, Alberta C, Olson K, Baracos V, Gamlich L. Malnutrition assessment in patients with cancers of the head and neck: A call to action and consensus. Crit Rev Oncol Hematol. 2013 Nov;88(2):459-476.23830808

LOINC® Map

Order Code Order Code Name Order Loinc Result Code Result Code Name UofM Result LOINC
460500 Malnutrition Cascade 010417 Insulin-Like Growth Factor I ng/mL 2484-4
460500 Malnutrition Cascade 166014 Malnutrition Reflex Storage N/A
Reflex Table for Insulin-Like Growth Factor I
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 371810 Albumin, Serum 002081 Albumin, Serum g/dL 1751-7
Reflex 2 000000 006637 000000 mg/L 1988-5 011484
Reflex 3 000000 011484 000000 N/A
Reflex Table for Insulin-Like Growth Factor I
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 371810 Albumin, Serum 002081 Albumin, Serum g/dL 1751-7
Reflex 2 000000 006637 000000 mg/L 1988-5 011503
Reflex 3 000000 011503 000000 N/A
Reflex Table for Insulin-Like Growth Factor I
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 371810 Albumin, Serum 002081 Albumin, Serum g/dL 1751-7
Reflex 2 000000 006637 000000 mg/L 1988-5 011476
Reflex 3 000000 011476 000000 N/A
Reflex Table for Insulin-Like Growth Factor I
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 371810 Albumin, Serum 002081 Albumin, Serum g/dL 1751-7
Reflex 2 000000 004973 000000 mg/dL 3034-6 376900
Reflex 3 000000 006638 000000 mg/L 1988-5 011481
Reflex 4 000000 011481 000000 N/A
Reflex Table for Insulin-Like Growth Factor I
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 371810 Albumin, Serum 002081 Albumin, Serum g/dL 1751-7
Reflex 2 000000 004973 000000 mg/dL 3034-6 376900
Reflex 3 000000 006638 000000 mg/L 1988-5 011488
Reflex 4 000000 011488 000000 N/A
Reflex Table for Insulin-Like Growth Factor I
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 371810 Albumin, Serum 002081 Albumin, Serum g/dL 1751-7
Reflex 2 000000 004973 000000 mg/dL 3034-6 376900
Reflex 3 000000 006638 000000 mg/L 1988-5 011485
Reflex 4 000000 011485 000000 N/A
Reflex Table for Insulin-Like Growth Factor I
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 371810 Albumin, Serum 002081 Albumin, Serum g/dL 1751-7
Reflex 2 000000 004973 000000 mg/dL 3034-6 376778
Reflex 3 000000 016941 000000 mg/dL 14338-8 377011
Reflex 4 000000 006639 000000 mg/L 1988-5 011500
Reflex 5 000000 011500 000000 N/A
Reflex Table for Insulin-Like Growth Factor I
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 371810 Albumin, Serum 002081 Albumin, Serum g/dL 1751-7
Reflex 2 000000 004973 000000 mg/dL 3034-6 376778
Reflex 3 000000 016941 000000 mg/dL 14338-8 377011
Reflex 4 000000 006639 000000 mg/L 1988-5 011482
Reflex 5 000000 011482 000000 N/A
Reflex Table for Insulin-Like Growth Factor I
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 371810 Albumin, Serum 002081 Albumin, Serum g/dL 1751-7
Reflex 2 000000 004973 000000 mg/dL 3034-6 376778
Reflex 3 000000 016941 000000 mg/dL 14338-8 377011
Reflex 4 000000 006639 000000 mg/L 1988-5 011489
Reflex 5 000000 011489 000000 N/A
Reflex Table for Insulin-Like Growth Factor I
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 371810 Albumin, Serum 002081 Albumin, Serum g/dL 1751-7
Reflex 2 000000 004973 000000 mg/dL 3034-6 376778
Reflex 3 000000 016941 000000 mg/dL 14338-8 376875
Reflex 4 000000 123074 000000 mg/dL 1836-6 377012
Reflex 5 000000 006640 000000 mg/L 1988-5
Reflex Table for Insulin-Like Growth Factor I
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 371810 Albumin, Serum 002081 Albumin, Serum g/dL 1751-7
Reflex 2 000000 004973 000000 mg/dL 3034-6 376778
Reflex 3 000000 016941 000000 mg/dL 14338-8 376875
Reflex 4 000000 123074 000000 mg/dL 1836-6 377013
Reflex 5 000000 006631 000000 mg/L 1988-5
Reflex Table for Insulin-Like Growth Factor I
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 011475 Interpretative Comment 011475 Interpretative Comment N/A

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