Evolution of kwashiorkor and marasmus

The Tolerance Model of Non-Inflammatory Immune Competence in Acute Pediatric Malnutrition: Origins, Evidence, Test of Fitness and Growth Potential

The tolerance model rests on the thesis of a physiologically regulated, albeit unsustainable, systemic attempt to adapt to the catabolic challenge posed by acute prepubescent malnutrition even in its severe forms. The model centers on the immunological component of the attempt, positing reorientation toward a non-inflammatory form of competence in place of the classic paradigm of immunological attrition and exhaustion. The foundation of the model was laid in 1990, and sixteen years later it was articulated formally on the basis of a body of evidence centered on T cell cytokines and interventions with cytokine and hormonal mediators. The benefit originally suggested was a reduced risk of autoimmune pathologies consequent to the catabolic release of self-antigens, hence the designation highlighting immune tolerance. Herein, the emergence of the tolerance model is traced from its roots in the recognition that acute malnutrition elicits an endocrine-based systemic adaptive attempt. Thereafter, the growth of the evidence base supporting the model is outlined, and its potential to shed new light on existing information is tested by application to the findings of a published clinical study of acutely malnourished children. Finally, some knowledge gaps pertinent to the model are identified and its potential for growth consonant with evolving perceptions of immunobiology is illustrated.

Endocrine Dysfunctions in Patients with Inherited Metabolic Diseases

OBJECTIVE

Inherited metabolic diseases (IMDs) can affect many organ systems, including the endocrine system. There are limited data regarding endocrine dysfunctions related to IMDs in adults, however, no data exist in pediatric patients with IMDs. The aim of this study was to investigate endocrine dysfunctions in patients with IMDs by assessing their demographic, clinical, and laboratory data.

METHODS

Data were obtained retrospectively from the medical reports of patients with IMDs who were followed by the division of pediatric metabolism and nutrition between June 2011 and November 2013.

RESULTS

In total, 260 patients [139 males (53%) and 121 females (47%)] with an IMD diagnosis were included in the study. The mean age of the patients was 5.94 (range; 0.08 to 49) years and 95.8% (249 of 260 patients) were in the pediatric age group. Growth status was evaluated in 258 patients and of them, 27 (10.5%) had growth failure, all cases of which were attributed to non-endocrine reasons. There was a significant correlation between growth failure and serum albumin levels below 3.5 g/dL (p=0.002). Only three of 260 (1.1%) patients had endocrine dysfunction. Of these, one with lecithin-cholesterol acyltransferase deficiency and another with Kearns-Sayre syndrome had diabetes, and one with glycerol kinase deficiency had glucocorticoid deficiency.

CONCLUSION

Endocrine dysfunction in patients with IMDs is relatively rare. For this reason, there is no need to conduct routine endocrine evaluations in most patients with IMDs unless a careful and detailed history and a physical examination point to an endocrine dysfunction.

Supplementary vitamin E, selenium, cysteine and riboflavin for preventing kwashiorkor in preschool children in developing countries

BACKGROUND

Protein Energy Malnutrition is an important cause of child morbidity and mortality in middle- and low-income countries. It has been suggested that excessive free radical activity may be responsible for the clinical manifestation of kwashiorkor. Antioxidants may be able to curb excessive free radical activity and prevent the development of kwashiorkor in susceptible children.

OBJECTIVES

To evaluate the benefits of supplementation of vitamin E, selenium, cysteine and riboflavin (alone or in combination) in preventing kwashiorkor.

SEARCH STRATEGY

We conducted searches of CENTRAL 2009 (The Cochrane Library 2009 Issue 2), MEDLINE 1966 to 2009, EMBASE 1980 to 2009, CINAHL 1982 to 2009, LILACS 1982 to 2009, Meta register of Controlled trials, Open Sigle, African Index Medicus.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs evaluating vitamin E, selenium, cysteine and riboflavin alone or in combination in healthy pre-school children in middle- and low-income countries.

DATA COLLECTION AND ANALYSIS

Two authors extracted and independently analysed data.

MAIN RESULTS

One cluster-RCT including 2372 children met our inclusion criteria. Children were randomised, based on household, either to a supplement containing all four micronutrients or to placebo. No statistically significant difference in the incidence of kwashiorkor between the intervention and control groups could be demonstrated at 20 weeks (RR 1.70; 95% CI 0.98 to 2.42). Nor could any statistically significant difference in all-cause mortality be demonstrated (RR 0.75; 95% CI 0.17 to 3.36).

AUTHORS' CONCLUSIONS

Based on the one available trial, we could draw no firm conclusion for the effectiveness of supplementary antioxidant micronutrients for the prevention of kwashiorkor in pre-school children.

Reassessment of albumin as a nutritional marker in kidney disease

The decision by nephrologists, renal dietitians, federal agencies, health care payers, large dialysis organizations, and the research community to embrace serum albumin as an important index of nutrition and clinical performance is based on numerous misconceptions. Patients with analbuminemia are not malnourished and individuals with simple malnutrition are rarely hypoalbuminemic. With the possible exception of kwashiorkor, a rare nutritional state, serum albumin is an unreliable marker of nutritional status. Furthermore, nutritional supplementation has not been clearly shown to raise levels of serum albumin. The use of serum albumin as a quality care index is also problematic. It has encouraged a reflexive reliance on expensive and unproven interventions such as dietary supplements and may lead to adverse selection of healthier patients by health care providers. The authors offer a rationale for considering albumin as a marker of illness rather than nutrition. Viewed in this manner, hypoalbuminemia may offer an opportunity to improve patient well-being by identifying and treating the underlying disorder.

