Transthyretin (TTR)

On December 27, 2010, in General Nutrition, Tests, by Andrea

Transthyretin (TTR) is the test formally known as prealbumin.  It still is known as prealbumin by some labs, so be aware that the two names may be used interchangeably.

Transthyretin is a transport protein for thyroxine (T4) and retinol (vitamin A).  The main clinical use for a transthyretin level is for monitoring nutritional status as it is a better indicator of protein status than albumin.

This is a non-fasting test.

Range: 20-40 mg/dL Range given are from MY laboratory ranges.  Yours may vary slightly.  Adapt as needed.

A low level indicates malnutrition.

I think I’ve made it very clear in the past that I believe everyone should look at their own labs and watch for trends.  Occasionally, I get the question of “I can ask for my own records?”

YES.

You have the right to your own medical records.  In fact, if you have screwed up insides that many doctors don’t understand, not only do you have the right, you really have an obligation to have your records and to (I’m going to lose a few of you here) understand them.

Now I’m not saying that you understand surgical notes enough that you can go in and perform your own surgery on someone else.  That would just be silly.  But to know what a 1721 means for a B12 level, or a 30ml pouch created, or that you had a cholecystectomy during your RNY are all important things to know and to understand.

You’re going to ask why — and that’s good.  Cause asking “why” is always good – unless you are my almost two year old asking “why?” when I’ve told him not to hit his sister or to stop throwing blocks at the dog, and in that instance asking “why” is liable to make me want to pull my hair out.. but you get my point.  You need to know because you never know when you’re going to run across an idiot with a medical degree.  Please, please, PLEASE do not get blinded by the white coat.  We all want to think that our doctors are the smartest people on the planet, that they are the best surgeon in the world, and we are the most important patient on their roster for the day.  But let’s face facts — we are one of several patients your doctor sees every day, one of hundreds of prescriptions your pharmacist fills each day, one of thousands of people that will walk through a hospital a year.  Mistakes will happen, a degree of detail that you wish would happen will not always happen — and you are the only person that will really have to suffer through the consequences of any mistakes.

So let me concentrate for a moment on lab work.  When you have your labwork done, get copies of every single draw.  Get the interpretation by your doc and your nutritionist — fine, I don’t care.  But put your eyeballs upon it.  Even better, make a spreadsheet.  Be g33ky if you want and put it on the computer, put it on regular note paper, or just compare it time to time — whatever floats your boat.  But look at it.  And here’s what you want to look for — trends.

Are your numbers staying stable?  Are they going up?  Are they going down?  If they are going down, how quickly are they going down?  Why are they going down?  What can you do to make them stop going down?

Why is this important?  Here’s a scenario.

You have a blood draw done at 3 months, another at 6 months, and one planned at 9 months.  At 3 months, your B12 is 800, with a range of 200-900.  At 6 months, B12 is 500, which is still in range.  Because it is still in range, it is not flagged and is not even mentioned by the doctor or nutritionist.  Assuming nothing changes, and everything is equal, what do we guess the 9 month labs to be?  If no one is looking at trends, we are now at deficiency range, something that easily could have been avoided if trends had been watched and measures had been taken to avoid a deficiency in the first place.

It is your right, as a patient, to have access to your medical records.  Take advantage of this right.

It is the right of a hospital or medical facility to charge you for copies of these records.  Many hospitals will charge you $1 per page for copies.  Many doctor’s offices will not.

A case for long-term aftercare

On January 21, 2009, in Uncategorized, by Andrea

This is an article that I wrote for the January OH e-newsletter.  Now that it’s been published by OH, I’ll publish it here as well.

A vertical sleeve gastrectomy patient traveled to Mexico to self-pay for his surgery three years ago, and has done a wonderful job with his surgery.  Knowing his surgery was notmalabsorptive , though, he never took the vitamins needed to help keep him healthy.  Now, three years later, he’s beginning to feel a bit run down and goes to his PCP for help since he cannot follow-up with his surgeon.  The PCP, having very limited knowledge of what blood work to order only orders a few labs, all of which come back normal.  The patient continues to decline, not realizing the lack of vitamins leading to his decline, and without theknowledge of which labs to look for, has no idea where to look for the help he so desperately needs.

