Platelet adhesiveness, plasma free fatty acids, and serum triglycerides in kwashiorkor

Oedema in kwashiorkor is caused by hypoalbuminaemia

It has been argued that the oedema of kwashiorkor is not caused by hypoalbuminaemia because the oedema disappears with dietary treatment before the plasma albumin concentration rises. Reanalysis of this evidence and a review of the literature demonstrates that this was a mistaken conclusion and that the oedema is linked to hypoalbuminaemia. This misconception has influenced the recommendations for treating children with severe acute malnutrition. There are close pathophysiological parallels between kwashiorkor and Finnish congenital nephrotic syndrome (CNS) pre-nephrectomy; both develop protein-energy malnutrition and hypoalbuminaemia, which predisposes them to intravascular hypovolaemia with consequent sodium and water retention, and makes them highly vulnerable to develop hypovolaemic shock with diarrhoea. In CNS this is successfully treated with intravenous albumin boluses. By contrast, the WHO advise the cautious administration of hypotonic intravenous fluids in kwashiorkor with shock, which has about a 50% mortality. It is time to trial intravenous bolus albumin for the treatment of children with kwashiorkor and shock.

Cystic fibrosis and Helicobacter pylori gastritis, megaloblastic anaemia, subnormal mentality and minor anomalies in two siblings: a new syndrome?

Two siblings of consanguineous Arab parents were found to have cystic fibrosis and gastritis associated with Helicobacter pylori, folate deficiency megaloblastic anaemia, subnormal mentality and minor anomalies. The association of H. pylori and megaloblastic anaemia has not been described in patients with cystic fibrosis. H. pylori infection and gastritis is probably more common in patients with cystic fibrosis than appreciated. We believe that the constellation of features in the two sibs represent a possible new autosomal recessive cystic fibrosis-like syndrome.

Substrate mobilization: a new hypothesis for the aetiology of the idiopathic respiratory distress syndrome

This hypothesis for the aetiology of the idiopathic respiratory distress syndrome of the newborn (IRDS) proposes that, although the aetiology is multifactorial, the factor of prime importance is the mobilization of substrate for surfactant synthesis. All factors known to influence the incidence, treatment, and prognosis of the IRDS can be shown to be associated with the mobilization of substrate and thereafter its continued availability for the synthesis of adequate surfactant. Thus factors which promote an antenatal increase in the breakdown of energy stores will be associated with a reduced incidence of the IRDS. On the other hand, despite adequate mobilization, factors associated with a lack of substrate secondary to poor transport of substrate, a reduction in pulmonary circulation or an alteration in fetal or neonatal metabolism which involves an increased utilization of substrate to provide energy, will be associated with an increased incidence of the IRDS.

Dietary effects in the early recovery phase of kwashiorkor. Plasma levels of triglycerides, FFA, D-beta-hydroxybutyrate, glycerol, postheparin lipoprotein lipase (LPL), glucose and insulin

The fatty liver often found in untreated kwashiorkor has been associated with highly variable concentration of circulating lipids. The effect on lipid metabolism of two isocaloric diets--one synthetic monomolecular (Vivonex) and one standard (Casilan)--which both initiated satisfactory clinical improvement was studied in 21 Ethiopian children with kwashiorkor during the first weeks of rehabilitation. Before treatment mean fasting values of all biochemical parameters were within normal ranges except for moderately elevated triglycerides--an unexpected finding-and low insulin. Individual values varied greatly; triglyceride between 0.39 and 3.49 mmol/1. FFA correlated both to glycerol, D-beta-hydroxybutyrate and triglyceride values. During treatment insulin, glucose and glycerol remained essentially unchanged and were similar in both dietary groups. In the Vivonex group only there was an initial marked, parallel fall of FFA and D-beta-hydroxybutyrate suggesting greater availability of carbohydrate and enhanced glucose utilization. This pattern of response seemed to occur without comparable inhibition of lipolysis. Triglycerides--like serum albumin--increased faster in the Casilan group. The highest mean triglyceride value was reached by day 8 in the Casilan group and by day 15 in the Vivonex group. Ten minutes following heparin injection triglycerides declined, FFA and glycerol increased indicating release of in vivo active lipase. LPL activity assayed in vitro was similar and unaffected by 2 weeks of dietary treatment in both groups. LPL activity was inversely correlated to triglycerides providing--beside the type of diet--another possible explanation for the wide variations seen in circulatory triglycerides.

Peripheral gangrene in hypernatraemic dehydration of infancy

Gangrene of the extremities complicating diarrhoea and severe hypernatraemic dehydration occurred in 6 infants. This is a rare complication of gastroenteritis, and its association with hypernatraemia does not seem to have previously been emphasized. The increased blood viscosity resulting from serum hyperosmolarity may have been responsible for the gangrene, and studies in our patients suggested that disseminated intravascular coagulation was present. In addition to fluid and electrolyte replacement, the infants were treated with heparin with some recovery of the affected extremities.