Pro-inflammatory cytokines in Turkish children with protein-energy malnutrition

BACKGROUND

Protein-energy malnutrition (PEM) results from food insufficiency as well as from poor social and economic conditions. Development of PEM is due to insufficient nutrition. Children with PEM lose their resistance to infections because of a disordered immune system. It has been reported that the changes occurring in mediators referred to as cytokines in the immune system may be indicators of the disorders associated with PEM.

AIMS

To determine the concentrations of pro-inflammatory cytokines in children with PEM, and to find out whether there was an association with the clinical presentation of PEM.

METHODS

The levels of serum total protein, albumin, tumour necrosis factor-alpha, and interleukin-6 were measured in 25 patients with PEM and in 18 healthy children as a control group. PEM was divided into two groups as kwashiorkor and marasmus. The kwashiorkor group consisted of 15 children and the marasmus group consisted of 10 children.

RESULTS

Levels of serum total protein and albumin of the kwashiorkor group were significantly lower than both the marasmus group and controls (p < 0.05). In view of tumour necrosis factor-alpha levels, there was no difference between groups (p > 0.05). While levels of interleukin-6 in both the marasmus group and the kwashiorkor group were significantly higher compared with controls (p < 0.05), there was no significant difference between the groups of marasmus and kwashiorkor (p > 0.05).

CONCLUSIONS

It was observed that the inflammatory response had increased in children with malnutrition.

Protein deficiency and energy restriction in young cebus monkeys

Infant cebus monkeys (Cebus albifrons) were fed liquid formulas that were limited in protein, energy, or a combination of the two restrictions. Weight gain, food intake, hematological development, and plasma protein and cholesterol levels were monitored over a 20-week period. The animals restricted in protein developed the classical signs of protein deficiency--reductions in plasma albumin, a mild anemia, accumulation of fat in the liver, and, in a few cases, facial edema. These animals maintained a relatively high energy intake, and apparently wasted energy when compared to similarly non-growing energy-restricted animals. Energy-restricted animals did not exhibit these symptoms, even when their daily protein intake was reduced to match that of protein-restricted monkeys. It is concluded that an energy restriction superimposed upon a limited protein intake did not increase protein requirements or precipitate protein deficiency.

A comparison of the pathogenesis of protein-energy malnutrition in Uganda and The Gambia

The pattern of growth, biochemical and endocrine development, dietary intake and disease patterns of rural children in Uganda and The Gambia have been monitored during the first three years of life in order to gain a more complete understanding of the reasons why in Uganda kwashiorkor predominates, whereas in The Gambia it is marasmus. Evidence is produced which supports the view that the hormonal balance, particularly cortisol and insulin status, can have a profound influence on which organs of the body are preferentially affected by malnutrition and hence on the type of protein-energy malnutrition which is likely to emerge. There were, however, also important differences in protein and energy intake between the two countries.

The effect of cortisone acetate on the course of development of experimental protein-energy malnutrition in rats

1. The role of corticosteroids in determining which clinical features of protein-energy malnutrition develop on a deficient diet has been studied by the administration of cortisone acetate to experimentally malnourished rats fed ad lib. on a mixture containing 31 g protein/kg. 2. Daily administration of 1-25 mg cortisone acetate did not affect dietary intake, which remained the same as in saline (9 g sodium chloride/l)-injected controls. Plasma albumin concentrations, however, increased from a low value of 25-7 g/l to 47-2 g/l and this was accompanied by an increase both in liver weight and protein content. On the other hand, the protein content of muscle decreased. 3. These changes in the protein contents of liver and muscle were associated with alterations in the corresponding free amino acid pools. The free amino acid content of muscle generally decreased, but in liver many amino acids were increased.

The relative effects of a low-protein-high-carbohydrate diet on the free amino acid composition of liver and muscle

1. Free amino acid concentrations in the plasma have been compared with those in liver and quadriceps muscle, in rats fed on diets containing 209 (control) and 31 (low-protein) g protein/kg. The effects of the low-protein diet on diurnal variations in these values were also measured.

2. In the plasma, the total amino acid concentration was significantly lower in animals given the low-protein diet, at all times of day except 12.00 hours. In the liver, and to a lesser extent the muscle, total amino acid concentration was maintained.

3. In the control animals, diurnal variation in the concentrations of both essential and non-essential amino acids was very similar in plasma, liver and muscle. In animals given the low-protein diet, although the same diurnal pattern was maintained for non-essential amino acids, that occurring among the essential amino acids had virtually disappeared.

4. In plasma, the mean 24 h concentration of essential amino acids decreased from 24· mmol/l in control animals to only 1·29 mmol/l in the low-protein-fed animals. Concentrations in muscle and liver were reduced by a similar proportion (from 8·6 to 5·56 μmol/g and from 8·67 to 5·05 μmol/g respectively). Conversely the concentrations of non-essential amino acids in animals given the low-protein diet were increased in plasma (from 1·53 to 2·00 mmol/l), muscle (from 12·5 to 14·3 μmol/g), and liver (from 16·8 to 20·5 μmol/g), muscle showing the lowest increase.

5. With the exceptions of lysine, threonine, cystine and tyrosine, the concentrations of all other essential amino acids were reduced more in liver than in muscle. The relationship between this and the failure to maintain plasma albumin concentrations is discussed.