Plasma concentration of taurine is higher in malnourished than control children: differences between kwashiorkor and marasmus

Plasma free amino acids were determined in the plasma of severely malnourished children under two years of age. A total of thirty-one patients and eleven controls were evaluated: seventeen cases of kwashiorkor, eight cases of marasmus, and six cases of marasmic-kwashiorkor. Fasting plasma samples were taken in the morning on the day of admission. Fasting plasma samples were also taken from nine patients at discharge after two months in the hospital where they received a balanced diet as treatment. A partial reversal of the signs of malnutrition was observed at discharge. In the whole group of patients ad admission, lower concentrations of tyrosine, methionine, tryptophan, and leucine and higher concentrations of aspartate, glutamate, and taurine were observed compared to controls. Taurine continued to be elevated in the malnourished group at the time of discharge. Marasmic children, as compared to controls, had high aspartate and low tryptophan levels, but taurine levels were not significantly different from controls. Kwashiorkor patients had low tyrosine, methionine, tryptophan, and lysine, and significantly higher taurine plasma levels. The elevated concentration of taurine might be the result of a redistribution of this amino acid to provide specific tissues with the required amount for development.

A case of kwashiorkor in the UK

A case of kwashiorkor in a British child of Caucasian origin is described. The 5-year-old boy was referred to hospital for investigation of a persistent anaemia, but on examination was found to have classical features of kwashiorkor. He was stunted with both height and weight below the fifth centile and had mild pitting oedema in both legs. His hair was pale and easily pluckable and a soft liver edge was palpable. Plasma albumin concentration was 16 g/l and the plasma amino acid pattern, which revealed markedly reduced levels of essential but normal to high non-essential amino acids, was similar to that described in kwashiorkor in Uganda. A dietary history revealed that for about 2 years the child's diet had contained very little protein but adequate energy and had been supplemented with multivitamin pills. There was no evidence of other pathology, neglect or abuse and the child responded rapidly to refeeding with a balanced diet.

Whole-body protein kinetics in children with kwashiorkor and infection: a comparison of egg white and milk as dietary sources of protein

This study tested the hypothesis that during treatment of kwashiorkor (including marasmic kwashiorkor) with infection there is a lower rate of amino acid oxidation when the dietary intake of amino acids resembles the amino acid composition of acute phase proteins (APPs). Twenty-two children in Blantyre, Malawi, with kwashiorkor and acute infection were fed an isoenergetic, isonitrogenous diet with either egg white or milk as a protein source. The whole-body amino acid oxidation rate was measured after 24 h by determining the plasma urea rate of appearance, and whole-body protein breakdown and synthesis rates were determined from the plasma leucine rate of appearance. Plasma concentrations of C-reactive protein, alpha1-antitrypsin, tumor necrosis factor alpha (TNF-alpha), and interleukin 6 (IL-6) were determined on admission and at 24 and 48 h. The 11 children who received milk had a lower rate of amino acid oxidation than the children who received egg white (x +/- SD: 137 +/- 65 compared with 195 +/- 66 micromol urea x kg body wt(-1) x h(-1), P < 0.05). No significant differences were found between the two groups in the rate of whole-body protein breakdown or protein synthesis. The TNF-alpha concentration correlated inversely with whole-body protein breakdown and synthesis rates, and the IL-6 concentration correlated directly with C-reactive protein. We conclude that by making the amino acid composition of the diet resemble that of APPs in the treatment of acute kwashiorkor, the rate of amino acid oxidation can be decreased.

Inflammatory mediators in children with protein-energy malnutrition

Edema is a typical sign in kwashiorkor, which is present in a subset of patients with protein-energy-malnutrition (PEM). The pathophysiology of this edema is not well established. One of the abnormalities found in kwashiorkor is reduced concentrations of antioxidants, suggesting a compromised capacity to neutralize free radicals, which are known to induce tissue damage. We have studied plasma concentrations of several mediators of the inflammatory cascade. Concentrations of interleukin 6 (IL-6), C-reactive protein, and the soluble receptors of tumor necrosis factor alpha (sTNFR-p55 and sTNFR-p75) are greater in children with PEM, particularly in those with kwashiorkor, whereas soluble receptors of IL-6 (sIL6R-gp80) and IL-1 receptor antagonist concentrations are not significantly different from those of healthy children. In addition, concentrations of IL-6, sTNFR-p55, and sTNFR-p75 are greater in kwashiorkor patients irrespective of the presence of infection. Antioxidant status, as determined by plasma concentrations of glutathione and vitamin E, is significantly reduced in kwashiorkor patients. These data support the notion that children with edematous malnutrition show increased inflammatory reactivity that may contribute to edema formation.

