Albumin

 
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Albumin is a globular protein with a molecular weight of 69,000 daltons (69 kDa). It is synthesized in the liver and is catabolized in various tissues where it is taken up by pinocytosis. The constituent amino acids are utilized by the cells.

Physiology

Albumin makes a large contribution to plasma colloid osmotic pressure due to its small size and abundance (35-50% of total plasma proteins by weight). It also serves as a carrier protein for many insoluble organic substances (e.g., unconjugated bilirubin). Albumin contains no carbohydrate and is not stored to any significant extent by hepatocytes. The plasma half-life various among species, and tends to increase with body size. Small amounts of albumin can be found in most extravascular body fluids, but little is excreted in the urine.

Methodology

Albumin is measured by its ability to bind to bromocresol green. Bromocresol purple is another dye that is used extensively in laboratories testing human samples, however this technique produces artefactually low values in animal sera and should not be used for measuring albumin in samples from animals. There are also species pecularities in the amount of bromocresol green that binds to albumin. Falsely high albumin values are seen in samples from new world monkeys (e.g. lemurs) and rabbits, whereas low values are seen with birds. The falsely high values in rabbits can be overcome by the use of rabbit serum as a calibrator for the reaction (normally a human-based calibrator is used), however this is not routinely done by veterinary laboratories. Serum is the preferred sample for albumin measurement.

Reaction type

Blanked end-point

Procedure

  • Albumin Bromocresol green (BCG) method: At an acidic pH of 4.1 albumin is significantly charged allowing it to bind to the anionic dye bromocresol green forming a blue-green complex. The color intensity of the complex is photometrically measured and is proportional to the concentration of albumin. Blanking indicates that a baseline reading is taken before the dye is added. This reduces falsely increased baseline absorbances, such as due to hemolysis or lipemia (as these are unchanged after addition of the dye and are subtracted from the results).
  • Reaction shown below:

albumin + bromocrescol green        pH 4.1      > blue-green complex

Units of measurement

Albumin concentration is measured in g/dL (conventional units) and g/L (SI units). The conversion equation is shown below:

g/dL x 10 = g/L

Sample considerations

Sample type

Serum and plasma (EDTA, heparin)

Anticoagulant

Citrate, oxalate, and fluoride anticoagulants distort protein concentration by causing water to diffuse from erythrocytes; therefore should be avoided for samples collection. Li-heparin and K2-EDTA anticoagulants are preferred.

Stability

The stability of albumin in human samples: 2.5 months at 15 – 25 °C, 5 months at 2 – 8 °C, and 4 months at (-15)-(-25) °C (per package insert, Roche).

Interferences

  • Lipemia/Turbidity, hemolysis, and icterus: Albumin values can be artifactually elevated in severely lipemic or hemolyzed samples, but this is analyzer- and method-dependent.
  • Drugs: Increases in albumin are reported in experimental studies in dogs administered corticosteroids. It is not clear if this is due to increased production of corticosteroids or dehydration secondary to free water losses from corticosteroid-induced polyuria.

Test interpretation

Changes in albumin concentration can selective (affecting albumin only) or non-selective (affecting both albumin and globulins). Selective versus non-selective changes in albumin and globulins yields potential clues as to the mechanism and cause for these abnormal results, as outlined below (the A:G ratio can be used as a guide as to selective versus non-selective changes).

Increased albumin concentration (hyperalbuminemia)

The most common cause of this is dehydration or volume contraction secondary to fluid loss.

  • Artifact: Albumin is higher in heparinized plasma than serum (due to non-specificity of bromocresol green which also binds to globulins, including fibrinogen), however newer procedures have been developed to minimize this phenomenon.
  • Physiologic: Hyperalbuminemia is a relative change seen with volume contraction secondary to fluid losses. Globulins may also increase in this situation, resulting in hyperproteinemia with no change in A:G ratio. However, globulins are frequently normal with volume contraction (low A:G), so the lack of hyperglobulinemia does not exclude dehydration or volume contraction as a cause of hyperalbuminemia.
  • Pathophysiologic:
    • Adrenal dysfunction: In one study of 114 Scottish Terriers, high albumin concentrations (up to 5.2 g/dL) were observed in 22% of 61 dogs with clinical signs of hyperadrenocorticism and vacuolar hepatopathy (glycogen accumulation). Some dogs had a concurrent copper-associated hepatopathy. Hyperadrenocorticism was documented with a low dose dexamathasone test in around 1/4 of 46 tested dogs, with a high cortisol post ACTH in up to 2/3 of 37 tested dogs. Around 80% of 25 tested dogs had high adrenal sex hormones (progesterone and androstenedione) after ACTH stimulation (defined as a >1 fold increase above a reference interval).  Thus adrenal dysfunction, particularly affecting sex hormones, may be associated with a high albumin concentration, although the mechanism is unknown. Most of the dogs had high serum ALP activity (values up to 22, 000/uL) (Cortright et al 2014).
    • Hepatocellular carcinoma: A high albumin concentration (5.3 g/dL), with a concurrent increase in colloidal osmotic pressure, has been documented in a dog with hepatocellular carcinoma. Both these findings corrected after surgical removal of the tumor, although the mechanism for the tumor-associated increase in albumin was not ascertained (Cooper et al 2009). In the above study of 114 Scottish terriers with adrenal dysfunction and vacuolar hepatopathy, 10% of 28 tested dogs with concurrent hepatocellular carcinomas had high albumin (up to 4.5 g/dL), although not as high as those dogs without the tumor (see above). In this study, hematologic or serum biochemical findings did not differentiate between dogs with and without hepatocellular carcinomas (Cortright et al 2014).

