Malnutrition in AIDS

Oesophageal cancer and cachexia: the effect of short-term treatment with thalidomide on weight loss and lean body mass

BACKGROUND

Cachexia is common in patients with advanced cancer and has a direct impact on well-being and mortality.

AIM

To test the hypothesis that thalidomide can promote weight gain and lean body mass in patients with advanced oesophageal cancer.

METHODS

In an open-label study, 11 patients with non-obstructing and inoperable oesophageal cancer were established on an isocaloric diet for 2 weeks, followed by 2 weeks on thalidomide, 200 mg daily. The primary end-points were weight change and lean body mass. Secondary end-points were quality of life and changes in resting energy expenditure.

RESULTS

Ten patients completed the study protocol. The average caloric intake remained the same throughout the study period in all patients. Nine of 10 patients (95% confidence interval, 0.60, 0.98) lost weight on diet alone. The mean weight gain on thalidomide in the following 2 weeks was 1.29 kg (median, 1.25 kg). A similar trend was shown in the lean body mass. Eight of nine patients (95% confidence interval, 0.57, 0.98) initially lost lean body mass on diet alone (missing data in one patient). The mean gain in lean body mass on thalidomide in the following 2 weeks was 1.75 kg (median, 1.33 kg).

CONCLUSIONS

Thalidomide treatment appeared to reverse the loss of weight and lean body mass over the 2-week trial period.

Involvement of the pancreas in AIDS: a prospective study of 109 post-mortems

BACKGROUND

Pancreatic involvement in AIDS is rarely mentioned in medical literature.

AIMS

To identify the main morphological patterns of the pancreas using optical and electron microscopy in AIDS patients.

DESIGN

An open, prospective, and sequential study in a tertiary institutional hospital.

METHODS

Consecutive post-mortems of 109 AIDS patients and 38 controls (1995). Baseline characteristics of AIDS patients and controls were evaluated. Morphological analysis consisted of: (i) semi-quantitative score of acinar and parenchymal elements; (ii) qualitative analysis of ducts, vascular components, nerves, and Langerhans' islets; (iii) specific stains and immunohistochemistry for opportunistic agents; (iv) ultrastructural data.

RESULTS

The mean age of AIDS patients was 37 years; 80% were male; 60% were white; 21% were alcoholic. All patients with AIDS had normal blood amylase, blood glucose, and pancreatic ultrasound. Histological findings were: acinar atrophy (60%), few zymogen granula in acinar cytoplasm (52%), abnormalities in acinar nucleus (65%), pancreatic steatosis (66%), and focal necrosis (17%). Immunohistochemistry revealed: mycobacteriosis (22%), toxoplasmosis (13%), cytomegalovirus (9%), Pneumocystis carinii (9%), and HIV p24 antigen in macrophage cytoplasm (22%). Ultrastructural examination showed: decreased zymogen granula, enlargement and proliferation of the endoplasmic reticulum and mitochondria, nuclear abnormalities, and increased lipid droplets in acinar cytoplasm.

CONCLUSION

Pancreatic involvement in AIDS is very frequent (90%) and is usually asymptomatic. Morphological changes showed three patterns of pancreatic alterations: 'nutritional-like', inflammatory and both of these together. The 'nutritional-like' pattern (atrophy, few zymogen granula and steatosis) may be due to many factors such as nutritional characteristics (Kwashiorkor-like) induced by the HIV infection or related to the HIV virus itself.

The prevalence and severity of intestinal disaccharidase deficiency in human immunodeficiency virus-infected subjects

BACKGROUND

Gastrointestinal symptoms are distressing features of human immunodeficiency virus (HIV) infection, and management is often empirical, including withdrawal of dietary lactose. We assessed the prevalence and severity of intestinal disaccharidase deficiency in vitro and in vivo.

METHODS

Fifty-four HIV-seropositive patients (19 HIV well +/- mild diarrhoea, 7 acquired immunodeficiency syndrome (AIDS) well, and 28 AIDS with diarrhoea) were studied with a combined non-invasive absorption-permeability-disaccharidase test that enables quantitative assessment of the rate of intestinal hydrolysis of lactose, sucrose, and palatinose. Thirty patients had jejunal biopsy specimens suitable for histomorphometric assessment, and 36 had in vitro disaccharidase activity measurement.

