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Serum-ascites albumin gradient

The serum-ascites albumin gradient or gap (SAAG) is a Pathophysiology sample values
calculation used in medicine to help determine the cause of BMP/ELECTROLYTES:
ascites.[1] The SAAG may be a better discriminant than the Na+ = 140 Cl = 100 BUN = 20 /
older method of classifying ascites fluid as a transudate versus Glu = 150

exudate.[2] K+ =4 CO2 = 22 PCr = 1.0 \

ARTERIAL BLOOD GAS:
The formula is as follows: HCO3 = 24 paCO2 = 40 paO2 = 95 pH = 7.40
ALVEOLAR GAS:
SAAG = (serum albumin) (albumin level of pACO2 = 36 pAO2 = 105 A-a g = 10
ascitic fluid). OTHER:
Ca = 9.5 Mg2+ = 2.0 PO4 = 1
Ideally, the two values should be measured at the same time. CK = 55 BE = 0.36 AG = 16
SERUM OSMOLARITY/RENAL:
This phenomenon is the result of Starling's forces between the PMO = 300 PCO = 295 POG = 5 BUN:Cr = 20

fluid of the circulatory system and ascitic fluid. Under normal URINALYSIS:
UNa+ = 80 UCl = 100 UAG = 5 FENa = 0.95
circumstances the SAAG is < 1.1 because serum oncotic
UK+ = 25 USG = 1.01 UCr = 60 UO = 800
pressure (pulling fluid back into circulation) is exactly
PROTEIN/GI/LIVER FUNCTION TESTS:
counterbalanced by the serum hydrostatic pressure (which LDH = 100 TP = 7.6 AST = 25 TBIL = 0.7
pushes fluid out of the circulatory system). This balance is ALP = 71 Alb = 4.0 ALT = 40 BC = 0.5
disturbed in certain diseases (such as the BuddChiari AST/ALT = 0.6 BU = 0.2
AF alb = 3.0 SAAG = 1.0 SOG = 60
syndrome, heart failure, or liver cirrhosis) that increase the
CSF:
hydrostatic pressure in the circulatory system. The increase in
CSF alb = 30 CSF glu = 60 CSF/S alb = 7.5 CSF/S glu = 0.4
hydrostatic pressure causes more fluid to leave the circulation
into the peritoneal space (ascites). The SAAG subsequently increases because there is more free fluid leaving the
circulation, concentrating the serum albumin. The albumin does not move across membrane spaces easily because it is
a large molecule.

Contents
1 Differential
1.1 High gradient
1.2 Low gradient

2 References

Differential

High gradient
A high gradient (> 1.1 g/dL, >11g/L) indicates the ascites is due to portal hypertension, either liver related or non-liver

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Serum-ascites albumin gradient - Wikipedia https://en.wikipedia.org/wiki/Serum-ascites_albumin_gradient

related, with approximately 97% accuracy.[2] This is due to increased hydrostatic pressure within the blood vessels of
the hepatic portal system, which in turn forces water into the peritoneal cavity but leaves proteins such as albumin
within the vasculature.

Important causes of high SAAG ascites (> 1.1 g/dL, >11 g/L) include: cirrhosis of the liver, heart failure, Budd-Chiari
syndrome, portal vein thrombosis, and idiopathic portal fibrosis.[3]

Low gradient
A low gradient (< 1.1 g/dL, <11 g/L) indicates causes of ascites not associated with increased portal pressure:
tuberculosis, pancreatitis, infections, serositis, various types of peritoneal cancers (peritoneal carcinomatosis) and
pulmonary infarcts.

SAAG vs Total ascities protein

SAAG

<1.1 >1.1

<2.5 Tuberculous Peritonitis, Nephrotic syndrome Cirrhosis, Budd-Chiari (late)

Total
Protein Cancer, Tuberculosis, Chylous ascites, Right HF, Budd-Chiari (early), veno-occlusive
>2.5
Pancreatitis disease

References
1. Wong CL, Holroyd-Leduc J, Thorpe KE, Straus SE (March 2008). "Does this patient have bacterial peritonitis or
portal hypertension? How do I perform a paracentesis and analyze the results?" (http://jama.ama-assn.org
/cgi/pmidlookup?view=long&pmid=18334692). JAMA. 299 (10): 116678. doi:10.1001/jama.299.10.1166 (//doi.org
/10.1001%2Fjama.299.10.1166). PMID 18334692 (//www.ncbi.nlm.nih.gov/pubmed/18334692).
2. Runyon BA, Montano AA, Akriviadis EA, Antillon MR, Irving MA, McHutchison JG (August 1992). "The serum-
ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites".
Annals of Internal Medicine. 117 (3): 21520. doi:10.7326/0003-4819-117-3-215 (//doi.org
/10.7326%2F0003-4819-117-3-215). PMID 1616215 (//www.ncbi.nlm.nih.gov/pubmed/1616215).
3. Gins, Pere; Crdenas, Andrs; Arroyo, Vicente; Rods, Juan (15 April 2004). "Management of Cirrhosis and
Ascites". New England Journal of Medicine. 350 (16): 16461654. doi:10.1056/NEJMra035021 (//doi.org
/10.1056%2FNEJMra035021). PMID 15084697 (//www.ncbi.nlm.nih.gov/pubmed/15084697).

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