Protein-calorie malnutrition: a study of red blood cell and serum enzymes during and after crisis

Severe Protein-Calorie Malnutrition-Associated Hepatic Steatosis in a Woman Who Had Roux-en-Y Gastric Bypass for Morbid Obesity Thirteen Years Ago

Hepatic steatosis is common in everyday liver pathology practice. There are many etiologies leading to hepatic steatosis. These etiologies include metabolic syndrome, alcohol, medications, monogenetic disease, infectious diseases, and malnutrition. Correct diagnosis of underlying etiology through clinicopathological correlation is key to adequate treatment and optimal outcome for the patient. In this case report, we describe severe protein-calorie malnutrition as an etiology for hepatic steatosis in a middle-aged woman who presented with lethargy, low body mass index (15.8 kg/m²), abdominal distention and bilateral lower extremity edema, hyperammonemia, and hypoalbuminemia, 13 years after Roux-en-Y gastric bypass for morbid obesity. Laboratory tests revealed hyperammonemia, hypoalbuminemia, and low ceruloplasmin levels. Hemodynamic measurement demonstrated high hepatic venous pressure gradient of 12 mm Hg. Transjugular liver biopsy showed moderate macrovesicular steatosis, mild siderosis, and abundant lipofuscin but no evidence of fibrosis, cirrhosis, or steatohepatitis. This patient was treated with lactulose and enteral feeding, however, the patient died of progressive liver failure 3 weeks after admission. We also review relevant literature to help diagnose protein-calorie malnutrition (kwashiorkor) and hepatic steatosis as a possible late complication of Roux-en-Y gastric bypass. In patients with hepatic steatosis, encephalopathy, hyperammonemia and portal hypertension, malnutrition should be considered as an etiology and diagnosed with a synthesis of clinical, pathological, and laboratory information. Kwashiorkor is a severe disease and should be treated promptly as it may be fatal as in our case.

Cysteine/Glutathione Deficiency: A Significant and Treatable Corollary of Disease

Glutathione (GSH) deficiency may play a pivotal role in a variety of apparently unrelated clinical conditions and diseases. Orally administered N-acetylcysteine (NAC), which replenishes the cysteine required for GSH synthesis, has been tested in a large number of randomized placebo-controlled trials involving these diseases and conditions. This chapter focused on developing a base of evidence suggesting that NAC administration improves disease by increasing cysteine and/or GSH in a variety of diseases, thereby implying a significant role for GSH deficiency in the clinical basis of many diseases. To develop this base of evidence, we systematically selected studies which considered the hypothesis that the therapeutic efficacy for NAC is an indication that cysteine and/or GSH deficiency is a pathophysiological part of the diseases studied. In this manner we focus this chapter on explaining the biological mechanisms of NAC therapy in a wide variety of disorders and demonstrate its ubiquitous role in improving disease that involves disrupted GSH and/or cysteine metabolism.

Red blood cell antioxidant enzyme concentrations in kwashiorkor and marasmus

Kwashiorkor may occur when an imbalance between pro- and antioxidants in malnourished children results in an excess of free radicals. The concentrations of the antioxidant enzymes catalase (CAT), superoxide dismutase (SOD), reduced glutathione (GSH) and glutathione peroxidase (GPX) were measured in erythrocytes of 22 children with kwashiorkor on admission to hospital and repeated on days 5, 10 and 30 of recovery. The concentrations were compared with those in 22 children with marasmus and in 20 children who were normally nourished but had infective illness necessitating their hospitalization. CAT and SOD were similar in all groups and did not change during recovery. GSH and GPX were significantly lower in kwashiorkor than in the other groups. Concentrations of thiobarbituric acid-reactive substances (TBARS), a marker of lipid peroxidation, were significantly elevated in children with kwashiorkor. During clinical recovery, GSH but not GPX concentrations rose despite an increase in plasma selenium levels and decreased concentrations of TBARS. These findings suggest that the antioxidant status of children with kwashiorkor differs from that of well nourished and marasmic children. Whether these differences are the cause of the consequence of the clinical picture is unresolved.

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.

Phosphoribosyl pyrophosphate synthetase and glutathione reductase in erythrocytes from hyperuricaemic and gout patients

The enzymic activities of erythrocyte phosphoribosyl pyrophosphate synthetase (EC 2.7.6.1) and glutathione reductase (EC 1.6.4.2) have been measured in 54 primary gout patients, 35 individuals having hyperuricaemia and 51 healthy controls. Statistical analyses have shown a significant increase (p less than 0.01) in the enzymic activity of erythrocyte PRPP synthetase in both the hyperuricaemic and gout groups compared with the controls. No correlation between activity and age was found in any of the three clinical groups. A significant decrease (p congruent to 0.01) was found in the enzymic activity of red cell glutathione reductase in the gout group compared with the other two groups. The biochemical significance of the changes in enzymic activities of the two enzymes in primary gout is discussed.

Effect of glucocorticoids on liver and blood cholinesterases

The effects of oral prednisone on plasma and red blood cell cholinesterases have been studied in human volunteers. While the activity of plasma pseudocholinesterase is depressed by glucocorticoid administration, the activity of red blood cell true cholinesterase is not affected. Cortisol administration to rats, intraperitoneal or subcutaneous, inhibited liver pseudocholinesterase activity, indicating a possible depression of the enzyme protein synthesis.