RESULTS

Patients with HIV (with mild diarrhoea) and AIDS (with and without severe diarrhoea) had frequent but mild histomorphometric changes in jejunal specimens. This was associated with frequent (21%-100%) and often severe in vitro jejunal disaccharidase deficiency. In vivo hydrolysis of lactose, sucrose, and palatinose was impaired in 25%-75% of patients, apart from HIV well patients, who were normal. The prevalence of the in vivo lactase and sucrase deficiency was significantly (P < 0.006) lower than in vitro and severe in about 30%.

CONCLUSIONS

Intestinal disaccharidase deficiency is common both in vitro and in vivo in HIV-seropositive patients but sufficiently severe to consider lactose withdrawal only in about a quarter of the patients with AIDS and diarrhoea.

Treatment guidelines for HIV-associated wasting

Patients with acquired immunodeficiency syndrome (AIDS) often suffer from weight loss manifested by a loss of body cell mass (BCM). The causes of human immunodeficiency virus (HIV)-associated wasting may include anorexia, malabsorption, and a variety of altered metabolic states. Malabsorption and diarrhea may result from gastrointestinal tract opportunistic infections or from direct effects of HIV on the gastrointestinal tract. Infection with HIV may produce metabolic derangements that alter nutrient utilization, resulting in loss of BCM. Nutritional assessment of the patient with AIDS should include an evaluation of BCM and physical and psychosocial functioning. Antiretroviral therapy and eradication of opportunistic infections do not always reverse wasting. Treatment should include nutritional counseling. Total parenteral nutrition is sometimes of benefit, particularly in patients with damaged gastrointestinal tracts. Dronabinol and megestrol acetate may promote weight gain; however, dronabinol may have adverse effects, and most of the gain with megestrol acetate is in fat rather than BCM. If gonadal dysfunction is present, testosterone replacement therapy should be included in the treatment plan. Some studies suggest that oral anabolic steroids may improve muscle strength and body composition. In randomized, placebo-controlled trials, mammalian-derived human growth hormone (rhGH[m]) has produced sustained weight and BCM gains in AIDS patients. If a patient continues to lose BCM after the above factors have been addressed and corrected, a 12-week course of rhGH[m] is indicated. Halting the progression of HIV-associated wasting may improve survival, enhance physical and social functioning, and enrich quality of life.

Alterations in head and neck cancer occurring in HIV-infected patients--results of a pilot, longitudinal, prospective study

To assess the impact of human immunodeficiency virus (HIV) infection on the presentation and course of head and neck squamous cell carcinoma (HNSCC), we performed a pilot, prospective, longitudinal study of all patients with HNSCC presenting to our institutions over a 6-month period (n = 10). A 60% incidence of HIV infection was seen in this study population, with SCC presenting as the initial manifestation of HIV infection in 2 of the 6 patients. In addition. HIV-infected patients were significantly younger than non-infected patients at (p = 0.01). None of the HIV-infected patients had acquired immunodeficiency syndrome (AIDS) at the time of presentation, but 5 of 6 patients had an abnormal CD4 count, compared to none of the non-infected patients (p = 0.05). The absolute CD4 count in HIV-infected patients decreased to less than 100x10(9)/L in the majority of these patients within 3 months of presentation with HNSCC (p = 0.05). Treatment-associated complications were common in HIV-infected patients, occurring in 4 of the 6 cases in contrast to none of the patients without HIV infection (p = 0.046). Outcome was significantly poorer for HIV-Infected patients, with 5 patients succumbing to their disease within one year, in contrast to none of the non-infected patients (p = 0.046). These data, combined with our previous work, justify further investigation of the relationship between HNSCC and HIV infection and the possibility of its inclusion as an AIDS-defining process.

Nutritional supplements combined with dietary counselling diminish whole body protein catabolism in HIV-infected patients

BACKGROUND

Weight loss and protein malnutrition are frequent complications in HIV-infected patients. The effect of an oral nutritional supplement combined with nutritional counselling on whole body protein metabolism was assessed.

MATERIALS AND METHODS

HIV-infected individuals with a body mass index < 21 kg m-2 or CD4-T cells < 500 micro L-1 in stable clinical condition were randomly allocated to [1] receive either oral nutritional supplements (containing 2510 kJ, complete macro- and micronutrients) and dietary counselling (n = 8), or [2] identical monitoring but no supplements or specific nutritional advice (controls, n = 7). Whole body leucine kinetics and leucine oxidation rate were determined by [1-13C]-leucine infusions and lean and fat mass were measured before and 12 weeks after intervention.

