Kwashiorkor. II. Clinical picture, pathology, and differential diagnosis

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.

Cystic fibrosis presenting as kwashiorkor with florid skin rash

Two infants with a florid erythematous rash and generalised oedema, hypoalbuminaemia, and anaemia were found to have cystic fibrosis. This rare presentation is associated with false negative sweat tests, delays in diagnosis, and a considerable mortality. It is proposed that this presentation represents a manifestation of kwashiorkor secondary to malabsorption. The recognition that these infants have kwashiorkor provides some insight into the pathogenesis and management of their illness.

[Skeletal age in children with cerebral palsy]

Os autores estudam a idade óssea de 30 crianças portadoras de paralisia cerebral. Verificaram haver atraso da idade óssea em relação à idade cronológica (mais evidente no sexo masculino), o que não impediu que continuasse a existir regressão entre os dois dados. Relacionando a idade óssea à altura e o pêso, verificaram que as crianças portadoras de paralisia cerebral têm idade óssea superior à esperada, mas só foi possível estabelecer regressão entre idade óssea e altura em crianças do sexo masculino. Estudos de função tireóidea em 10 casos mostraram normalidade em praticamente todos êles. Os dados sugerem: 1) atraso da idade óssea de crianças com paralisia cerebral, proporcional ao atraso somático geral, possivelmente em função da desnutrição que tais crianças apresentam; 2) perturbação das relações de proporcionalidade entre idade óssea e pêso para o sexo masculino e entre idade óssea e pêso e idade óssea e altura para o sexo feminino, possivelmente na dependência da própria paralisia cerebral; 3) a ação desorganizadora da paralisia cerebral não deve depender de um componente de hipotireóidismo; 4) as alterações verificadas são mais intensas no sexo masculino.

Megaloblastic anaemia of infancy in Jamaica

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The effect of diuretics on the water excretion of protein deficient rats

Adult rats kept for eleven weeks on a diet deficient in protein lost weight and some developed scrotal oedema. The retention of bromsulphthalein was increased, but the thymol turbidity test was unaffected; the apparent plasma volume was increased.Water diuresis in the protein deficient animals was impaired. There was no apparent delay in the mean rate of water absorption from the whole gastro-intestinal tract although a delayed absorption of water from the intestine was found in some animals. The concentrations of total plasma proteins and plasma albumin were low as compared with normal animals, but the plasma sodium levels were within normal limits. The inulin clearance (glomerular filtration rate) of the animals on the protein-deficient diet was significantly lower than that of the controls.In normal rats, aminophylline and acetazolamide were diuretic. Caffeine and sodium benzoate did not increase the urine output and mersalyl was antidiuretic. In the protein deficient rats, cortisone acetate increased the water diuresis. Caffeine and sodium benzoate, aminophylline and acetazolamide did not significantly increase this response, mersalyl had an antidiuretic effect. Cortisone acetate increased the food and water intake of the protein deficient rats; it also increased the glomerular filtration rate.

[Infantile multiple deficiency syndrome in Central America (Kwashiorkor)]

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Hepatic cirrhosis associated with fibrocystic disease of the pancreas; clinical and pathological reports of five patients

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