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Serum Ascites Albumin Gradient (SAAG)

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Albumin gradient in ascites.

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Serum Ascites Albumin Gradient (SAAG) - Comprehensive Medical Test Guide

  • Why is it done?
    • The SAAG measures the difference between albumin concentration in serum and ascitic fluid to determine the cause of ascites (abnormal fluid accumulation in the abdominal cavity)
    • Primary indications: Evaluation of patients with ascites to determine if the cause is related to portal hypertension or other non-portal hypertensive causes
    • Helps differentiate conditions such as cirrhosis, hepatic fibrosis, portal vein thrombosis, Budd-Chiari syndrome, and peritoneal carcinomatosis
    • Performed when a patient presents with new-onset ascites or when the etiology of ascites is uncertain
    • Used as part of diagnostic paracentesis (needle aspiration of ascitic fluid) procedures to guide clinical management and prognosis
  • Normal Range
    • Normal SAAG value: Less than 1.1 g/dL (or <11 g/L)
    • Borderline/Elevated SAAG: 1.1 g/dL or greater (≥1.1 g/dL or ≥11 g/L) indicates portal hypertension
    • Units of measurement: grams per deciliter (g/dL) or grams per liter (g/L)
    • Normal results suggest ascites is not due to portal hypertension; abnormal (elevated) results strongly suggest portal hypertensive causes with high accuracy (approximately 97% specificity)
    • The gradient remains stable over time in individual patients and is useful for repeated measurements
  • Interpretation
    • SAAG ≥1.1 g/dL (Portal Hypertensive Ascites): Indicates portal hypertension is the cause; suggests conditions such as cirrhosis (alcoholic or viral hepatitis-related), chronic liver disease, hepatic fibrosis, portal vein thrombosis, Budd-Chiari syndrome, or splenic vein thrombosis
    • SAAG <1.1 g/dL (Non-portal Hypertensive Ascites): Suggests causes unrelated to portal hypertension such as peritoneal carcinomatosis, peritonitis (spontaneous bacterial or tuberculous), pancreatic disease, renal disease, heart failure-related, or lymphatic obstruction
    • Accuracy and Clinical Significance: SAAG has approximately 97% specificity and 66% sensitivity for detecting portal hypertension; is considered a gold standard for diagnosing portal hypertensive ascites
    • Factors Affecting Results: Timing between serum and ascitic fluid collection (should be within 12 hours for accuracy), presence of infection or malignancy, renal function, nutritional status, and severe hypoalbuminemia
    • Mixed Ascites: Some patients may have both portal hypertensive and non-portal hypertensive causes; SAAG helps identify the predominant mechanism
    • The gradient remains constant over time and is not affected by treatment of ascites or changes in total serum albumin levels
  • Associated Organs
    • Primary Organ System: Hepatic (liver) and portal venous system; peritoneum and abdominal cavity
    • Portal Hypertensive Conditions: Cirrhosis (alcohol-related, hepatitis B or C, nonalcoholic fatty liver disease), hepatic fibrosis, portal vein thrombosis, Budd-Chiari syndrome, splenic vein thrombosis, schistosomiasis
    • Non-portal Hypertensive Conditions: Peritoneal carcinomatosis (ovarian, gastric, pancreatic cancers), bacterial peritonitis, tuberculous peritonitis, pancreatic disease, renal failure, heart failure, lymphatic obstruction, peritoneal dialysis
    • Associated Complications: Spontaneous bacterial peritonitis (SBP), hepatorenal syndrome, encephalopathy, variceal bleeding, liver failure, electrolyte abnormalities, malnutrition
    • Risks Related to Paracentesis: Infection, bleeding, bowel perforation, loculated ascites, abdominal pain, and fluid leakage are potential complications from the diagnostic procedure needed to obtain ascitic fluid for SAAG measurement
  • Follow-up Tests
    • If SAAG ≥1.1 g/dL (Portal Hypertensive): Liver function tests (AST, ALT, bilirubin, albumin), prothrombin time (PT/INR), platelet count, abdominal ultrasound or CT imaging, esophagogastroduodenoscopy (EGD) to screen for varices, hepatitis serologies
    • If SAAG <1.1 g/dL (Non-portal Hypertensive): Ascitic fluid cell count and differential, culture and sensitivity, acid-fast bacilli (AFB) smear and culture for TB, glucose, LDH, total protein, adenosine deaminase (ADA), cytology for malignancy
    • Complementary Ascitic Fluid Tests: Total protein level in ascites helps further differentiate portal hypertensive causes; ascites albumin gradient (same procedure as SAAG)
    • Imaging Studies: Abdominal ultrasound with Doppler to assess portal vein patency and liver echotexture, CT abdomen/pelvis for further evaluation, MRI for suspected Budd-Chiari syndrome or portal vein thrombosis
    • Monitoring Frequency: For chronic liver disease with portal hypertension, periodic monitoring may be indicated; for malignancy-related ascites, imaging studies repeated based on treatment response; for infection-related causes, follow-up based on clinical course
    • Prognostic Assessment: Child-Pugh score, Model for End-Stage Liver Disease (MELD) score for cirrhotic patients, evaluation for liver transplantation candidacy
  • Fasting Required?
    • Fasting Requirement: No fasting is required for this test
    • Patient Preparation: Standard blood draw precautions apply; patient should wear comfortable clothing allowing easy access to the abdomen and inner forearm for blood collection
    • Paracentesis Preparation: SAAG requires both serum and ascitic fluid samples; paracentesis (needle aspiration of abdominal fluid) should be performed by a trained healthcare provider; patient should empty bladder before procedure and may be given light sedation
    • Medication Considerations: Continue all regular medications unless otherwise instructed; inform provider of anticoagulation therapy or antiplatelet agents (aspirin, warfarin, etc.) as they may need to be adjusted before paracentesis
    • Timing Considerations: Serum and ascitic fluid samples should be collected within 12 hours of each other for maximum accuracy; samples should be transported to laboratory promptly in sterile containers
    • Post-Procedure Instructions: Patient may resume normal activities after paracentesis; monitor for signs of infection, excessive bleeding, or abdominal pain; keep puncture site clean and dry

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