Background: The bromocresol green (BCG) assay is commonly used for measuring albumin (ALB), but is affected by 1 -and 2 -globulins, which are elevated in systemic inflammation. The modified bromocresol purple (mBCP) assay is another dye-binding method developed to overcome non-specific reactions. Concentrations of 2 -macroglobulin, a major 2 -globulin component, are increased in nephrotic syndrome (NS), but not in inflammation. There is little direct evidence that 2 -macroglobulin affects BCG or mBCP assays. Methods: We measured serum albumin concentrations in 33 patients with NS and 13 reference healthy controls using BCG (ALB BCG ) and mBCP (ALB mBCP ) assays, and nephelometry (nALB) as a reference method. We also determined five specific proteins belonging to the 1 -and 2 -globulins by nephelometry. After adding purified 2 -macroglobulin to albumin solutions, protein reactivity in these three assays was compared. Results: Nephrotic syndrome patients were categorized to tertiles according to nALB concentration. In all tertiles, ALB BCG was significantly higher than nALB, especially in the severe hypoalbuminemia group, in which 2 -macroglobulin was 43-49% higher. By contrast, ALB mBCP and nALB were almost identical in all three groups. The difference between ALB BCG and nALB was positively correlated with the 2 -macroglobulin concentration. In vitro, when 2 -macroglobulin was added to solutions containing identical albumin concentrations, 2 -macroglobulin dose-dependently increased ALB BCG , but not ALB mBCP . Conclusions: In NS, 2 -macroglobulin is a major factor for positive bias of ALB BCG , especially in patients with severe hypoalbuminemia. The mBCP assay is useful for measuring albumin concentrations in NS.