Assessment of plasma fibronectin in malnourished Nigerian children

BACKGROUND

Severe malnutrition is associated with septic infections. The concentrations of fibronectin, albumin, and transferrin in plasma were measured in three groups of children with protein-energy malnutrition, aged 1-3 years, each group comprising 20 children. The aim of which was to test whether plasma fibronectin, being an opsonic protein, was reduced in such children, and if it was a useful index for assessing the severity of malnutrition.

METHODS

The concentrations of fibronectin, albumin, and transferrin in plasma were studied by enzyme immunoassay/ immunoblotting, spectrophotometry and immunoturbidimetry respectively.

RESULTS

All values were significantly lower in the patients with malnutrition than in the age- and sex-matched well-nourished Nigerian reference children. Within the malnourished group, the fibronectin value was evenly reduced in all subgroups. Albumin and transferrin values were lowest in the patients with kwashiorkor, highest in the marasmic patients, and intermediate in the patients with marasmic kwashiorkor; the values correlated mutually in individual cases as well, but not with the fibronectin levels. Neither plasma fibronectin fragmentation nor tissue fibronectin was detected in any patient with malnutrition or in the reference subjects.

CONCLUSIONS

The reduced plasma fibronectin values in these patients may be due to reduced synthesis by the liver, as evidenced by the equally reduced albumin and transferrin concentrations and/or to the multiple infections characteristic of the patients.

Pharmacokinetics of amikacin in children with kwashiorkor

The pharmacokinetics of intravenous amikacin, administered as a mean (SD) bolus dose of 5.5 (1.2) mg/kg to children between the ages of 1 and 4 years with kwashiorkor, was studied. Although there was a tendency for the average volume of distribution to increase to the upper limit of normal, plasma elimination half-life, first order elimination-phase rate constant and clearance remained close to the reference values for adults. Despite marginal elevation of the average t1/2 beta-value, reflecting a general trend, renal impairment in respect of amikacin clearance could not be demonstrated. It was concluded that the changes in pharmacokinetic parameters found in kwashiorkor are not large enough to amend the current therapeutic regimens for amikacin in this condition.

Polyunsaturated fatty acids in erythrocyte and plasma lipids of children with severe protein-energy malnutrition

The fatty acid composition of plasma cholesterol esters, plasma phospholipids, erythrocyte phosphatidylcholine and erythrocyte phosphatidylethanolamine was investigated in severely malnourished Nigerian children with kwashiorkor (n = 12) and marasmus (n = 32). Normally nourished children from the same area (n = 23) served as controls. The malnourished children showed a significant reduction of highly polyunsaturated fatty acids in cholesterol esters, phospholipids and phosphatidylcholine. No differences between the groups were found in erythrocyte phosphatidylethanolamine. Children with kwashiorkor had lower levels of linoleic acid metabolites and docosahexaenoic acid than marasmic children. The results suggest that the kwashiorkor syndrome is associated with impaired desaturation and elongation of PUFA and/or increased lipid peroxidation.

Misplaced iron in kwashiorkor

OBJECTIVES

To determine the presence of radical promoting iron (non-protein-bound or loosely bound or free iron) in the plasma of children with kwashiorkor.

DESIGN

The bleomycin assay was employed for the quantitation of free or loosely bound iron.

SETTING

The Red Cross War Memorial Children's Hospital, Cape Town, Tertiary Care.

SUBJECTS

Fifty children on admission with kwashiorkor: six with marasmus and twelve healthy well-nourished controls.

RESULTS

Non-protein-bound iron was detected in the plasma of 58% of children with kwashiorkor but was absent in marasmic and healthy well-nourished children.