Decreased albumin concentration (hypoalbuminemia)

  • Physiologic: Excessive fluid administration (overdilution).
  • Pathophysiologic
    • Decreased production: Decreased production can occur if there are insufficient amino acids available for hepatic production of albumin. This occurs in cases of chronic severe malnutrition due to dietary deficiency) or starvation. The liver is the main site of albumin production. Chronic hepatic disease will result in hypoalbuminemia when there is a > 80% reduction in functional mass.
      • Acute phase reaction response: An acute phase reactant response is initiated in response to trauma, inflammation, neoplasia, etc and involves release of cytokines (IL-1, IL-6, TNFα) from macrophages. These cytokines act on regulatory elements in hepatocyte genes, resulting in upregulation of transcription of acute phase reactant proteins (fibrinogen, serum amyloid A, ceruloplasmin, haptoglobin) and downregulation of transcription of other proteins, including albumin and transferrin (so-called “negative acute phase reactants”). Increased degradation of albumin may also play a role in the hypoalbuminemia in this reaction. In acute phase proteins, the A:G is decreased due to the combination of low albumin and high globulins (this type of response is associated with an increase in α2 globulins on serum electrophoresis). In one prospective study of 116 dogs admitted to an emergency center, dogs with systemic inflammation (systemic inflammatory response syndrome or sepsis) and dogs with localized inflammation had significantly lower albumin concentrations (1.9 ± 0.5 g/dL and 2.5 ± 0.4 g/dL, respectively) than clinically healthy blood donor dogs (3.2 ± 0.3 g/dL). Low albumin concentrations had good discriminatory ability between inflammation (localized or systemic) versus health (area under a receiver operator characteristic curve of 0.991-0.992) and between localized and systemic inflammation (area under the curve of 0.834), performing better than other markers of inflammation (low plasma iron, high fibrinogen, and high C-reactive protein concentrations) for the latter (Torrente et al 2015).
    • Loss: The most common cause of low albumin and low globulins (non-selective protein loss) are protein-losing enteropathy and severe hemorrhage. Severe decreases in albumin alone, without concurrent change in globulins, should prompt a search for albumin loss through the kidney (glomerular disease) or decreased liver production (the latter is often accompanied by increased globulins, because the liver normally clears antigens derived from the gut and defective liver clearance of antigens can result in a polyclonal gammopathy).
      • Protein-losing glomerulopathy: This can result in hypoalbuminemia when protein loss is severe.  Nephrotic syndrome is characterized by proteinuria, hypoalbuminemia, hypercholesterolemia and edema. In these conditions, albumin is lost, but globulin levels are usually maintained, resulting in a low A:G. Not all animals with nephrotic syndrome are edematous.
      • Severe hemorrhage: Both albumin and globulins are lost, resulting in a normal A:G.
      • Protein-losing enteropathies: In these conditions, albumin and globulins are usually lost concurrently, thereby maintaining a normal A:G. There are exceptions to this, e.g. Basenjis with immunoproliferative bowel disease have hyperglobulinemia.
      • Severe exudative dermatopathies: This may also associated with concomitant albumin and globulin loss (A:G tends to remain normal), unless the dermatopathy stimulates an immune response (with hyperglobulinemia).
    • Sequestration: Hypoalbuminemia can be due to sequestration of albumin within body cavities in protein-rich effusions, e.g. peritonitis. The low albumin is also likely due to dilution from compensatory mechanisms associated with decreased effective circulating volume if fluid accumulation is severe, including stimulation of ADH release and thirst. Mild effusions are unlikely to affect albumin concentrations much.
    • Catabolism: This is not a well-characterized mechanism for low albumin. Increased albumin catabolism may occur with negative energy balance or protein malnutrition (e.g. chronic infections, neoplasia, trauma) and, potentially, as part of an acute phase response (see decreased production above). Older animals (and people) may also have hypoalbuminemia or hypoalbuminemia rapidly develops with poor nutrition or reduced food intake. The mechanism is unclear, but may be related to decreased protein production as well as increased protein catabolism.
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