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Prealbumin (Transthyretin)

Transthyretin is a liver-synthesized protein that transports thyroid hormone and complexes with retinol-binding protein. Its approximately two-day half-life explains rapid concentration changes, but does not make it a reliable measure of nutritional status or response to feeding.[1][2]

Interpreting a Result​

Reference intervals vary by assay and laboratory. Individual studies define a low result as <15 or <20 mg/dL, but neither is a diagnostic cutoff for malnutrition.[10][7][2] Inflammation, liver disease, fluid balance and renal disease can alter the concentration, and kidney dysfunction may raise it.[2][3]

Prealbumin can remain normal despite severe nutritional deprivation. A low result may reflect acute or chronic disease, and a rise can accompany resolving inflammation. The same limitations apply to albumin.[2]

Why Routine Nutrition Monitoring Is Inappropriate​

ASPEN advises against using prealbumin as a proxy for body protein or muscle mass, or as a basis for changing nutrition support. The shorter half-life does not remove the inflammatory confounding.[2] In a retrospective study of 154 mostly critically ill adults receiving enteral nutrition, prealbumin changes did not differ between 70 patients receiving at least 60% and 84 receiving less than 60% of prescribed calorie needs (P = 0.86); among 94 patients with repeated CRP measurements, changes in prealbumin correlated with changes in CRP (r = −0.544).[4]

Nutrition monitoring relies on delivered intake, tolerance, weight and fluid context, physical findings, function and clinical recovery. Adding CRP does not make prealbumin a validated test of nutritional adequacy.[2][5]

Prognostic and Exploratory Evidence​

EvidenceFindingPractical limit
Nichols 2020. Retrospective cohort of 926 ICU patientsPatients who died had a larger fall in prealbumin; baseline concentration was not associated with mortality or length of stayThe association is prognostic; targeting the concentration has not been shown to help
Kim 2023. Single-surgeon cohort of 69 patients undergoing lower-extremity free tissue transfer for chronic woundsPreoperative prealbumin <20 mg/dL was not associated with flap healing or time to healingSingle-surgeon retrospective series; low albumin (<2.7 g/dL) was associated with worse healing[7]
Dellière 2021. Retrospective derivation followed by small prospective groups stratified by CRP and transthyretinProposed thresholds of 0.17 and 0.12 g/L for nutritional classificationReference standard was nutritional status estimated from patient files, not GLIM

Sources: Nichols,[6] Kim,[7] and Dellière.[8]

Dellière and Cynober argue that transthyretin can help diagnose malnutrition and its severity in patients without an inflammatory syndrome, is a good prognostic marker, and is useful for monitoring refeeding despite inflammation. ASPEN takes the opposite position and does not accept prealbumin as a nutrition marker.[1][2]

Application to Reconstruction​

  • Diagnose and treat malnutrition using an accepted clinical assessment, not a low prealbumin result.
  • Do not routinely order serial prealbumin to judge response to supplements, immunonutrition or parenteral nutrition.
  • Assess intake, weight trajectory, symptoms and operative risk directly.
  • A prealbumin threshold should not determine whether a patient proceeds with reconstruction.[2] For severe malnutrition and/or high metabolic risk, ESPEN 2025 recommends preoperative nutrition even if surgery is postponed (grade A, strong consensus) and suggests considering 10–14 days (grade B).[9] Weigh disease urgency and the overall assessment; see the Nutritional Assessment overview.[9]

See Also​

References​

1. Dellière S, Cynober L. "Is Transthyretin a Good Marker of Nutritional Status?" Clinical Nutrition. 2017;36(2):364–370. doi:10.1016/j.clnu.2016.06.004

2. Evans DC, Corkins MR, Malone A, et al. "The Use of Visceral Proteins as Nutrition Markers: An ASPEN Position Paper." Nutrition in Clinical Practice. 2021;36(1):22–28. doi:10.1002/ncp.10588

3. Ostermann M, Lumlertgul N, Mehta R. "Nutritional assessment and support during continuous renal replacement therapy." Seminars in Dialysis. 2021;34(6):449–456. doi:10.1111/sdi.12973

4. Davis CJ, Sowa D, Keim KS, Kinnare K, Peterson S. "The Use of Prealbumin and C-Reactive Protein for Monitoring Nutrition Support in Adult Patients Receiving Enteral Nutrition in an Urban Medical Center." JPEN. Journal of Parenteral and Enteral Nutrition. 2012;36(2):197–204. doi:10.1177/0148607111413896

5. McClave SA, DiBaise JK, Mullin GE, Martindale RG. "ACG Clinical Guideline: Nutrition Therapy in the Adult Hospitalized Patient." The American Journal of Gastroenterology. 2016;111(3):315–334. doi:10.1038/ajg.2016.28

6. Nichols DC, Flannery AH, Magnuson BL, Cook AM. "Prealbumin Is Associated With in-Hospital Mortality in Critically Ill Patients." Nutrition in Clinical Practice. 2020;35(3):572–577. doi:10.1002/ncp.10414

7. Kim KG, Mishu M, Zolper EG, et al. "Nutritional markers for predicting lower extremity free tissue transfer outcomes in the chronic wound population." Microsurgery. 2023;43(1):51–56. doi:10.1002/micr.30794

8. Dellière S, Pouga L, Neveux N, et al. "Assessment of Transthyretin Cut-Off Values for a Better Screening of Malnutrition: Retrospective Determination and Prospective Validation." Clinical Nutrition. 2021;40(3):907–911. doi:10.1016/j.clnu.2020.06.017

9. Weimann A, Bezmarevic M, Braga M, et al. "ESPEN guideline on clinical nutrition in surgery - Update 2025." Clin Nutr. 2025;53:222–261. doi:10.1016/j.clnu.2025.08.029

10. Takemoto E, Yoo J, Blizzard SR, Shannon J, Marshall LM. "Preoperative prealbumin and transferrin: Relation to 30-day risk of complication in elective spine surgical patients." Medicine (Baltimore). 2019;98(9):e14741. doi:10.1097/MD.0000000000014741.