CONCLUSIONS

The presence of radical promoting iron supports the hypothesis that a free radical injury probably plays a role in the pathogenesis of kwashiorkor and its removal may improve mortality.

Serum amino acids and genesis of protein energy malnutrition

Twenty four patients of classical marasmus and kwashiorkor along with equal number of healthy controls were selected for the study. Their serum amino acid patterns analysis revealed a mean ratio of glutamate to alanine in fasting samples of normal individuals to be 0.33, while it as 9.3 in kwashiorkor and 1.6 in marasmus. This differences in controls, kwashiorkor and marasmus was statistically significant. This observation may explain evolution of marasmus and kwashiorkor in children with similar diets. On the basis of the present observation it is postulated that in kwashiorkor, the conversion of pyruvate to alanine in presence of glutamate, an aminogroup donor does not proceed normally, resulting in accumulation of glutamate and low alanine. Thus the development of marasmus and kwashiorkor may not be related to dietary inadequacy alone but also to the transaminase function. This could be genetic in origin.

Glutathione and association antioxidant systems in protein energy malnutrition: results of a study in Nigeria

Marasmus and kwashiorkor are manifestations of protein energy malnutrition. The pathophysiology of these disorders is poorly understood. We studied a number of blood antioxidants [glucose-6-phosphate dehydrogenase (G6PDH), glutathione reductase (GR) and its cofactor flavin adenine dinucleotide (FAD), the tripeptide glutathione as the major nonprotein thiol], serum albumin, and retinol-binding protein in 12 children suffering from kwashiorkor with all classical symptoms, in 13 patients with clinically severe marasmus, in 19 marasmic but active children, and in 23 controls. Significant changes were observed for erythrocyte glutathione and correspondingly for nonprotein thiols in whole blood (0.72 +/- 0.29 mM thiols in controls, 0.50 +/- 0.22 mM in marasmus, 0.35 +/- 0.23 mM in severe marasmus, and 0.22 +/- 0.13 mM in kwashiorkor). These differences were paralleled by a decrease in serum albumin concentration so that the molar ratio of nonprotein thiols/albumin had an average value of approximately 1.5 in all groups. The erythrocyte glutathione-reducing system, represented by G6PDH and glutathione reductase, showed only slight differences among the four groups of children; the supposition that kwashiorkor occurs predominantly in children with aberrant G6PDH could not be substantiated. Unexpectedly, erythrocyte FAD, an index of riboflavin status, was normal in most malnourished patients. Discussed is the prospect of administering glutathione in kwashiorkor patients.

In vitro lymphocyte-differentiating effects of thymulin (Zn-FTS) on lymphocyte subpopulations of severely malnourished children

This work investigates how thymic dysfunction contributes to the depression of cell-mediated immunity in protein-energy malnutrition (PEM). In Bolivian children hospitalized for severe PEM, the size of the thymus was measured by echography, and the lymphocyte subpopulations were detected by using monoclonal antibodies. These data were compared with those obtained from healthy control subjects. Regardless of the clinical form of PEM, our results show a high degree of T lymphocyte immaturity in severely malnourished children, which correlates with a severe involution of the thymus. Before in vitro incubation with thymulin, this significant increase in the percentage of circulating immature T lymphocytes was concomitant with a decrease in mature T lymphocytes and a slight increase in cytotoxic T subpopulations. After in vitro incubation with thymulin, immature T lymphocytes decreased and mature T lymphocytes increased.

Apparent hypocalcaemia in Nigerian children with kwashiorkor

Thirty children with kwashiorkor had a mean +/- SEM plasma calcium (Ca) of 7.15 +/- 0.10mg/100ml; total proteins (TP) of 4.60 +/- 0.17g/100ml and albumin (A) of 1.89 +/- 0.11g/100ml. These values are significantly lower (p < 0.001) than the corresponding values of 9.07 +/- 0.10; 7.30 +/- 0.11 and 3.85 +/- 0.07 observed in thirty other age-matched normal controls. No significant differences exist in the plasma alkaline phosphatase (AP) levels in both groups. Correction of calcium for hypoalbuminaemia in the kwashiorkor group revealed that the observed hypocalcaemia in kwashiorkor is merely apparent.