RESULTS

Leucine oxidation (protein catabolism) decreased in the group receiving nutritional intervention from 0.33 +/- 0.02 to 0.26 +/- 0.02 micromol kg-1 min-1 after 12 weeks (P < 0.05; P < 0.05 vs. control group) but remained unchanged in the control group. Whole body leucine flux showed a tendency to decrease in the intervention group from 1.92 +/- 0.19 to 1.73 +/- 0.14 micromol kg-1 min-1 (P = 0.07) and remained unchanged in the control group (2.21 +/- 0.16 and 2.27 +/- 0.14 micromol kg-1 min-1, respectively). Lean body mass determined by bioelectrical impedance analysis increased in the nutritional intervention group from 84 +/- 2 to 86 +/- 2 per cent (P < 0.05) and fat mass decreased from 17 +/- 2 to 14 +/- 2 per cent (P < 0.05) of total body weight whereas neither mass changed in the control group. Nutritional intervention had no significant effect on lymphocyte CD4 counts, on plasma TNFR 55, TNFR 75 and ILR 2 concentrations and on quality of life.

CONCLUSIONS

The data demonstrate an anticatabolic effect of nutritional supplements combined with dietary counselling in HIV-infected subjects. They suggest that diminished whole body protein catabolism resulted in a change of body composition (increased lean mass, decreased fat mass).

Rapid mucosal CD4(+) T-cell depletion and enteropathy in simian immunodeficiency virus-infected rhesus macaques

BACKGROUND & AIMS

Human immunodeficiency virus (HIV) infection leads to severe immunologic and functional disturbances in the intestinal tract in late stages of the disease. Information on mucosal pathology directly after infection is limited. We characterized this early phase in rhesus macaques infected with simian immunodeficiency virus (SIV).

METHODS

Eight rhesus macaques were infected with SIV. Upper endoscopy was performed at defined times before and after infection. Viral load, percentage of CD4(+) T cells, villus height, crypt depth, and Ki-67-positive crypt cells were analyzed in duodenal biopsy specimens. Serum beta-carotene and vitamin D levels were assessed.

RESULTS

A rapid increase of duodenal SIV core protein (p27) concentration and an almost complete loss of intestinal CD4(+) T cells was found within 2 weeks after infection. A decrease of villus height was observed, and the percentage of Ki-67-positive (proliferating) crypt cells increased. Serum concentrations of vitamin D decreased in 6 of 8 animals, and beta-carotene concentrations decreased in 3 of 8 animals after infection.

CONCLUSIONS

Mucosal SIV replication and intestinal CD4(+) T cell depletion are early events in SIV-infected rhesus macaques. The structural changes of the mucosa strongly support the concept of HIV/SIV-induced enteropathy. In contrast to late-stage human HIV infection, early small intestinal villous atrophy in SIV infection is associated with crypt hyperplasia.

Impact of tuberculosis on the body composition of HIV-infected men in Brazil

OBJECTIVE

Tuberculosis (TB) is the commonest HIV-related opportunistic infection in many developing countries and is thought to be a frequent underlying cause of HIV-associated wasting. We have used reference water dilution methods to examine the body composition changes associated with TB and to assess the severity and pattern of wasting.

METHODS

The study was conducted at a charitable support house for poor and homeless HIV-infected people in Rio de Janeiro, Brazil. Male patients who were HIV-positive and receiving treatment for active TB (HIVTB+) and HIV-infected controls without TB (HIVTB-) were studied. Total body water (TBW) and extracellular water (ECW) were measured by giving oral doses of deuterium oxide and sodium bromide, respectively, and determining enrichment in plasma after 4 hours. Intracellular water (ICW), body cell mass (BCM), lean body mass (LBM) and fat mass were calculated from these parameters using standard equations.