A two year post-op roux-en Y gastric bypass patient is pregnant with her first child.  She’s recently moved from her hometown, and is now seeing an unfamiliar obstetrician who has never had an RNY patient before.  Due to the move, our mother-to-be cannot follow-up with her surgical practice.  What little routine blood work the OB thinks to draw shows rapidly dropping vitamin B-12 levels, and standard anemia panels come back normal.  Nutritional counseling is limited and based on requirements for the practice’s standard patient: a single prenatal vitamin, an iron tablet, and a Tums tablet for calcium.  Postpartum, our mother begins feeling more sluggish than usual (even for a first-time mom) and begins to ache deep in her bones.  Frustrated, she finally does some research online and asks her doctor for additional blood tests which show abysmal numbers in iron and vitamin D levels.  Now, not only is our mom recovering from having a child, but is diagnosed with pernicious anemia andosteomalacia — adult-form rickets.

While these hypothetical cases are certainly extreme, they point to two underlying problems concerning the Weight Loss Surgical community: the lack of information for medical practitioners outside thebariatric community, as well as the lack of eduction of the surgical patient themselves.

In 2008, there were 344,221 weight loss surgeries performed, which was an increase of 135% over 2003 (Metabolic / Bariatric Surgery Worldwide 2008).  Given the current estimate that 44.1 million Americans will have diabetes by 2032, a number that is nearly double the current number of 23.7 million, there will be more and more weight loss surgeries performed each year (Study: Cost of treating diabetes to triple by 2034).  This especially holds true given that 90% of diabetes cases are Type 2, a form of diabetes that develops over time with the predominant risk factor being obesity.  With new technologies currently in clinical trials that promise incisionless and lower cost options to a wider variety of patients, weight loss surgery is here to stay, and thus patients are going to become more and more common.

There are many reasons why a patient may turn to a different medical provider to help maintain their health post weight loss surgery.  If there is not enough information for that provider to give adequate medical advice to the patient, and if the patient is not savvy enough regarding their own care, the post-op road will not only be bumpy, but could also be paved with disaster.

Therefore it’s extremely important for two things to happen:

  1. More professional literature needs to be published for reference and learning to medical professionals in all fields of practice.
  2. The weight loss surgical patient needs to become more self-aware and involved in their own care in order to assure their health does not become compromised in any way.

As patients, we cannot really push the medical establishment to publish more literature, nor force additional courses for learning for our medical professionals.  However, we can completely control our own self-knowledge and can help educate our own providers to the best of our ability.  By educating ourselves, not only do we have more faith and confidence in our health, but we become better patients by learning more about the clues our bodies give us and can give better information to those who are treating us.  In this process of self-education, we can help educate our medical team by providing medical literature pertinent to our care.  Nutrition guidelines, information about the different surgical procedures, medicinal guidelines for your surgical type — all are critical information pieces for your health care provider and should be given to any one providing care to a bariatric surgical patient.

When considering any weight loss surgery – from a restrictive-only procedure to a malabsorptive one, a potential patient must consider all manner of possibilities.  What would happen to your care if you moved far from your surgical practice?  If you lost your health benefits, and could not afford routine lab work, how would you determine nutritional status?  What if you lose your income and cannot afford a high-protein diet, much less the supplements needed to keep you healthy?  What happens if you develop a nutritional deficiency due to an inability to pay for your supplements or lab work?  It’s a sad fact that preventing a deficiency is cheaper than treating one, but what if you can’t even afford that?  Who will manage your care in six months?  Two years?  Five years?  Twenty years?  These are all questions that we should be asking prior to even the surgical consultation, yet don’t.

Long-term aftercare is important, and while we expect the medical community to be there for us, and to provide for us, ultimately it is up to us, the bariatric patients, to be responsible for our own health and well-being.  In the process of making ourselves better informed, we make our community a stronger one — one that can push for more education and resources to be available to the medical professionals that treat us.

ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient — Aills, Blankenship, Buffington, Furtado, & Parrott