Plasma free carnitine levels in children with malnutrition

In this study, plasma free carnitine and albumin levels were measured in children with protein-energy malnutrition (PEM). A total of 71 children with malnutrition were studied. The control group consisted of 20 healthy children. The mean plasma carnitine level was 78.4 +/- 1.94 nmol/ml in the control group. Marasmus and kwashiorkor patients displayed lower plasma free carnitine values, which were found to be statistically significant when compared to those of the control (P < 0.001). However, the values were significantly lower in kwashiorkor patients than in marasmic cases (29.7 > 5.46). There was no correlation between serum albumin and free carnitine levels in cases with kwashiorkor.

[Effects of refeeding on serum immunoglobulin (IgA, IgG, IgM) concentrations in children with severe protein-energy malnutrition]

BACKGROUND

Published studies on the serum immunoglobulin concentrations of patients with protein-energy malnutrition (PEM) have been contradictory. This report describes such a study in 21 Senegalese children.

POPULATION AND METHODS

Twenty one Senegalese infants (mean age: 19 +/- 2 months) with severe PEM were included in the study. Their weight was less than 32% of the normal range-for-height and all had sparse, thin hair and dyspigmentation of the skin. They were all suffering from hypoproteinemia (less than 70% of normal) and hypoalbuminemia (less that 61% of normal). The presence or absence of edema, loss of subcutaneous fat and mental changes were used to classify them into three groups. 1) kwashiorkor: eight infants; 2) marasmus: eight infants; 3) kwashiorkor plus marasmus: five infants. The control group comprised 27 infants living in the same area and having the same dietary habits as the 21 sick infants. The 21 infants with malnutrition were refed for 3 weeks with a diet supplying 100-150 Kcal/kg/d and 5-8 g/kg/d protein. The plasma concentration of proteins, prealbumin and immunoglobulins was measured on days 0, 8, 15 and 21.

RESULTS

The only significant change was in the IgG concentrations of group 1, which increased to normal levels by day 15 as did the total protein and prealbumin.

CONCLUSION

Severe PEM can lead to a loss of one class of immunoglobulins, but this can be restored by refeeding.

Aflatoxin, kwashiorkor, and morbidity

Children suffering from kwashiorkor could be grouped as those in whom aflatoxin was detectable in both serum and urine, and those in whom this mycotoxin was undetectable. Examination of the clinical records of the aflatoxin-positive and -negative children (58% and 42% of the sample, respectively) showed several other differences between the two groups. Compared with the aflatoxin-negative group, the children scored as aflatoxin-positive showed a significantly lower haemoglobin level (P = 0.02), a longer duration of oedema (P = 0.057), an increased number of infections (P = 0.037), and a longer duration of hospital stay (P = 0.008). The present findings suggest that the consumption of a staple food such as maize that is contaminated with the fungus Aspergillus flavus exposes susceptible kwashiorkor children to the metabolic hazards of aflatoxins, resulting in a greater risk of frequent infections.

Selenium in malnourished Sudanese children: status and interaction with clinical features

Plasma selenium (Se), haemoglobin (Hb) and packed cell volume (PCV) were measured in 53 malnourished Sudanese children, age 6-36 months, and 11 children who had tuberculosis. Twelve healthy well-nourished children served as controls. The mean (+/- SD) plasma Se (mg/kg) was 0.05 (0.036), 0.070 (0.040), 0.063 (0.015), 0.73 (0.012), 0.082 (0.014) in children with kwashiorkor/marasmic kwashiorkor (oedematous group), marasmus, tuberculosis and healthy controls. The mean Se level in the various groups showed a significant difference (p < 0.002). Whereas the oedematous group differed significantly from the rest, there was no difference between the means of the marasmic, underweight, tuberculosis patients and controls. The mean plasma albumin (+/- SD) in oedematous group was 19.6 (6.6) g/l and ranged between 22.6 (5.0) and 33.1 (3.0) in the other groups. A significant positive correlation was found between plasma Se level, albumin, Hb and PCV (respectively, r = 0.46, p < 0.0001; r = 0.37, p < 0.001; r = 0.36, p < 0.002).