RESULTS

HIVTB+ (n = 11) and HIVTB- (n = 12) groups were similar in age, height, CD4 count and HIV risk factors. HIVTB+ men had significantly lower mean ICW (13.2 versus 16.6 kg; p = .02) and BCM (18.4 versus 23.0 kg; p = .02), a relative expansion of ECW (35.0 versus 30.0 L/kg body weight; p = .04), and small and nonsignificant reductions in total body weight (58.0 versus 62.1 kg; p = .26), LBM (45.5 versus 47.7 kg; p = .33) and fat mass (12.5 versus 14.4 kg; p = .51) compared with HIVTB- controls. BCM in the HIVTB+ group was similar to reference values for severe malnutrition. The relative depletion of BCM appeared excessive in comparison with reference values for uncomplicated starvation.

CONCLUSION

The nutritional status of HIVTB+ patients was significantly worse than HIVTB- patients. Body weight and LBM underestimated the nutritional deficit, and measurement of BCM is therefore necessary to appreciate the extent of malnutrition in such patients. Malnutrition in HIVTB+ patients is severe and may therefore contribute to decreased survival. Hypermetabolism appears to play a role in the wasting process in patients coinfected with HIV and TB.

HIV/SIV enteropathy

Evidence is increasing that HIV/SIV-induced changes in the highly differentiated gut-associated immune system play a central role in the pathogenesis of gastrointestinal manifestations in HIV/SIV infection. It has been shown in both humans infected with HIV and in nonhuman primates infected with SIV that a rapid, very early, and more pronounced loss of CD4+ T-cells occurs in the mucosa in comparison to the peripheral blood. The loss of this important regulatory T-cell subset might explain mucosal immunodeficiency with the consequence of opportunistic mucosal infections. In addition, there is evidence that small intestinal damage occurs independently of secondary infections (HIV/SIV enteropathy). In late-stage human disease, HIV enteropathy is characterized by villous atrophy with hyporegeneration and dysmaturation of intestinal epithelial cells. In SIV infection of macaques, villous atrophy is a very early event; however, it is accompanied by crypt cell hyperproliferation. Early- and late-stage enteropathy in immunodeficiency virus infection may represent two types of immunologically mediated mucosal transformation in which the number and state of activation of regulatory T cells determine whether hypo- or hyperproliferative villous atrophy occurs.

Intergroup comparisons of oral lesions in HIV-positive South Africans

OBJECTIVE

To determine whether there are any differences in the oral manifestations of sub-groups of persons with HIV. These data could provide information for planning of oral health promotion and prevention programmes.

DESIGN

A comparative inter-group cross-sectional investigation of the oral manifestations of HIV. Ethnic, gender and sexual orientation differences were taken into consideration.

SETTING

Three large general hospitals that offer comprehensive medical investigations and care to persons with HIV.

SUBJECTS AND METHODS

A total of 485 HIV-positive adults participated. Clinical examination and, where necessary, swabs or smears of lesions for microbiology, biopsies for histology.

MAIN OUTCOME MEASURES

Presence of lesions, associated signs, incidence and type of micro-organisms.

RESULTS

A total of 485 HIV-positive persons were examined over a period of 3 years consisting of 225 Blacks, 191 Coloureds (persons of 'mixed' descent) and 69 Whites. Data were analysed using, where relevant, the chi 2 test or Fisher's exact test. Heterosexual males revealed a higher prevalence of all oral lesions combined when compared with heterosexual females. A similar finding was evident when HIV-associated periodontal diseases was compared in these two groups. Homosexual males had a higher prevalence of candidal infections than heterosexual males. Coloured heterosexuals had a higher prevalence of oral lesions combined than black heterosexuals. All these results showed statistical significance.

CONCLUSIONS

The study tends to show that different patterns of prevalence emerge when inter-group comparisons are made of oral soft tissue diseases evident in HIV-infected South Africans.

Body composition in clinically stable men with HIV infection

Clinically stable HIV-infected men (N = 106) receiving investigational antiretrovirals were recruited. Subjects were divided into three HIV disease severity groups by CD4+ cell count. Standard measures of body composition were assessed, as well as serum measures of visceral protein stores and kilocalorie intake. Group 1 subjects (CD4+ T cells < 200) had significantly lower measures of body fat as compared with Group 2 (CD4 between 200 and 600) and Group 3 (CD4 > 600) despite adequate kilocalorie intake. Group 2 and Group 3 were not significantly different from each other. Our entire cohort had significantly lower muscle mass compared to norms. Our data demonstrate that people with advanced HIV disease have reduced muscle and fat.