Elevated glutathione S-transferase activity in erythrocytes from malnourished children

Glutathione S-transferases (GSTs) are principally involved in detoxification. These enzymes can be induced by an increased flux of substrate, such as occurs during pro-oxidative stress or antioxidant deficiency. We tested the hypothesis that the postulated oxidative stress in severe malnutrition would result in induction of GSTs in erythrocytes. Erythrocyte GST activity towards 1-chloro-2,4-dinitrobenzene (CDNB) was measured in 271 malnourished children (22 undernourished; 92 marasmic; 82 kwashiorkor; 75 marasmic-kwashiorkor) and 48 healthy children. GST activity in the malnourished children was significantly higher than the control group (P < 0.01). The GST activity in the four classes of malnutrition did not differ. There was a weak relationship between GST activity and the height deficit, but not with the weight deficit, or the clinical features displayed by the children. The 11 children that died had a higher value than the survivors. There was no change in GST with anthropometric recovery. We conclude that erythrocyte GST has been induced in children with malnutrition. Induction of erythrocyte GST may be the result of exposure of the children to oxidative stress during the months prior to their presentation with severe malnutrition.

Lipids and lipoproteins of malnourished children during early renutrition: apolipoprotein A-IV as a potential index of recovery

Twenty-six children with marasmus and 27 with kwashiorkor were compared with 23 control children of matching ages. Kwashiorkor was characterized by increased phospholipids (NS), low (P < 0.01) apolipoprotein (apo) B-rich LDL, and near normal apo A-I and HDL-C. In children with marasmus apo B (P < 0.02) LDL-C (NS), apo A-I (P < 0.01), and HDL-C (P < 0.001) decreased. Fifteen children in each group were followed for 2 wk. Control values were progressively reached after 2 wk. In the younger children final apo B was higher than in control subjects (P < 0.03) but apo A-I was identical. Apo A-IV, assayed because it correlates with the functional state of intestine, was near normal in children with kwashiorkor and decreased with treatment. In children with marasmus apo A-IV decreased by 50%, increased with treatment in older children, but further diminished in younger children. After 2 wk apo A-IV was significantly lower in all patients than in control subjects. Apo A-IV, by remaining depressed after other variables normalized, seems a good index of nutritional status.

Role of zinc supplementation in the rehabilitation of severely malnourished children

A double-blind study was conducted to assess the role of zinc supplementation in the rehabilitation of severely malnourished children. Thirty-three children with severe protein-energy malnutrition received either 40 mg of zinc as zinc sulphate or a placebo during their rehabilitation in addition to the diet containing about 700 kJ and 3-4 g protein per kg body weight/day. Their clinical and biochemical responses were examined. Clinical response and serum albumin synthesis were found to be similar in both the groups. The leukocyte (micrograms/10(10) cells) and plasma zinc levels (micrograms/dl) showed a significant (P < 0.001 and P < 0.01) increase from 46.9 +/- 5.490 to 107.2 +/- 13.224 and 80.4 +/- 9.972 to 107.5 +/- 11.822, respectively, after zinc supplementation. The placebo group also showed a significant (P < 0.025) increase in leukocyte zinc from 45.7 +/- 4.409 to 70.9 +/- 8.414. However, the plasma zinc in the placebo group fell from 83.6 +/- 10.363 to 68.2 +/- 7.031. Plasma copper showed a significant improvement in both zinc supplemented (P < 0.01) and placebo (P < 0.025) groups. The results indicate that zinc supplementation along with the diet would result in rapid restoration of zinc status, though there is no effect on the weight gain or other responses.

Effect of reactive oxygen species on the erythrocyte calcium-pump function in protein-energy malnutrition

The presence of detectable amounts of non-heme iron in erythrocyte ghost membranes have been postulated to lead to the initiation of membrane lipid peroxidation and the attendant perturbation of membrane functions. We have investigated the presence of non-heme iron and endogenous products of lipid peroxidation in erythrocyte membranes of normal and kwashiorkor (KWA) subjects and assessed the susceptibility of the membranes to exogenously generated reactive oxygen species. The modulation of the basal and calmodulin-stimulated calcium-pumping activity of these membranes by reactive oxygen species was also assessed. The results show the presence of significant amounts of non-heme iron and endogenous free radical reaction products in the red cell membranes of KWA subjects compared with that of normal children. Estimation of the extent of lipid peroxidation in the presence of exogenously generated reactive oxygen species further revealed that erythrocyte ghost membranes of KWA subjects are more susceptible to oxidative stress than those of normal individuals. Although both the basal and calmodulin-stimulated activities of the membrane-bound Ca(2+)-pump enzyme in normal and KWA subjects were inhibited by oxygen-free radicals, the erythrocyte enzyme in KWA subjects showed higher susceptibility to inhibition by oxygen free radicals than that of normal individuals. We propose that the reduced erythrocyte calcium-pump function in KWA is not unconnected with excessive generation of reactive oxygen species.

Response of Blood Serum Constituents to Production of and Recovery from a Kwashiorkor-Like Syndrome in the Young Pig

Twenty-six 3-week-old genetically obese pigs were fed in two experiments to determine the serum chemistry profile during severe protein malnutrition and repletion. Severe protein deficiency was produced in pigs fed the high-fat, low-protein diet (growth failure, rough hair, low serum total protein and albumin). In Experiment 1, blood was sampled from the anterior vena cava of each pig five times during depletion and three times during repletion to determine serum total cholesterol, high density lipoprotein (HDL)-cholesterol, triglycerides, total protein, albumin, glucose, Ca, inorganic P, Mg, Na, K, Cl, total bilirubin, urea N, creatinine, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, and gamma-glutamyltransferase. In Experiment 2, blood was sampled weekly for 8 weeks for serum total cholesterol, HDL-cholesterol, triglycerides, albumin, glucose, Ca, P, Mg and alkaline phosphatase. HDL-cholesterol was increased (P less than 0.01) and albumin was decreased (P less than 0.01) in protein-deficient pigs in both experiments. Creatinine, total bilirubin, gamma-glutamyltransferase, alanine aminotransferase, and aspartate aminotransferase were elevated in protein-deficient pigs compared with controls after 7 weeks of depletion. Inorganic P (P less than 0.01), Ca (P less than 0.01), and Mg (P less than 0.05) concentrations were depressed in protein-depleted pigs compared with controls in both experiments. After 8 weeks of repletion in Experiment 1, all elements except inorganic P were similar in the two groups. Short-term, severe, protein malnutrition affected lipid, electrolyte, and structural mineral metabolism and indices of liver function in the absence of parasites, diarrhea, and infection. The effects were reversed after 8 weeks of repletion. We conclude that the elevated serum cholesterol in protein deficiency is related primarily to an increase in the HDL fraction.

Plasma zinc, copper, selenium, ferritin and whole blood manganese concentrations in children with kwashiorkor in the acute stage and during refeeding

Plasma zinc, copper, selenium, ferritin and whole blood manganese concentrations were measured in 22 children with kwashiorkor on admission to hospital and on days 5, 10 and 30 of refeeding. Twenty similarly aged, healthy, well nourished children served as controls. The mean (SEM) zinc, copper and selenium concentrations of 7.5 (0.93), 10.8 (0.64) and 0.29 (0.02) mumol/l, respectively, in the children with kwashiorkor on admission were all significantly lower than the values of 13.7 (0.66), 25.6 (1.72) and 0.72 (0.04) mumol/l in the controls. In contrast, the erythrocyte manganese level of 1.67 (0.09) micrograms/gHb and the median ferritin concentration of 293 micrograms/dl were significantly higher than in the controls. After 30 days there was full clinical recovery with significant weight gain and a return of the plasma albumin, caeruloplasmin, copper and ferritin to normal. However, manganese remained elevated and zinc and selenium concentrations remained significantly low. Our results suggest that nutritional rehabilitation of children with kwashiorkor is incomplete by 30 days and cannot be judged purely by a return of the plasma proteins to normal. Addition of selected trace elements to the diet may hasten full recovery.