Nutrition and HIV infection in children

HIV infection has profound effects on a patient's nutritional status because it can modulate appetite, nutrient absorption and basal metabolic rate. In addition, HIV infection can lead to the depletion of a variety of vitamins and micronutrients including vitamins A, D, B2, B6, B12, L-carnitine, iron, zinc and selenium. This review article summarizes existing data regarding nutritional defects in HIV-infected patients and the results of clinical studies addressing the effects of nutritional supplementation in infected patients.

Clinical predictors of functioning in persons with acquired immunodeficiency syndrome

To help clinicians better assess and treat functional disabilities in persons with acquired immunodeficiency syndrome (AIDS), the authors estimate empirical relations among biologic and physiologic variables, symptoms, and physical functioning in persons with AIDS. The sample of 305 persons with AIDS for this cross-sectional analysis came from three sites in Boston, Massachusetts: a hospital-based group practice, a human immunodeficiency virus clinic at a city hospital, and a staff-model health maintenance organization. Physical functioning, 10 AIDS-specific symptoms, and mental health were assessed by interview. Clinical diagnoses, comorbidities, health habits such as smoking, laboratory results, and selected medication use were assessed by chart review. Significant predictors of physical functioning P < 0.01, R2 = .58) in a multivariable regression model included energy/fatigue, neurologic symptoms, fever symptoms, a lower hemoglobin level, and current non-pneumonia bacterial infection. Ninety-six percent of the explained variance in physical functioning was accounted for by three symptom complexes: energy/fatigue, neurologic symptoms, and fever symptoms. Significant predictors of energy/fatigue in multivariable models included poorer mental health, lower white blood cell count, longer time since diagnosis, and weight loss (P < 0.01, R2 =.36). Significant predictors of neurologic symptoms included poorer mental health, weight loss, and no zidovudine use (P < 0.001, R2 = .30). Predictors of fever symptoms included poorer mental health, no zidovudine use, weight loss, and history of asthma or chronic obstructive pulmonary disease (P < 0.05, R2 = .25). In conclusion, symptom reports were strong predictors of physical functioning. Poorer mental health and weight loss were correlated consistently with worse symptoms, and not using zidovudine was correlated with worse neurologic and fever symptoms. These variables, and the others the authors identified, may represent mutable determinants of physical functioning in persons with AIDS, and potential targets for specific clinical interventions.

[The "malnutrition-infection" complex, the most widespread public health problem in underprivileged populations.]

The synergistic association between malnutrition and infection remains today the most worrisome public health problem in the world. Although the high level of mortality among children in developing countries is mainly due to infectious and parasitic diseases, more than half of these children die in a state of overt undernourishment. Energy and nutrient deficiencies adversely affect various aspects of immunocompetence, thus malnourished people are particularly sensitive to many opportunistic infections. These, in turn, induce anorexia, various metabolic changes and malabsorption, which affect nutritional reserves, and lead to malnutrition if prolonged. In the absence of efficient measures to break this vicious cycle, malnutrition and morbidity lead to high levels of mortality. Experience from developing countries suggests that to improve the prevention and treatment of infectious diseases in such a context of poverty, one need to take into account simultaneously the basic environment of underprivileged groups and their dietary intake as well as their level of access to health care services.

Cellular and molecular effects of malnutrition and their relevance to periodontal diseases

In response to periodontal pathogens, the leukocytes (PMN) elaborate destructive oxidants, proteinases, and other factors. The balance between these factors, the antioxidants and endogenously synthesized antiproteinases determine the extent of periodontal damage. Malnutrition (PEM) is characterized by marked tissue depletion of the key antioxidant nutrients, including GSH (gamma-glutamyl-cysteinyl-glycine), and impaired acute-phase protein response (APR) to infections. The latter results in diminished production of the acute-phase proteins (APP). The APR plays a key role in promoting healing, and its deficit in PEM is due to impairment in the production and cellular action of the cytokines. Other features of malnutrition include inverted helper-suppressor T-cell ratio, histaminemia, hormonal imbalance with increased blood and saliva levels of free cortisol, and defective mucosal integrity. Malnutrition, particularly of the PEM type which usually involves concomitant deficiencies of several essential macro- and micronutrients, therefore has the potential to adversely influence the prognosis of periodontal infections.